The development of complex multicellular human in vitro systems holds great promise for modelling disease and advancing drug discovery and tissue engineering. In the liver, despite the identification of key signalling pathways involved in hepatic regeneration, in vitro expansion of human hepatocytes directly from fresh patient tissue has not yet been achieved, limiting the possibility of modelling liver composite structures in vitro. Here we first developed human hepatocyte organoids (h-HepOrgs) from 28 different patients. Patient-derived hepatocyte organoids sustained longterm expansion of hepatocytes in vitro and maintained patient-specific gene expression and bile canaliculus features and function of the in vivo tissue. After transplantation, expanded h-HepOrgs rescued the phenotype of a mouse model of liver disease. By combining h-HepOrgs with portal mesenchyme and our previously published cholangiocyte organoids, we generated patient-specific periportal liver assembloids that retain the histological arrangement, gene expression and cell interactions of periportal liver tissue, with cholangiocytes and mesenchyme embedded in the hepatocyte parenchyma. We leveraged this platform to model aspects of biliary fibrosis. Our human periportal liver assembloid system represents a novel in vitro platform to investigate human liver pathophysiology, accelerate drug development, enable early diagnosis and advance personalized medicine. https://creativecommons.org/licenses/by/4.0/
Background: There is currently no pharmacological therapy proven to alter the natural course of primary sclerosing cholangitis (PSC). The PRIMIS trial evaluated the efficacy and harms of the farnesoid X-activated receptor agonist cilofexor in participants with non-cirrhotic PSC. Methods: In this phase 3, double-blind, placebo-controlled, multi-centre trial (205 sites across 16 countries), adults aged 18-75 years with non-cirrhotic (F0-F3 [Ludwig classification]) large-duct PSC were randomly assigned (2:1) via an interactive web response system to receive cilofexor 100 mg or placebo (identical in appearance) orally once daily for 96 weeks. Randomisation was stratified by ursodeoxycholic acid use (yes or no) and the presence of bridging fibrosis (F3 vs F0-F2), with a block size of six within each stratum. Participants, personnel directly involved in the conduct of the study, and outcome assessors were masked to treatment assignment. The primary endpoint was the proportion of participants with histological progression of liver fibrosis (a stage increase of one or more [Ludwig classification]) at week 96. After study termination, the primary endpoint analysis set was amended to include all participants in the harms analysis set (all who received at least one dose of the study drug) who had biopsy data at baseline and week 96. This trial is complete (ClincalTrials. gov, NCT03890120). Findings: Between June 13, 2019, and July 22, 2021, 419 participants were randomly assigned, and 416 were included in the full and harms analysis sets (cilofexor: n=277; placebo: n=139); 257 (62%) men and 159 (38%) women. The study was terminated early on Sept 26, 2022, after a planned interim futility analysis after 160 patients had reached 96 weeks of follow-up indicated a 6 & centerdot;8% probability of detecting a significant difference between cilofexor over placebo (futility boundary <-10%). In the final analysis of the primary endpoint, for which 133 patients in the cilofexor group and 64 in the placebo group had liver biopsy results available, fibrosis progression occurred in 41 (31%) participants in the cilofexor group and 21 (33%) in the placebo group at week 96 (treatment difference-1 & centerdot;4% [95% CI-15 & centerdot;2 to 12 & centerdot;3]; p=0 & centerdot;42). The most common adverse events were pruritus (cilofexor: 136 [49%] of 277 patients; placebo: 50 [36%] of 139 patients; grade 3 or higher in 11 [4%] patients in the cilofexor group and one [1%] patient in the placebo group), COVID-19 (cilofexor: 65 [23%]; placebo: 26 [19%]), and upper abdominal pain (cilofexor: 40 [14%]; placebo 20 [14%]). The proportion of serious adverse events was similar between groups (cilofexor: 53 [19%]; placebo: 26 [19%]). There were no treatment-related deaths. Interpretation: Cilofexor did not significantly reduce the rate of fibrosis progression (vs placebo) in participants with non-cirrhotic PSC. A greater percentage of cilofexor-treated participants had pruritus than placebo-treated participants; this study provides valuable harms data for cilofexor and other drugs in its class.
BACKGROUND & AIMS:Federal agencies define heavy drinking by average increased or episodic heavy alcohol consumption, yet steatotic liver disease (SLD) nomenclature only captures average alcohol consumption to define subcategories. We evaluated episodic heavy drinking among SLD subcategories and its association with liver fibrosis. METHODS:We utilized the 2017 to 2023 National Health and Nutrition Examination Survey (NHANES) including adults with vibration-controlled transient elastography data. Significant and advanced liver fibrosis were liver stiffness ≥8 and ≥12 kPa. Episodic heavy drinking was ≥4 drinks (women) and ≥5 (men) on any day, at least once per month. Multivariable logistic regression (adjusted for age, sex, average alcohol consumption) analyzed the association of episodic heavy drinking with liver fibrosis in SLD groups. RESULTS:Among 8006 individuals, 4571 had SLD: 3969 had metabolic dysfunction-associated steatotic liver disease (MASLD), 373 had metabolic and alcohol-associated liver disease (MetALD), and 144 had alcohol-associated liver disease (ALD). Among patients with MASLD, 632 (15.9%) had episodic heavy drinking, which was associated with significant (adjusted odds ratio, 1.69; 95% confidence interval [CI], 1.11-2.58) and advanced (adjusted odds ratio, 2.76; 95% CI, 1.58-4.80) liver fibrosis. Adjusted weighted-prevalence of significant liver fibrosis among MASLD with episodic heavy drinking (23.6%; 95% CI, 17.6%-29.6%) was higher than MASLD without episodic heavy drinking (15.6%; 95% CI, 13.5%-17.6%]). Subgroup prevalence using consensus nomenclature vs including episodic heavy drinking as MetALD or ALD decreased the weighted prevalence of MASLD (48.0%; 95% CI, 46.0%-50.0% to 40.4%; 95% CI, 38.5%-42.4%), increased MetALD (5.3%; 95% CI, 4.6%-6.1% to 12.9%; 95% CI, 11.9%-13.9%), whereas ALD was similar (1.9%; 95% CI, 1.5%-2.3% to 2.1%; 95% CI, 1.7%-2.5%). CONCLUSIONS:Episodic heavy drinking is prevalent in MASLD and associated with 3-fold higher odds of advanced liver fibrosis. Reclassifying these patients to MetALD would more than double the estimated prevalence of MetALD.
Vascular diseases of the liver include portal vein thrombosis (with or without cirrhosis), portosinusoidal vascular disorder, Budd-Chiari syndrome, sinusoidal obstruction syndrome, non-obstructive sinusoidal dilatation and peliosis, splanchnic artery aneurysms, and hepatic arteriovenous fistulas. Except for portal vein thrombosis in cirrhosis, these are all rare conditions. Since the last Clinical Practice Guidelines were issued by the European Association for the Study of the Liver in 2016, much data has been published on the diagnosis and management-medical and interventional-of patients with vascular liver diseases. Based on a thorough review of the relevant literature, recommendations are provided to address key clinical dilemmas. The document emphasises personalised care, considering individual risk factors and clinical presentation. Multidisciplinary management involving hepatologists, haematologists, pathologists, interventional radiologists and surgeons is essential in this area. Our aim is to provide guidance on the management of patients with vascular liver diseases based on the best available evidence. (c) 2025 European Association for the Study of the Liver. Published by Elsevier B.V. All rights are reserved, including those for text and data mining, AI training, and similar technologies.
BACKGROUND & AIMS:In hepatocellular carcinoma (HCC) with cirrhosis, portal hypertension worsens outcomes. Esophagogastroduodenoscopy (EGD), the current screening method for esophageal varices (EVs), is invasive and may delay therapy. We aimed to develop and externally validate non-invasive models to detect EVs and predict hepatic decompensation (bleeding, ascites or hepatic encephalopathy), a major cause of mortality in patients with HCC, using routine contrast-enhanced CT and clinical data. METHODS:This multicenter retrospective study included 489 patients with unresectable HCC treated with atezolizumab-bevacizumab (AtezoBev) from five French centers, divided into a development cohort (n = 279) and an external validation cohort (n = 210). Arterial-phase contrast-enhanced CTs were processed through a Deep Learning pipeline using a foundation model (HepatoSageCT). Logistic and Cox models generated clinical models and combined models integrating the HepatoSageCT scores with key clinical variables for EVs and hepatic decompensation. Performance was assessed using AUROC, sensitivity, specificity, C-index and cause-specific hazard ratios. RESULTS:Portosystemic shunts (PSS) at imaging identified EVs with an AUROC of 0.78, increasing to 0.84 when combined with HepatoSageCT. A decision algorithm incorporating PSS and HepatoSageCT missed 4.2% of varices needing treatment, compared to 8.4% when using only PSS, while missing 0% of large EVs. HepatoSageCT predicted hepatic decompensation in the validation cohort (C-index: 0.73, hazard ratio: 3.17) with significant stratification (p <0.001), comparable to a composite score of ascites, splenomegaly and HepatoSageCT risk (C-index: 0.73, hazard ratio: 3.48). Patients stratified at higher risk of decompensation by HepatoSageCT also exhibited significantly lower overall survival (p <0.001). CONCLUSIONS:HepatoSageCT scores, supplemented with clinical data, enable accurate non-invasive detection of EV in AtezoBev-treated unresectable HCC and stratify patients according to their risk of hepatic decompensation. This approach may reduce unnecessary endoscopies and improve prognostic assessment. IMPACT AND IMPLICATIONS:The present study demonstrates that foundation models applied to routine CT imaging, when combined with routinely collected features such as the presence of portosystemic shunts, can accurately predict the presence of esophageal varices and the risk of first or further hepatic decompensation in patients with AtezoBev-treated unresectable hepatocellular carcinoma. These findings are particularly relevant for hepatologists and oncologists, as they highlight a promising non-invasive tool for timely risk assessment in a time-sensitive patient population. While prospective validation is warranted, this approach could support more personalized management and care of patients with unresectable hepatocellular carcinoma.
BACKGROUND & AIMS:Fibrolamellar carcinoma (FLC) is a rare primary liver cancer that predominantly affects young patients with normal known serum tumor biomarkers. An observation of elevated procalcitonin (PCT) in one patient prompted us to investigate PCT as a biomarker in a larger FLC cohort. METHODS:We measured serum PCT levels in 34 samples from 18 patients with FLC and in 64 patients with hepatocellular carcinoma (HCC), 24 with cholangiocarcinoma (CCA), and 20 with cirrhosis. Using RNA sequencing, we analyzed expression of CALCA, which encodes PCT, in 27 FLC tumors, 331 HCC tumors, 39 CCA tumors, 71 hepatoblastomas, 34 hepatocellular adenomas, and 55 non-tumor liver samples. Spatial transcriptomics was performed on three FLC tumors, and PCT immunohistochemistry was performed on 13 FLC tumors and 34 other primary or secondary liver cancers. RESULTS:In eight patients with FLC from the European cohort, median serum PCT was significantly elevated (55.2 μg/L) compared to patients with HCC (0.14 μg/L), CCA (0.16 μg/L), and cirrhosis (0.11 μg/L; p = 0.0005). These findings were validated in a US cohort of 10 patients with FLC compared to HCC and CCA (p = 0.0002). Across these cohorts, elevated serum PCT was observed in 83% of FLC cases vs. 3% of HCC and CCA cases (p <0.0001). In four patients, changes in serum PCT levels correlated with radiologic response according to RECIST 1.1. RNA sequencing demonstrated significant overexpression of CALCA in FLC compared to other primary liver tumors (p <0.0001), and spatial transcriptomics localized CALCA expression specifically to tumor cells. Immunohistochemistry confirmed PCT overexpression in 77% of FLC tumors but not in other liver cancers. CONCLUSION:Procalcitonin is a sensitive and specific serum biomarker for FLC among primary liver cancers, with potential utility for diagnosis and monitoring of treatment response. IMPACT AND IMPLICATIONS:This study is justified by the lack of reliable serum biomarkers for fibrolamellar carcinoma (FLC) and demonstrates that procalcitonin is specifically overexpressed by FLC tumor cells and detectable in the blood of the patients with FLC. These findings are important for clinicians and researchers, as they identify a readily available biomarker that may facilitate diagnosis, improve disease monitoring, and support clinical trial design in a rare cancer that predominantly affects young patients. In clinical practice, serum PCT measurement could be incorporated as a non-invasive adjunct to imaging for the diagnosis and longitudinal assessment of FLC, although prospective studies in larger and more diverse cohorts are needed to refine diagnostic cut-offs and confirm specificity.
BACKGROUND & AIMS:Disruption of the intestinal barrier facilitates microbial translocation to the liver and contributes to chronic liver disease. We aimed to study the role of the fecal proteome in disease progression in patients with alcohol-associated hepatitis. METHODS:We used fecal proteomics data from a multicenter cohort of patients with alcohol-associated hepatitis (n = 80), alcohol use disorder (n = 20), and controls (n = 19) (InTeam), and a cathepsin B activity assay in an independent multicenter cohort of patients with alcohol-associated hepatitis (n = 80), alcohol use disorder (n = 20), and controls (n = 18) (AlcHepNet). Mice lacking cathepsin B in myeloid cells and transgenic mice overexpressing occludin in intestinal epithelial cells, were subjected to the chronic-plus-binge ethanol feeding model (NIAAA). RESULTS:Fecal proteomics and activity analysis revealed that the protease cathepsin B progressively increased with alcohol use disorder and alcohol-associated hepatitis compared to controls, and is associated with higher short-term mortality in patients with alcohol-associated hepatitis. Cathepsin B is predominantly expressed in intestinal macrophages and is upregulated by ethanol. Cathepsin B deficiency in myeloid cells or oral treatment with the gut-restricted cathepsin B inhibitor CA074 stabilized the gut barrier by preserving the tight junction protein occludin, lowered serum lipopolysaccharide levels, and attenuated ethanol-induced steatohepatitis. Transgenic overexpression of occludin in intestinal epithelial cells sufficed to reduce steatohepatitis and blunted the effects of CA074 in ethanol-fed mice. Cathepsin B proteolytically cleaves occludin in enzymatic assays, and its inhibition prevented occludin degradation and barrier disruption in intestinal organoids and epithelial monolayers. Molecular modeling and peptide profiling reveal specific cathepsin B-induced cleavage sites in the extracellular region of occludin. CONCLUSIONS:Intestinal cathepsin B is an essential mediator of gut barrier dysfunction and a potential therapeutic target in alcohol-associated liver disease. IMPACT AND IMPLICATIONS:Intestinal barrier disruption facilitates microbial translocation to the liver, contributing to the progression of alcohol-associated liver disease; however, the molecular mechanisms driving barrier dysfunction remain incompletely understood. Our study identifies the protease cathepsin B as a key contributor to alcohol-associated liver disease progression by degrading the extracellular region of the tight junction protein occludin in the intestine, thereby leading to barrier disruption. This work advances the field by establishing causality, uncovering the molecular target, and proposing cathepsin B as a promising therapeutic target in alcohol-associated hepatitis - a condition for which liver transplantation remains the only effective treatment in a limited subset of patients.
BACKGROUND & AIMS:Although the liver exhibits remarkable regenerative capacity, expanding hepatocytes in large quantities in vitro without compromising their function remains challenging, presumably due to the absence of key environmental signals. Identifying factors that enable long-term in vitro expansion of hepatocytes is essential for advancing liver research. METHODS:Mouse models of hepatectomy and hepatocyte transplantation were used to identify cytokines involved in liver regeneration. Mouse and human hepatocytes were cultured and passaged in IL-22 medium to assess their expansion ability. Genetic lineage tracing was applied to track the origin of the expanding cells. The function of expanded hepatocytes was evaluated by transplantation into Fah-/- mice. The mechanism of IL-22-mediated proliferation was investigated via transcriptomic analysis and lineage-specific gene deletion. RESULTS:We discovered that IL-22 supports long-term expansion (>30 passages, with a theoretical expansion of ∼1030 times within ∼150 days) of mouse hepatocytes in vitro by dedifferentiating hepatocytes into hepatocyte progenitor cells (HPCs), which retain the capacity to differentiate into mature hepatocytes. The Stat3 pathway is essential in this process. Two key transcription factors downstream of Stat3, Bhlha15 and Arntl2, govern IL-22-induced hepatic dedifferentiation. Expression of these two transcription factors directly initiates the dedifferentiation of hepatocytes into HPCs, which could subsequently be expanded long term without IL-22 supplementation. IL-22 also promoted the growth of human hepatocytes under simple culture conditions; within 30 days, human hepatocytes expanded more than 10,000-fold via dedifferentiation into HPCs that retained maturation capacity. CONCLUSIONS:IL-22 enables large-scale expansion of both mouse and human hepatocytes in vitro by activating the Stat3-Bhlha15/Arntl2 axis. Our discoveries may support future utilization of IL-22 in liver/hepatocyte-related clinical applications. IMPACT AND IMPLICATIONS:Hepatocytes have wide applications in drug development, disease modeling, and cell therapy. However, expanding hepatocytes in large quantities in vitro without compromising their function remains a significant challenge. We demonstrate that IL-22, a unique cytokine primarily mediating localized epithelial repair and cytoprotection without inducing systemic immune activation, enables large-scale expansion of both mouse and human hepatocytes in vitro by activating the Stat3-Bhlha15/Arntl2 axis. Our findings not only bridge the gap between liver regeneration in vivo and hepatocyte growth in vitro, but also support the future utilization of IL-22 in liver/hepatocyte-related clinical applications.
Dual immune checkpoint inhibitors (ICIs) targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4) and programmed cell death-1 (PD-1) or its ligand (PD-L1) have reshaped the treatment landscape of unresectable hepatocellular carcinoma (HCC). However, their clinical uptake remains limited by the high incidence of severe immune-related adverse events (irAEs), underscoring the urgent need for effective prophylactic strategies. Corticosteroids are traditionally viewed as antagonistic to antitumour immunity and have long been prohibited from prophylactic use in ICI-only regimens. Yet this dogma is increasingly at odds with both clinical practice and emerging evidence. Prophylactic corticosteroids (PC) are routinely administered in patients with lung cancer receiving immunochemotherapy, primarily to prevent chemotherapy-related toxicity. In this context, prophylactic corticosteroids have been associated with a reduction in severe irAEs without compromising efficacy. Our preclinical HCC studies demonstrate that corticosteroid premedication does not impair T-cell activation or antitumour activity induced by dual ICI therapy. Emerging clinical data similarly suggest that baseline or concomitant corticosteroid use does not adversely affect oncological outcomes in HCC. In this Expert Opinion, we argue that it is time to rethink the long-standing prohibition of prophylactic corticosteroids in ICI-based treatment. Judicious prophylactic corticosteroid use may offer a practical means to mitigate severe irAEs - particularly in anti-CTLA-4-containing regimens - while maintaining antitumour activity. We advocate for prospective evaluation of prophylactic corticosteroids in ICI-based regimens associated with higher immune-mediated toxicity, to better define their role in HCC.
BACKGROUND & AIMS:At the pre-specified interim analysis (IA; median follow-up, 17.4 months), IMbrave050 met its primary endpoint of improved independent review facility (IRF)-assessed recurrence-free survival (RFS) in patients with high-risk hepatocellular carcinoma (HCC). The RFS hazard ratio (HR) for atezolizumab plus bevacizumab vs. active surveillance was 0.72 (adjusted 95% CI 0.53-0.98; p = 0.012), and overall survival (OS) data were immature. Here, we report an updated post hoc analysis of RFS and the second IA of OS, along with additional data. METHODS:IMbrave050 enrolled patients with HCC who had high recurrence risk following curative-intent resection or ablation. Patients were randomized 1:1 to receive atezolizumab 1,200 mg plus bevacizumab 15 mg/kg intravenously every 3 weeks (17 cycles) or active surveillance for 1 year; patients were eligible to cross over to atezolizumab plus bevacizumab following IRF-assessed recurrence. Stratification factors included geographic region and a composite factor comprising the number of high-risk features, curative procedure, and use of optional adjuvant transarterial chemoembolization (one cycle) post-resection. Secondary endpoints included OS and safety. RESULTS:In the updated analysis, RFS HR was 0.90 (95% CI 0.72-1.12). At the second IA, OS data remained immature (HR 1.26; 95% CI 0.85-1.87). RFS and OS results were consistent across clinically relevant subgroups. Updated safety data were consistent with the primary analysis. CONCLUSIONS:In this updated analysis, the initial RFS benefit seen with atezolizumab plus bevacizumab vs. active surveillance was not sustained and OS data remained immature. The safety profile of atezolizumab plus bevacizumab remained manageable and consistent with that of each agent and the underlying disease. Overall, the benefit-risk profile does not support atezolizumab plus bevacizumab as adjuvant therapy. IMPACT AND IMPLICATIONS:Based on results from the IMbrave150 trial, atezolizumab in combination with bevacizumab is the standard-of-care first-line treatment for unresectable hepatocellular carcinoma (HCC), prompting interest in investigating the combination in earlier treatment settings. IMbrave050 was the first immunotherapy study to report data in the adjuvant setting for HCC, where an early recurrence-free survival benefit was observed at the pre-specified interim analysis but not maintained with longer follow-up; overall survival data remained immature. The updated results of IMbrave050 do not support the use of atezolizumab plus bevacizumab in the adjuvant setting. However, subgroup analyses suggest a potential benefit in select patients, warranting further prospective evaluation. Effective perioperative or adjuvant treatment remains a major unmet need for patients with HCC given the high rate of early post-operative relapse. CLINICAL TRIAL NUMBER:NCT04102098.
BACKGROUND & AIMS:The eastern woodchuck (Marmota monax), which can be naturally infected with woodchuck hepatitis virus (WHV), has served as a model for studying aspects of human HBV infection, including the establishment of chronic infection and progression from chronic hepatitis to liver cancer. However, the cellular landscape of the woodchuck liver and its parallels to HBV infection remain uncharacterized. METHODS:We generated a single-cell and spatial transcriptomic atlas of the woodchuck liver in health and chronic WHV infection, characterizing cell types and infection-associated processes in hepatic tissue (healthy: 52,024 cells; infected: 40,810 cells; n = 8 per group) and peripheral blood mononuclear cells (healthy: 25,314 cells, n = 7; infected: 19,518 cells, n = 8). We further examined shared WHV-HBV disease pathways transcriptionally and assessed woodchuck liver immune responses functionally using PCLS (precision-cut liver slice) stimulation. RESULTS:Using this atlas, we found that hepatic cellular and immune diversity in the woodchuck liver is comparable to that of human livers. Immune cells in PMA/ionomycin-stimulated PCLS exhibited a robust type I inflammatory response, as expected, supporting the accuracy of our cell-type annotations. Our atlas further revealed transcriptional and cellular similarities between WHV- and HBV-infected livers, including periportal dendritic cell activation and a restructuring of the T-cell compartment from memory toward exhaustion during WHV infection, a hallmark of chronic human HBV. CONCLUSIONS:We present a multi-omic atlas of healthy, diseased, and ex vivo-stimulated woodchuck liver. This work identified shared WHV-HBV pathological processes, reinforces the value of this preclinical model, and provides a resource to advance HBV pathogenesis studies and therapeutic development. IMPACT AND IMPLICATIONS:Limited treatment options for liver disease, often culminating in the need for liver transplantation, underscore the requirement for human-relevant animal models to speed up the development of new therapeutic interventions. Woodchucks infected with woodchuck hepatitis virus develop chronic hepatitis and liver cancer, mirroring human HBV infection. However, the cellular composition and active biological processes within the woodchuck liver have remained poorly understood, limiting the model's utility for therapeutic discovery. In this study, we characterize the healthy and chronically infected woodchuck liver at single-cell resolution and compare it with human HBV infection, thereby reinforcing the value of the WHV-infected woodchuck as a model for human HBV disease.
BACKGROUND & AIMS:Alcohol abstinence enables hepatic recompensation in patients with decompensated alcohol-related cirrhosis. This study investigated the incidence, predictors, and impact of abstinence-induced recompensation. METHODS:This multicentre study included patients with decompensated alcohol-related cirrhosis recruited at the time of abstinence up to December 2022. Recompensation was defined by Baveno VII criteria: (i) sustained abstinence (≥3 months), (ii) resolution of ascites and hepatic encephalopathy off therapy, (iii) absence of variceal bleeding for 1 year, and (iv) restored liver function (Child-Pugh A or MELD <10). RESULTS:A total of 633 patients from 17 centres were included (71.7% male; median age 55 years). Alcohol-associated hepatitis superimposed on cirrhosis was present in 40.8%. Median MELD was 19 (13-24), and 47.2% had progressed to further decompensation at abstinence. Median time from index decompensation to abstinence was 0.2 (0.0-7.6) months. Over a follow-up of 36.3 (19.2-63.2) months, 197 patients (31.1%) achieved recompensation (cumulative incidence: 12.3% at 1 year, 23.4% at 2 years, 33.8% at 5 years). Early abstinence (within 1 month of decompensation; adjusted subdistribution hazard ratio [aSHR] 2.042), higher aspartate aminotransferase (aSHR per 10 U/L increase: 1.011) and gamma-glutamyltransferase (aSHR per 10 U/L increase: 1.004) (all p <0.001) increased recompensation likelihood in both supervised and machine-learning models, while the presence of further decompensation decreased it (aSHR 0.650, p = 0.013). During follow-up, 123 patients died (56.1% liver-related). Recompensation was independently associated with lower all-cause mortality (aHR 0.255, p = 0.001). No recompensated patient who remained abstinent died of liver-related causes or developed hepatocellular carcinoma. CONCLUSIONS:Alcohol abstinence enabled hepatic recompensation in approximately one-third of patients with decompensated alcohol-related cirrhosis, particularly when abstinence was achieved early and in the absence of further decompensation. Recompensation was associated with a substantial survival benefit under sustained abstinence, with a negligible residual risk of liver-related death and hepatocellular carcinoma. IMPACT AND IMPLICATIONS:Hepatic recompensation, as defined by Baveno VII, is a novel clinical concept reflecting the potential for disease regression and resolution of decompensating events in patients with cirrhosis once the underlying aetiological factor is removed or controlled. In this multicentre study, sustained alcohol abstinence led to recompensation in one-third of patients with decompensated alcohol-related cirrhosis within 5 years, particularly if abstinence was achieved early and in the absence of further decompensation. Recompensation markedly improved outcomes, with a negligible residual risk of liver-related death and hepatocellular carcinoma when abstinence was maintained. These findings support personalised treatment approaches in decompensated alcohol-related cirrhosis by enabling the identification of patients at risk of progression or with the potential for regression.
BACKGROUND & AIMS:Recent small studies suggest improved hepatocellular carcinoma (HCC)-related outcomes with transarterial radioembolization (TARE) compared with transarterial chemoembolization (TACE), although it is unclear whether this translates into superior transplant-related outcomes. We aimed to compare waitlist outcomes for TARE vs. TACE as first-line locoregional treatment (LRT) for HCC in the contemporary MMaT (median MELD at transplant minus 3) era, with standardized wait times nationwide. METHODS:The study cohort comprised 5,677 adult liver transplant candidates from the United Network for Organ Sharing database who had at least one approved HCC exception between May 14, 2019, and October 3, 2024, and received first-line LRT with either TACE (50.0%) or TARE (50.0%). RESULTS:The TARE group had a slightly higher proportion of patients with solitary initial tumors (76.4% vs. 70.5%) and a slightly larger median largest tumor size, although total tumor burden was similar. A higher proportion of patients in the TARE group received only one LRT (80.6% vs. 57.8%) and achieved complete necrosis on explant (35.3% vs. 20.2%) compared with the TACE group. In inverse probability of treatment-weighted competing risk analysis, TARE was associated with a 22% lower hazard of waitlist dropout (hazard ratio 0.78, 95% CI 0.69-0.89, p <0.001; cumulative incidence at 1 year: 8.9% vs. 11.4%; 2 years: 14.2% vs. 19.0%; 3 years: 16.8% vs. 22.1%), after adjusting for patient and tumor characteristics. CONCLUSIONS:In a large national cohort of liver transplant candidates with HCC, TARE as first-line LRT was associated with higher rates of complete necrosis on explant, lower likelihood of requiring multiple LRTs, and a lower risk of waitlist dropout compared with TACE. IMPACT AND IMPLICATIONS:With nearly all patients with hepatocellular carcinoma in the US now receiving locoregional therapies, a better understanding of the optimal type of locoregional therapy to achieve tumor control and maintain tumor stage within transplant criteria is needed. In this contemporary study of over 5,000 patients using the US national database (UNOS), we show that transarterial radioembolization (TARE) may be the preferred bridging therapy over chemoembolization (TACE), based on a significantly lower probability of waitlist dropout after controlling for liver function and tumor characteristics. Additionally, TARE-treated patients demonstrated higher probability of complete pathologic response and reduced tumor under-staging on explant, which taken together strongly suggests that TARE is a more effective tumor treatment than TACE.
BACKGROUND & AIMS:Bile acid (BA) metabolism plays an important role in the progression of liver cancer; however, the underlying mechanisms remain poorly understood. Hepatic afadin (AF6) is involved in primary BA synthesis, but its role in shaping the tumor microenvironment and immune responses in hepatocellular carcinoma (HCC) is unclear. We hypothesized that an axis involving primary BAs, butyric acid, and CXCL14 contributes to immune regulation in HCC and may inform the development of improved therapeutic strategies. METHODS:A diethylnitrosamine-induced liver cancer model with Af6 knockout was established to investigate alterations in BA synthesis. Hepatocyte-specific Af6 deficiency was used to evaluate BA profiles, gut microbiota composition, and microbial metabolites in HCC models. Mechanistic studies were conducted using murine and patient-derived HCC organoids, combined with single-cell and bulk RNA sequencing. RESULTS:Af6 deficiency increased primary BA levels, altering gut microbiota composition and elevating butyrate production. Butyrate, not BAs, reshaped the tumor microenvironment via enterohepatic circulation, upregulating Cxcl14 expression and secretion. Cxcl14 recruited activated dendritic cells, enhancing CD8+ T-cell cytotoxicity. Hepatocyte-specific Cxcl14 overexpression created a tumor-suppressive immune microenvironment, significantly inhibiting HCC progression. CONCLUSIONS:AF6 modulates primary BA synthesis, driving gut microbiota-dependent butyrate production and Cxcl14-mediated immune remodeling in HCC. This axis highlights a novel mechanism linking BA metabolism, gut microbiota, and immune regulation, offering potential therapeutic targets for liver cancer treatment. IMPACT AND IMPLICATIONS:This study establishes that hepatic Af6 deficiency restrains hepatocarcinogenesis via a bile acid (BA)-driven, microbiota-dependent butyrate-CXCL14 axis. This axis highlights a novel mechanism linking BA metabolism, gut microbiota, and immune regulation, providing potential therapeutic targets for liver cancer treatment. Notably, we describe the first mouse model in which enhanced primary BA production occurs without concomitant alterations in epithelial morphology. This model could provide a valuable platform for investigating BA-associated pathological processes in the gastrointestinal tract, including cancer progression.
The redefinition of steatotic liver disease, including metabolic dysfunction-associated steatotic liver disease (MASLD) and steatohepatitis (MASH), has sharpened the distinction between benign hepatic fat accumulation and true liver pathology. MASLD has a global prevalence of 25-30%, but this should not be regarded as the prevalence of individuals with liver disease requiring diagnosis and treatment, as only a minority will progress to advanced disease with liver-related morbidity or mortality. Steatosis alone is often a phenotype or risk marker for liver disease or cardiometabolic disease - not a disease per se in the conventional sense. Clinically relevant liver disease arises when steatosis progresses to steatohepatitis and fibrosis -conditions identifiable by emerging non-invasive tests or histology. MASH has a substantial global prevalence of around 5%. The risk of adverse liver outcomes in MASLD/MASH is primarily determined by the stage of liver fibrosis (e.g. liver stiffness >10 kPa by elastography), severity of metabolic dysfunction (e.g. type 2 diabetes) and other risk factors (e.g. alcohol, genetics, age and sex). From a therapeutic perspective, this distinction underscores that isolated steatosis warrants primarily cardiometabolic management, whereas both established MASH and MASLD with fibrosis require liver-targeted interventions. Recognising the difference between steatosis (not a standalone liver disease) and MASH/fibrosis (true driver of liver-related risk) enables more precise risk communication, guides targeted surveillance and treatment, and helps to avoid unnecessary alarm and inefficient use of resources in already strained healthcare systems. This paradigm shift supports credible, evidence-based public health strategies focused on metabolic health and fibrosis prevention.
BACKGROUND & AIMS:Single nucleotide polymorphisms (SNPs) in the HBV genome may impact the efficacy of novel drugs for chronic HBV infection. This analysis of the B-Clear study (NCT04449029) evaluated the frequency of baseline and treatment-emergent SNPs in the bepirovirsen binding site and their association with virological response. METHODS:HBV sequencing was attempted for all baseline samples collected from B-Clear participants and for selected post-baseline samples from participants meeting predefined resistance-monitoring criteria. Participants were categorized according to nucleos(t)ide analogue (NA) treatment status and hepatitis B surface antigen (HBsAg) response. SNPs were identified using next-generation sequencing and reported if the allelic frequency was ≥5%. The effects of binding site SNPs on viral fitness and susceptibility to bepirovirsen were assessed in vitro. RESULTS:Baseline sequences were obtained for 40% (90/226) and 96% (219/229) of On-NA and Not-on-NA participants, respectively. Baseline SNPs were identified in 7% (22/309) of participants. These participants showed numerically smaller HBsAg reductions than those without SNPs, but 18% (4/22) achieved transient HBsAg loss. Post-baseline sequences were obtained for 22% (49/226) and 62% (143/229) of On-NA and Not-on-NA participants, respectively. Of 16 post-baseline SNPs, eight were treatment-emergent. SNPs were detected at 12 of the 20 binding site positions; however, only two SNPs had an allelic frequency >50% (C1589A [max 99%] and C1600T [max 99%]). Six SNPs showed sufficient viral fitness to be evaluated for susceptibility to bepirovirsen in vitro. C1589A demonstrated the largest reduction in susceptibility (4.1-fold) to bepirovirsen. CONCLUSIONS:Most participants achieved >1 log reductions in HBsAg, including transient HBsAg loss in some. Although participants with baseline SNPs showed numerically smaller HBsAg reductions, further investigation is required to better understand potential mechanisms of resistance to bepirovirsen. IMPACT AND IMPLICATIONS:HBV sequence polymorphisms can contribute to antiviral resistance in the treatment of chronic HBV infection. Therefore, it is important for healthcare professionals to understand the prevalence and emergence of single nucleotide polymorphisms (SNPs) within the bepirovirsen binding site and their potential impact on virological response. Findings from this phase IIb clinical study demonstrate that the vast majority (92%) of non-responders, partial responders, or relapsers did not harbor bepirovirsen binding site SNPs. Moreover, participants with binding site SNPs (7% of participants) still achieved reductions in hepatitis B surface antigen. These results suggest that routine testing for specific HBV variants prior to bepirovirsen administration is not currently warranted, and that resistance due to altered sequence complementarity is likely minimal and multifactorial. Ongoing phase III studies of bepirovirsen will provide additional context to further evaluate the need for variant testing and to better elucidate potential resistance mechanisms.
BACKGROUND & AIMS:Extended molecular profiling (EMP) is recommended to tailor targeted treatment for advanced cholangiocarcinoma (CCA). However, neither the impact of EMP nor the availability of targeted therapies has been extensively described in a real-world setting. METHODS:ANITA is an observational (retrospective and prospective) study enrolling 621 patients with CCA from 10 tertiary Italian cancer centers between 2017 and 2023. Current analyses are focused on access to EMP, evolving rates of EMP over time, access to targeted treatments and respective outcomes. Moreover, we explore the prognostic and predictive role of major driver molecular alterations. RESULTS:EMP was performed in 79.9% of patients with advanced CCA. The rate of EMP increased significantly over time (2017-2023: +25.8%). Overall, 139 patients harbored ESMO Scale for Clinical Actionability of molecular Targets (ESCAT) I-III alterations, and 18.7% of these patients received matched targeted therapies. No differences were seen in overall survival (OS) and progression-free survival (PFS) according to EMP availability. Patients receiving targeted therapies had the best OS, which was significantly longer than that of patients who did not receive targeted treatments (hazard ratio 0.49, 95% CI 0.28-0.86) or those without EMP available (hazard ratio 0.34, 95% CI 0.21-0.54). Among ESCAT I-III-positive cases, 42 patients had FGFR2 fusions/rearrangements and 59 had IDH1 mutations. After excluding patients treated with targeted therapies, only FGFR2 fusions/rearrangements retained a prognostic association with OS. CONCLUSIONS:Despite the increasing availability of EMP in advanced CCA, patient access to targeted therapies remains suboptimal. Our findings demonstrate that targeted treatments can markedly improve OS. Therefore, strategies to increase access to - and accelerate the availability of - targeted therapies are warranted. IMPACT AND IMPLICATIONS:ANITA is the largest observational, retrospective and prospective, study exploring the impact of molecular profiling and matched targeted treatment in a large cohort of patients with advanced cholangiocarcinoma. While the availability of molecular profiling has increased in recent years, access to targeted therapy is still limited in routine practice. Administration of targeted treatment has a significant impact on overall survival, highlighting the importance of promoting timely and early access to new agents in this disease. CLINICAL TRIAL NUMBER:ESR-21-21387.
BACKGROUND & AIMS:Intercellular orchestration across hepatic and immune lineages governs critical liver development and disease processes. Existing in vitro human liver models limit immune lineage outputs partly due to the lack of an endogenous niche for blood co-development. By modeling a developmental niche, we developed human fetal liver-like organoids (FLOs) harboring a multipotent hematopoietic system to model and study the complex multilineage interaction in liver development and injury. METHODS:We generated FLOs from human pluripotent stem cells to study cross-lineage self-organization by co-developing a hemogenic mesoderm and hepatic endoderm. Hematopoietic progenitor cell and epithelial lineage potential and dynamics were assessed through single-cell and bulk transcriptomics, immunophenotyping, and functional assays. RESULTS:FLOs established a bona fide niche that supports the simultaneous emergence of hepatobiliary, endothelial, and mesenchymal lineages, along with multipotent hematopoietic progenitor cells exhibiting predominant myeloid lineage commitment while retaining the potential for fetal B and T cell differentiation. Within the FLO microenvironment, hepatic and hematopoietic lineages continued to mature in the absence of extrinsic differentiation factors. Enriching hematopoietic derivatives with a small molecule-cytokine cocktail generated divergent immune cell populations, including granulocytes and polarized macrophages equipped with immunoreactive and lineage-specific function. Finally, FLOs mechanistically revealed an IL-8-mediated neutrophil-driven injury response upon steatotic-lipotoxic injury, highlighting key liver-intrinsic immune mechanisms. CONCLUSIONS:FLOs provide a physiologically relevant model for multi-lineage hemato-hepatogenesis and innate immunity in the liver. By recapitulating critical fetal liver tissue functions, FLOs offer a translational platform for studying human fetal liver development, immune-mediated hepatic injury, and regenerative therapies. IMPACT AND IMPLICATIONS:This study establishes a human pluripotent stem cell-derived fetal liver-like organoid (FLO) system that reconstitutes hepato-hematopoietic co-development and innate immune function. FLOs offer a human platform to dissect cross-lineage signaling during liver development and immune-mediated injury. Clinically and translationally, FLOs enable mechanistic modeling of pediatric liver diseases and regenerative interventions, offering a tractable in vitro system for preclinical screening and precision-medicine approaches.
BACKGROUND & AIMS:The use of invasive intracranial pressure monitoring (IICPM) in acute liver failure (ALF) is controversial. The incidence of intracranial hypertension (ICH) in ALF appears to have declined since it was first recognised, and the risk-benefit ratio of IICPM has therefore been questioned. Anecdotal reports suggest that the use of IICPM has fallen significantly in the UK. We investigated trends in IICPM use, the incidence of ICH, and factors associated with ICH and cerebral death (CD). METHODS:This retrospective cohort study collected data on consecutive patients with ALF, admitted to three liver transplant centres in the UK from 2009 to 2018 from prospective audits. Data on the incidence of ICH, CD, the use of IICPM, liver transplantation and hospital survival were collected. Factors associated with ICH and CD were investigated. RESULTS:The incidence of ICH fell over the study period from 13% in 2009 to 3% in 2018 (p <0.001). The use of IICPM fell over the study period from 20.6% of patients admitted in 2009 (n = 13) to 1.4% (n = 1) in 2018 (p <0.001). Hospital survival, liver transplantation and CD did not vary significantly during this period. Peak arterial ammonia concentration was strongly associated with both ICH and CD. CONCLUSION:In three high-volume liver transplant centres, the use of IICPM declined markedly over a 10-year period without an associated worsening of clinical outcomes. These findings suggest that a management strategy focused on early preventive measures without invasive ICP monitoring is a rational approach and does not increase the risk of ICH, CD, or mortality. IMPACT AND IMPLICATIONS:With advances in intensive care supportive management, the incidence of intracranial hypertension as a complication of acute liver failure has declined. Serum ammonia levels remain central to its pathogenesis and risk stratification. Although invasive intracranial pressure monitoring is considered the gold standard for detection of intracranial hypertension, concerns regarding availability, clinical utility, and complications have limited its use. Our findings demonstrate that reduced use of invasive intracranial pressure monitoring was not associated with adverse patient-centred outcomes.
There are many new compounds in development for the treatment of chronic hepatitis B (CHB). Although major on-treatment declines in hepatitis B surface antigen (HBsAg) can be achieved with some of these drugs, achieving sustained post-treatment HBsAg loss with undetectable HBV DNA (functional cure) remains challenging, particularly in patients with high pretreatment HBsAg levels. Interestingly, a substantial proportion of patients in these trials who did not achieve HBsAg loss did maintain low HBsAg levels after withdrawal of study treatments. Based on data from natural history studies and studies on finite treatment with currently available agents, off-treatment sustained low HBsAg levels with low or undetectable HBV DNA levels (referred to as partial cure) is associated with excellent virological and clinical outcomes. In this expert opinion article, we argue that it is important to shift focus from HBsAg loss as the sole endpoint of HBV trials to a more individualised assessment of response that also considers partial cure (defined as off-treatment sustained low HBsAg with undetectable HBV DNA, potentially combined with other biomarkers) as a favourable treatment outcome. Such an approach could increase the number of patients considered responders and, in doing so, potentially extend eligibility for novel therapies to more patients with CHB who may derive significant clinical benefit.
