Background & Aim: Cholestatic liver diseases are heterogeneous conditions and may remain unexplained despite extensive diagnostic work-up. Genetic variants affecting bile acid transport and hepatobiliary homeostasis can contribute to these disorders. We evaluated, in a national multicentre adult cohort, the diagnostic yield of a cholestasis-targeted next-generation sequencing (NGS) panel.Methods: This multicentre, cross-sectional study included consecutive adults from 8 Italian centres with cholestatic phenotypes and no alternative/prior genetic diagnosis: chronic unexplained cholestasis, low-phospholipid–associated cholelithiasis(LPAC), intermittent cholestasis(IC), drug-induced cholestasis(DIC), intrahepatic cholestasis of pregnancy(ICP). Clinical, biochemical, imaging and histological data were captured. A 77-gene cholestasis panel covering PFIC(progressive familial intrahepatic cholestasis) and non-PFIC cholestasis genes, ciliopathies and inborn errors of metabolism was used. Variants were classified per ACMG in pathogenic(P) and likely pathogenic(LP) sub-tiered as variants of uncertain significance(VUS)-cold/warm/hot using the ACGS framework. Genetic diagnosis required P/LP variants consistent with clinical phenotype and inheritance; possible contribution required i)monoallelic P/LP variant in recessive genes ii)ACGS VUS-warm/hot in genes implied in disease pathogenesis.Results: Among 263 patients, clinical phenotype was defined in 235(chronic unexplained cholestasis 74.0%, LPAC 10.2%, IC 7.7%, DIC 5.1%, ICP 3.0%). Cohort characteristics are shown in Tab1.Overall, 417 variants across 74(96.1%) panel genes were identified in 253(96.2%) patients(Fig.1). Among these, 57(13.7%) involved PFIC genes, and 139(33.3%) non-PFIC cholestasis genes. Sixty-four(15.34%) variants were P/LP and 352(84.41%) as VUS. Genetic diagnosis was established in 11 patients(4.2%). A possible contribution to phenotype was identified in 76(28.9%) patients.Of these, 50(67.6%) were attributed to monoallelic P/LP variants in recessive disease genes; 24(32.4%) to ACGS warm/hot VUS in disease-related genes. Among contributing variants, 29(39.2%) involved PFIC genes.Patients with PFIC‐related variants(P/LP and VUS) were more often female(p<0.05) and had higher serum bile acid(p<0.01). LPAC/DIC/ICP phenotypes were more commonly represented in this group(p<0.05), with more frequent MRCP abnormalities and hepatobiliary complications(p<0.01). Pruritus tended to be more common(p=0.055), cirrhosis was less frequent(p<0.05).Conclusions: In this adult cohort with cholestatic liver disease, a targeted cholestasis NGS panel yielded a genetic diagnosis in 4.2% of patients and contributory variants in a further 28.9%. Targeted-NGS informs counselling and follow-up, and contributory variants, especially in PFIC genes, may refine prognosis and management. Systematic reinterpretation and data-sharing may convert a proportion of these contributory findings into definitive diagnoses over time.

Background and Aims: Non-invasive estimation of clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD) is essential for implementing tailored strategies to prevent hepatic decompensation (HD). We aimed to non-invasively predict CSPH using the ANTICIPATE-NASH and NICER models and to stratify the risk of HD in cACLD patients based on these scores.Methods: We conducted a monocentric retrospective observational study including 337 patients with cACLD (defined according to Baveno VI criteria by liver stiffness measurement [LSM] ≥10 kPa) of various etiologies. All patients consecutively underwent vibration-controlled transient elastography (VCTE) with assessment of LSM and spleen stiffness measurement (SSM) between December 2022 and June 2025. The ANTICIPATE-NASH was applied as published: Logit=-3.9529402 + 2.2835809 x ln(LSM) - 0.033777725 x BMI - 0.014490895 x platelets (PLTs). The probability of CSPH = 1 / (1+ e–Logit). The NICER model was applied as published: Logit = -6.40032480 + ln(SSM) × 1.96952565 + ln(LSM) × 1.83093447 – BMI × 0.12882190 – PLT × 0.01850461. HD-free survival probability was assessed using Kaplan–Meier analysis.Results: Among the 337 cACLD patients (23% viral, 22% MASLD, 28% ALD, 7% AIH, 9% PBC, 11% other), 59.6% were male, median age was 65.9 years (IQR 57–74), median BMI 25.7 kg/m² (IQR 22.7–29.7), median LSM 20.1 kPa (IQR 14–33.1), median SSM 40.6 kPa (IQR 27.7–53.1), median CAP 237 dB/m (IQR 202–283), and PLT 147 × 10⁹/L (IQR 103–197). Using ANTICIPATE-NASH, CSPH risk was <25% in 27% of patients and ≥75% in 28%. Using NICER, CSPH risk was <25% in 26% and ≥75% in 41%. During a median follow-up of 12 months (IQR 7–21), 19 patients developed HD and 25 died (10 liver-related, including 3 from hepatocellular carcinoma). Patients who developed HD had significantly higher baseline LSM (38 vs. 19.5 kPa, p=0.001), SSM (51.1 vs. 39.9 kPa, p=0.03), CSPH risk by ANTICIPATE-NASH (89% vs. 50%, p<0.0001), and CSPH risk by NICER (96% vs. 61%, p<0.0001). Stratifying patients according to CSPH risk calculated by ANTICIPATE-NASH, HD probability at 24 months was 2.8% in patients with CSPH risk <75% and 15.7% in those ≥75% (p<0.0001); a combined endpoint of HD or death was reached in 9.7% vs. 27.1% (p<0.0001), respectively. Stratifying patients according to CSPH risk calculated by NICER model, HD probability at 24 months was 2.4% in patients with CSPH risk <75% and 12% in those ≥75% (p=0.001); the probability of reaching the combined endpoint of HD and death was 7.9% vs. 23.9% (p<0.0001), respectively.Conclusion: Integration of LSM, PLTs, and BMI in the ANTICIPATE-NASH model—and the addition of SSM in the NICER model—allows accurate point-of-care non-invasive prediction of HD risk in cACLD patients across different etiologies.

Background-Aim: Primary biliary cholangitis (PBC) is a rare autoimmune liver disease. Epidemiological data in Italy are limited. To address this the Italian PBC Registry was established in 2019 to collect retrospective and prospective data. This study provides an overview of the Registry and its collected data.Methods: The Registry is based on a centralized database collecting demographics, biochemistry, disease stage and treatments. Tests at diagnosis were defined as those performed 3 months before to 30 days after diagnosis; tests at 1 year after UDCA were those performed 11–15 months after treatment initiation. Categorical variables are reported as frequencies (%); continuous variables are reported as mean ± SD or median and interquartile range (IQR). ALP, AST, ALT, GGT are expressed as ratios of their ULN, bilirubin as mg/dL.Results: From 2019 to 2025 enrolment increased from 128 to 3310 (37±22 patients/month). 3199 were analyzed (111 excluded for missing data). The Registry involves 69 active centers, 61 entering data, distributed across Italy (40 North, 9 Center, 20 South/Islands). 2836 (89%) were female with mean age 55.3 ± 12 years, BMI 24.96 ± 4.64, 3067 (96.7%) were Caucasian. Median follow-up was 6.9 years [3.1, 12.6]. 2018 (80.3%) reported no alcohol consumption, 456 (18.1%) consumed < 10/20 g/day (women/men) and 40 (1.6%) consumed >10/20 g/day (women/men). 1724 (70%) never smoked, 423 (17.2%) were former and 315 (12.8%) were current smokers. Optional biological samples (blood, urine, stool, liver tissue) are collected; 13 centers collect blood annually (recruitment/follow-up): 422 patients provided one sample, 116 two and 105 three or more. At diagnosis, among 1840 patients (57.5%) with available tests, the mean values were: ALP 1.59 [1.07, 2.67], AST 1.25 [0.83, 2.10], ALT 1.32 [0.80, 2.18], GGT 3.90 [1.89, 7.49], bilirubin 0.65 [0.50, 0.92] mg/dL. AMA positivity was detected in 1241 (68.5%), while 243 (13.4%) were negative and 328 (18.1%) had not been tested. Liver biopsy was performed in 666 (20.8%) patients and transient elastography in 653 (20.4%) with a median liver stiffness of 6.6 kPa [5.0, 9.1]. After one year of UDCA 809 (25.3%) patients had: ALP 1.11 [0.78, 1.64], AST 0.78 [0.59, 1.06], ALT 0.70 [0.48, 1.10], GGT 1.26 [0.70, 2.78], bilirubin 0.60 [0.44, 0.83] mg/dL. Elevated ALP (>1.67) was observed in 185 (22.9%) patients. However, considering the entire cohort, 923 (28.8%) patients initiated second-line therapy: 429 (46.5%) with Obeticholic Acid (OCA), 277 (30%) with fibrates (bezafibrate/fenofibrate), 163 (17.7%) with combination therapy (OCA and fibrate). Regarding the new PPAR-targeted therapies, 125 (13.5%) patients initiated Elafibranor and 52 (5.6%) initiated Seladelpar.Conclusions: The Italian PBC Registry provides a national picture of PBC, supporting disease monitoring and management. Continued commitment from participating centers will enhance data completeness and strengthen the reliability of future analyses.

PURPOSE:Lifestyle factors (i.e. obesity) worsen infertility in both sexes. Metabolic dysfunction-associated steatotic liver disease (MASLD) in particular and adverse metabolic profile in general seem to be related to infertility, for the relationship with the over-weight and the endocrinological dysregulation as in Polycystic Ovary Syndrome, erectile disfunction and hypogonadism. OBJECTIVES:Deeping metabolic- hepatic disorders (i.e. MASLD) in infertility, with focus on markers of hepatic fat. The aims of this exploratory study are: the analysis of metabolic disturbs and the higher prevalence in infertiles compared to controls; genotype the recruited subjects to evaluate MASLD genetic predisposition in the sample population. METHODS:This is a prospective, case-control study on an Italian cohort of couples. We evaluated in infertile (cases) vs fertile (controls) participants: personal and anamnestic information about health and metabolic disorders through questionnaire, blood data, liver Elastometry, and genetic variants related to MASLD to create a polygenic risk score (TMP6SF2 - rs58542926, GCKRP446L - rs1260326, MBOAT7 - rs641738, PNPLA3 rs738409 and HSD17B13 rs72613567). RESULTS:A total sample of 253 patients was obtained, 213 liver Fibroscan exams were performed, 192 participants underwent in-depth genetic analyses (109 cases vs 83 controls). AST/ALT(index of fibrosis), CAP(for steatosis), and abdominal circumference were increased among infertile patients. , PRS-5 shows an association with the individual status of the subject (to be a case or a control in the study), meaning that high value of PRS-5 could increase the probability to belong to the population at risk (case). CONCLUSIONS:Adverse metabolic profiles could be related to a series of alterations and genetic variants potentially involved in the reduction of couple fertility.

Background: Elafibranor, a dual peroxisome proliferator-activated receptor agonist, has recently been conditionally approved as second-line treatment for patients with Primary Biliary Cholangitis (PBC) and a suboptimal response to ursodeoxycholic acid (UDCA). In this study, we aimed to evaluate the efficacy and safety of elafibranor 80 mg/day in patients with PBC consecutively enrolled in the Italian Elafibranor Early Access Program and who had discontinued Obeticholic acid (OCA) treatment due to revocation of its marketing authorization.Methods: Patients were recruited into the Italian PBC Registry, a multicentre, observational cohort study that includes more than 60 secondary/tertiary centres managing patients with PBC across Italy. The primary endpoint was the median change in alkaline phosphatase (ALP) levels from the beginning of elafibranor treatment until most recent follow up, and the secondary endpoints were: rate of patients with ALP <1,67 the upper limit of normal (ULN), rate of normalization of ALP (≤1x ULN), change in pruritus intensity from baseline as measured on the Worst Itch Numeric Rating Scale (WI-NRS) in those with baseline severe-to-moderate pruritus (WI-NRS ≥4) and the occurrence of Adverse Events (AEs).Results: We included 80 patients whose median age was 60 years, 87% were female, 16% with cirrhosis, 59% with ALP <1.67x ULN and 17% with ALP ≤1x ULN. Median duration of OCA before initiation of elafibranor was 17 (4-93) months; median time between last OCA use and elafibranor initiation was 3 (0-6) months. During a median treatment duration with elafibranor of 6 months (3-9), median ALP significantly decreased from 170 to 119 U/L (p=0.013), and 77% and 46% of patients had ALP <1.67 × ULN and ALP ≤1x ULN, respectively. Among 11 patients who had moderate-to-severe pruritus, 10 improved (91%, median improvement: -4 points). Five patients (6%) prematurely discontinued elafibranor because of gastrointestinal AEs.Conclusion: This real-world experience on the largest cohort reported to date of patients with PBC previously exposed to OCA and treated with elafibranor, suggests that elafibranor is an effective and safe alternative second-line therapy for such patients . Given the relatively short treatment duration of treatment with elafibranor, further evaluation with extended follow-up is warranted.

Background & Aims: Biliary abnormalities in autoimmune hepatitis (AIH) and interface hepatitis in primary biliary cholangitis (PBC) occur frequently, and misinterpretation may lead to therapeutic mistakes with a negative impact on patients. This study investigates the use of a deep learning (DL)-based pipeline for the diagnosis of AIH and PBC to aid differential diagnosis. Methods: We conducted a multicenter study across six European referral centers, and built a library of digitized liver biopsy slides dating from 1997 to 2023. A training set of 354 cases (266 AIH and 102 PBC) and an external validation set of 92 cases (62 AIH and 30 PBC) were available for analysis. A novel DL model, the autoimmune liver neural estimator (ALNE), was trained on whole- slide images (WSIs) with H&E staining, without human annotations. The ALNE model was evaluated against clinico-pathological diagnoses and tested for interobserver variability among general pathologists. Results: The ALNE model demonstrated high accuracy in differentiating AIH from PBC, achieving an area under the receiver operating characteristic curve of 0.81 in external validation. Attention heatmaps showed that ALNE tends to focus more on areas with increased inflammation, associating such patterns predominantly with AIH. A multivariate explainable ML model revealed that PBC cases misclassified as AIH more often had ALP values between 1 x upper limit of normal (ULN) and 2 x ULN, coupled with AST values above 1 x ULN. Inconsistency among general pathologists was noticed when evaluating a random sample of the same cases (Fleiss's kappa value 0.09). Conclusions: The ALNE model is the first system generating a quantitative and accurate differential diagnosis between cases with AIH or PBC. (c) 2024 The Author(s). Published by Elsevier B.V. on behalf of European Association for the Study of the Liver (EASL). This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

INTRODUCTION:Primary biliary cholangitis (PBC) is a rare, chronic autoimmune cholestatic liver disease causing progressive destruction of intrahepatic bile ducts. Predominantly affecting women aged 35 to 70, PBC may remain asymptomatic for years before symptoms such as pruritus, fatigue, or sicca symptoms manifest. If untreated, PBC can progress to cirrhosis, liver failure and need for transplantation, significantly impacting life expectancy. AREAS COVERED:Ursodeoxycholic acid (UDCA) remains the only approved first-line therapy. The recent withdrawal of obeticholic acid (OCA) from the European market, the only available second-line agent since 2016, highlighting the need for alternative options. The recent European Medicine Agency (EMA) approval of new peroxisome proliferator-activated receptor (PPAR) agonists is promising for patients with suboptimal response to UDCA. A literature review was conducted to map the patient journey and examine current treatments. EXPERT OPINION:A panel of Italian expert hepatologists was involved to explore unmet needs along the patient journey and define clinical priorities. Focus areas included response monitoring, treatment evaluation timing, symptoms management - particularly pruritus and fatigue - and care of comorbid and high-risk patients. Many patients live with indolent disease, but some may require a more structured pathway, where emerging treatments can be an important turning point.