BACKGROUND & AIMS:The recent approval of pharmacological therapies for fibrotic metabolic dysfunction-associated steatohepatitis (MASH) has increased the need for accurate identification of treatment-eligible patients. Current recommendations increasingly rely on non-invasive tests (NITs), including vibration-controlled transient elastography (VCTE), while multiparametric ultrasound (MPUS) may provide additional opportunities for non-invasive assessment. However, agreement between histology and imaging-based approaches remains uncertain. We compared treatment eligibility based on histology, VCTE, and MPUS in two international biopsy-proven cohorts of metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS:We analysed two biopsy-proven MASLD cohorts: CAP-IPDMA (n=1029), including VCTE and controlled attenuation parameter (CAP), and iLEAD (n=124), including MPUS. Treatment eligibility was assessed using histologically confirmed F2/F3 MASH and NIT-based recommendations from international expert panels. RESULTS:In CAP-IPDMA, 277/1029 patients (26.9%) met the histological definition of "at-risk MASH". Depending on the VCTE cut-off, 13.2-32.0% qualified for treatment. Overlap between histological "at-risk MASH" and VCTE thresholds was limited, reaching 27.8% when using VCTE 8-15 kPa, and decreasing when narrower or higher thresholds were applied. Among patients identified only by VCTE 8-15 kPa, males had lower median AST and ALT than those fulfilling only the histological indication (35 vs 48 IU/L p=0.034 and 45 vs 62 IU/L p=0.0072, respectively). In iLEAD, 21/124 patients (16.9%) met the histological definition, while 13.7-16.1% were eligible based on SWE thresholds, again with a similarly limited overlap. CONCLUSIONS:Histology and non-invasive tests capture partly distinct patient populations, meaning that both the number and type of patients selected for therapy depend on the chosen modality and cutoffs. As vibration-controlled transient elastography and multiparametric ultrasound become increasingly accessible in clinical practice, prospective validation is essential for establishing reliable non-invasive treatment pathways. IMPACT AND IMPLICATIONS:The current literature reflects a paradigm shift away from biopsy-based approaches toward NIT-based assessment of treatment eligibility in metabolic dysfunction-associated steatotic liver disease (MASLD), which may substantially affect which patients receive newly approved therapies. Our results are important for clinicians, researchers, and guideline developers because histology and current NIT cut-offs identify only partially overlapping patient populations, implying that different diagnostic strategies select different risk profiles. In practice, these findings support thoughtful implementation of NIT-based treatment pathways, the use of repeated measurements, and prospective validation of NIT thresholds to guide clinical care, trial design, and health policy decisions.

BACKGROUND:Alcohol-related hepatitis (AH) is characterised by acute cholestasis and liver dysfunction in patients consuming alcohol. AIMS:To define the bile acid (BA) profile in AH compared to decompensated alcohol-related cirrhosis (DC) and healthy controls (HC). METHODS:Serum and faecal BAs were measured by UHPLC-MS; FGF19 by ELISA; RNA-sequencing data obtained from liver biopsies; serum cytokines and growth factors quantified by multiplex immunoassay. Hepatocyte growth factor (HGF) was applied to primary human hepatocytes (PHH) and BA transporter expression was assessed by RT-qPCR. RESULTS:In two cohorts (Cohort 1: 164 AH, 63 DC, 36 HC; Cohort 2: 94 AH, 175 DC, 72 HC), total serum BAs were highest in AH (median concentration 186.0 μM vs. 64.5 DC vs. 5.0 HC), driven by elevated conjugated primary BAs (182.0 μM vs. 54.0 vs. 2.2). Unconjugated primary BAs were highest in DC. Serum BAs distinguished AH from DC (Cohort 1 AUROC 0.964; Cohort 2 0.922; p < 0.001). Faecal BAs were reduced in AH (0.47 mg/g vs. 1.11 DC vs. 2.64 HC); serum FGF19 elevated (5835 pg/mL AH vs. 865 jaundiced DC [bilirubin > 80 μmol/L]). Serum conjugated BAs correlated negatively with NTCP expression (n = 25, Spearman's rho -0.432, p = 0.031). CYP7A1 was below the limit of detection. HGF was elevated in AH (7899 pg/mL vs. 2607 DC, p < 0.001). HGF treatment reduced PHH BSEP expression. CONCLUSION:Serum conjugated primary BAs accumulate in AH. Elevated HGF may detrimentally affect the hepatoprotective adaptive reduction in NTCP/increase in BSEP seen in cholestasis, contributing to the AH BA profile.

Metabolic dysfunction-associated steatotic liver disease (MASLD) is a chronic condition impacting over 30% population, yet the dynamic changes in macrophage composition from steatosis to steatohepatitis (metabolic dysfunction-associated steatohepatitis, MASH) remain unclear. Here, by integrating single-nucleus transcriptomics, spatial multi-omics and proteomics on human samples, we delineate the evolving landscape of hepatic macrophages across the MASLD spectrum. Our analysis reveals a progressive depletion of Kupffer cells accompanied by the emergence of diverse, phenotypically distinct macrophage subsets. Spatial multi-omics further demonstrates that disease progression toward MASH is marked by an accumulation of antigen-presenting, phagocytic GPNMB+ macrophages, supported by IL32-producing hepatocytes. These macrophages showed an adaptive metabolic and pro-inflammatory phenotype that is tightly regulated by both spatial context and disease stage. Identified macrophage markers enable patient stratification by disease activity and its stage across independent clinical cohorts. Our study sheds light on the diversity of macrophage identities and metabolic-adaptive phenotypes during the progression of MASLD.

BACKGROUND:Normothermic regional perfusion (NRP) has shown superior outcomes in donation after circulatory death, with a low incidence of biliary complications. Not all NRP parameters are unequivocal in supporting transplantation, and further assessment may be required using ex situ normothermic machine perfusion (NMP). Theater and recipient factors may also require extended preservation using NMP. The present study reports our experience with sequential NRP-NMP livers. METHODS:Single-center retrospective analysis of livers undergoing both NRP and NMP, divided into cohorts based on indication for NMP: D-NRP-NMP for donor indications and R-NRP-NMP where the indication was recipient/logistical reason. RESULTS:There were 70 NRP-NMP assessments between May 2017 and August 2024. Sixty-five percent (24/37) of D-NRP-NMP livers and 85% (28/33) of R-NRP-NMP livers were transplanted. Two-thirds of the livers (19/30) failing NRP lactate criteria in the D-NRP-NMP group were transplanted after favorable NMP. Similarly, 60% (9/15) of livers failing NRP alanine transaminase (ALT) cutoff criteria, including 3 livers with ALT >1000 U/L, were successfully transplanted. Collectively, 11 livers (30%) failed both lactate and ALT criteria, with NRP-NMP able to recover 7 (64%) of these livers for transplant. Overall, outcomes of NRP-NMP were satisfactory with 2% primary nonfunction, 23% Olthoff early allograft dysfunction, 56% Kidney Disease Improving Global Outcome acute kidney injury stage ≥2, and 6% nonanastomotic stricture, none requiring biliary intervention. There was no difference in transplant outcomes between the 2 groups, with similar 1- and 3-y patient and graft survival. CONCLUSIONS:NRP and NMP are complementary, with further NMP assessment able to use liver grafts with marginal NRP parameters or facilitating increased preservation time.

INTRODUCTION:Primary sclerosing cholangitis (PSC) may reoccur following liver transplantation (LT), and the diagnosis established once imaging studies demonstrate the diagnostic cholangiographic appearance. To evaluate whether the development of recurrent PSC (rPSC) is associated with cholestasis soon after LT, we studied whether changes in hepatic biochemistry within the first 12 months were linked with the development of rPSC and graft loss. METHODS:We conducted a retrospective cohort analysis of 158 transplant recipients with PSC in Canada and 549 PSC transplant recipients from the United Kingdom. We evaluated serum liver tests within 12 months after LT and the subsequent development of a cholangiographic diagnosis of rPSC as a time-dependent covariate using Cox regression. Severe cholestasis was defined as either alkaline phosphatase > 3x upper limit of normal or total bilirubin > 100 mu mol/L. RESULTS:Patients who developed rPSC were more likely to have severe cholestasis vs those without at 3 months (20.5% vs 8.2%, P = 0.011), at 6 months (17.9% vs 10.0%, P = 0.026), and 12 months (15.4% vs 7.8%, P = 0.051) in the Canadian cohort and at 12 months in the UK cohort (27.9% vs 12.6%, P < 0.0001). By multivariable analysis, development of severe cholestasis in the Canadian cohort at 3 months (hazard ratio [HR] = 2.41, P = 0.046) and in the UK cohort at 12 months (HR = 3.141, P < 0.0001) was both associated with rPSC. Severe cholestasis at 3 months in the Canadian cohort was predictive of graft loss (HR = 3.88, P = 0.0001). DISCUSSION:The development of cholestasis within 3-12 months following LT was predictive of rPSC and graft loss.

INTRODUCTION AND OBJECTIVES:Alcohol-related liver disease (ALD) is a known contributor to non-hepatic cancers (NHC). We aimed to describe the incidence and predictors of NHC in patients with ALD. MATERIALS AND METHODS:The WALDO study is a multicenter cohort study of patients with histologically characterized ALD. Participants are followed from the time of liver biopsy and outcomes are captured from health records. The primary outcome was the incidence of the first NHC. Risk factors for NHC were presented as unadjusted and adjusted sub-distribution hazards (SDH) based on competing risk analysis. Statistical analyses were done in R. RESULTS:694 patients were included. The median age was 51 years (IQR 43- 59), 428 (62 %) patients were male and 349 (50 %) had cirrhosis on biopsy. During a median follow-up of 4.9 years (IQR 1.3 - 9.6 years), 78 patients (11 %) with ALD developed NHC. The cumulative incidence of NHC in ALD was 2.4 % (1.4 - 3.9 %) over five years. The most common site of NHC was respiratory (17 cases, 22 % of NHC) and digestive tract (17 cases, 22 %) and cancers of the head and neck (13 cases, 17 %). On multivariable analysis, increasing age (SDH 1.03; CI 1.00-1.07; p=0.037), previous smoking (SDH 5.11; CI 1.91-13.66; p= 0.001) and current smoking (SDH 3.84; CI 1.50-9.84; p = 0.005) along with cirrhosis (SDH 2.14; CI 1.10 -4.13; p=0.024) were associated with a higher risk of NHC. CONCLUSIONS:NHC's are common in patients with biopsy-confirmed ArLD. Addressing risk factors for NHC's should be encouraged during routine follow-up to reduce the incidence.

BACKGROUND:Alcohol associated liver disease (ALD) is a common condition that is a significant global cause of morbidity and mortality. Diabetes mellitus (DM) increases the risk of adverse outcomes in other types of steatotic liver disease. This retrospective study sought to explore the relationship between ALD and DM. METHODS:The Worldwide Alcohol-related Liver Disease Outcomes (WALDO) study is an international multicenter cohort of patients with biopsy-proven ALD. The presence of DM at baseline or during follow-up was noted. Clinical events after index biopsy were noted, including death and liver-associated clinical events (LACE). Risks for adverse outcomes were assessed with Cox proportional hazard models with DM as a time-dependent variable to reflect periods of time without or with diabetes. All analyses were done in R. RESULTS:In total, 712 patients with a median age of 52 years were followed up for a median of 4.8 years (IQR: 1.2-9.5). At baseline, DM was present in 113 patients (15.9%), and a further 56 patients (7.8%) developed DM in follow-up. During follow-up, 113 patients developed LACE. One hundred fifty-two patients died from liver disease, and 46 underwent liver transplantation. DM was significantly associated with liver-related mortality (HR: 1.77, 1.15-2.73, p=0.009) and incident LACE (HR: 1.90, 1.23-2.95, p=0.004). In multivariable analysis, DM remained significantly associated with liver-related mortality (HR=1.79, 1.30-2.48, p<0.001). CONCLUSIONS:DM is a frequent comorbidity in persons with ALD and is associated with a higher risk of liver-related mortality. Patients' diabetic status should be an important consideration for clinicians treating people with ALD.

Objective Liver transplant guidelines in the UK mandate a minimum of 3 months of abstinence for patients with alcohol-related liver disease. We assessed the outcomes of patients in our region during an admission to hospital with decompensated alcohol-related cirrhosis and in the subsequent, critical, 3 months.Design A network of clinicians and nurse specialists in East Anglia collected prospective data on admissions for this regional service evaluation. We included patients aged 18-70 years admitted with decompensated alcohol-related cirrhosis. Data were collected between 1 February 2023 and 30h April 2023, and outcomes analysed at 3 months post admission.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Results Data were provided for 203 patients from 10 centres. Patients were 59% male with a median UK Model for End-stage Liver Disease (UKELD) score of 57 (range 43-67), 93% having a UKELD >= 49 and 47% having Child Pugh C disease. On admission, 72% of patients were consuming alcohol. Of those, 48% were reviewed by an Alcohol Care Team during their admission and 47% were engaged with alcohol services at 3 months. The relapse rate to alcohol at 3 months was 65%. At 3 months, 10% of the total cohort were transplanted or referred for transplant assessment. Mortality at 3 months was 24%. 47% of the surviving cohort were ineligible for transplant consideration due to ongoing alcohol use. 8% of the cohort had been lost to follow-up.Conclusions In the critical 3 months following an admission to hospital with decompensated cirrhosis, patients experienced high levels of mortality, relapse to alcohol and drop out from follow-up.

BACKGROUND & AIMS:The liver's ability to regenerate is well established, yet the mechanisms involved in chronic liver disease remain to be fully uncovered. Recent animal and human studies showed that transdifferentiation between cholangiocytes and hepatocytes could play a role in this process. Here, we uncover the molecular mechanisms that drive this cellular plasticity in human patients. METHODS:We derived intrahepatic cholangiocyte organoids from the three liver lobes of patients with end-stage metabolic dysfunction-associated steatohepatitis. The resulting organoid lines were differentiated into biphenotypic cells expressing hepatocyte markers mimicking the transdifferentiation process occurring during chronic injury in vivo. We then combined single-nuclei RNA sequencing and single-nuclei ATAC sequencing to uncover molecular pathways and epigenetic regulations required for the in vitro conversion of cholangiocytes into hepatocytes. These analyses led to the identification of transcription factors regulating this process. RESULTS:Our analyses suggest that cholangiocyte plasticity is independent of their liver location and that specific lobes are unlikely to be more regenerative than others. Single-nuclei ATAC sequencing analyses identify the opening of chromatin in intrahepatic cholangiocyte organoids as a mechanism of plasticity, while functional validations reveal that the transcription factor HNF4G could play a key role in the induction of hepatocyte markers. The relevance of these findings was validated against single-nuclei RNA sequencing data from liver biopsies of patients with end-stage metabolic dysfunction-associated steatohepatitis. CONCLUSIONS:Overall, our results confirm that cholangiocytes can transdifferentiate into hepatocytes. This process is promoted by HNF4G, it involves epigenetic remodelling, and is consistent across the three liver lobes. This knowledge paves the way for future therapies aiming to enhance liver regeneration by increasing cholangiocyte plasticity. IMPACT AND IMPLICATIONS:Recent reports proposed the transdifferentiation of cholangiocytes into hepatocytes as the main regenerative process occurring during chronic liver diseases. However, the mechanisms involved remain to be fully uncovered. Our study addresses this knowledge gap in humans. We first showed that cholangiocyte organoids derived from different liver lobes have equivalent capacity to produce cells expressing hepatocyte markers. Furthermore, detailed single-nucleus analyses of transcriptomic and epigenetic signatures in cholangiocytes transdifferentiating into hepatocytes in vitro revealed that this process involves genome-wide chromatin reorganization, confirming that cellular plasticity is closely linked to epigenetic regulation. Finally, these experiments indicated the expression of HNF4G in transdifferentiating cholangiocytes, while functional studies established that HNF4G upregulation is sufficient to increase the expression of hepatocyte markers in cholangiocytes. Thus, manipulating HNF4G expression can act as a potential therapeutic target for promoting liver plasticity and regeneration in end-stage liver disease.