Hepatology Communications

IntroductionFibrolamellar carcinoma (FLC) is a rare primary liver cancer that predominantly affects young patients with normal known serum tumor biomarkers (alpha-fetoprotein (AFP) and CA19-9). An observation of a markedly elevated procalcitonin (PCT) in one patient prompted us to investigate the potential role of PCT as a biomarker in a larger cohort of FLC. MethodsWe measured serum PCT levels in 34 samples from 18 patients with metastatic FLC and in 64 patients with hepatocellular carcinoma (HCC), 24 with cholangiocarcinoma (CCA), and 20 with cirrhosis. Using RNA sequencing, we analyzed CALCA expression, the gene encoding 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 and PCT immunohistochemistry was conducted on 13 FLC and 34 other primary or secondary liver cancers. ResultsIn 8 FLC from the European cohort, median serum PCT was significantly elevated (55.2 {micro}g/l) compared to patients with HCC (0.14 {micro}g/l), CCA (0.16 {micro}g/l), and cirrhosis (0.11 {micro}g/l; P=0.0005). These findings were independently validated in a U.S. cohort of 10 FLC patients compared to HCC and CCA (P=0.0002). Across these cohorts, elevated serum PCT was observed in 83% of FLC cases versus 3% of HCC and CCA cases (P<0.0001). In four patients with longitudinal measurements, changes in 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 but not in other liver cancers. ConclusionProcalcitonin is a sensitive and specific biomarker for FLC at both the serum and tumor levels among primary liver cancers, with potential utility in diagnosis and monitoring of treatment response. Evidence before this studyWe searched PubMed from 01th January 2000 to 03th October 2025 using the terms "fibrolamellar carcinoma", "fibrolamellar hepatocellular carcinoma" "biomarker", "serum", in articles written in English Language. This analysis identified numerous studies describing the clinical, molecular, and histopathological features of fibrolamellar carcinoma (FLC), but none of them have identified a serum biomarker robustly validated for clinical use. FLC is a rare primary liver cancer typically arising in adolescents and young adults with normal liver, and current serum biomarkers used for hepatocellular carcinoma, hepatoblastoma or cholangiocarcinoma (such as alpha-fetoprotein and CA19-9) are systematically normal in FLC. Prior molecular studies have focused mainly on the DNAJB1-PRKACA fusion gene, which is pathognomonic for FLC, but no reliable circulating biomarker has been established for FLC diagnosis or disease monitoring. Added value of this studyOur study identifies procalcitonin as a sensitive and specific biomarker for FLC, both at the serum and tumor levels. Across two independent cohorts, elevated serum PCT distinguished FLC from other primary liver cancers and from cirrhosis with high accuracy. Serum PCT level correlated with radiologic tumor response or progression, suggesting utility for disease monitoring. Transcriptomic analyses demonstrated that the CALCA gene, encoding PCT, is overexpressed in FLC compared with other liver tumors, and spatial transcriptomics localized CALCA expression specifically to tumor cells bearing the DNAJB1-PRKACA fusion gene. Immunohistochemistry confirmed PCT protein expression in most FLC tumors but not in other primary hepatic cancer. These findings establish a novel and readily measurable serum biomarker for FLC. Implications of all the available evidenceTaken together, current evidence indicates that serum PCT is a robust diagnostic biomarker for FLC, distinguishing it from other primary liver cancers and chronic liver diseases. Routine measurement of serum PCT could facilitate earlier recognition of FLC and also provide a non-invasive tool to track treatment response. Future research should validate these findings prospectively, explore the biological mechanisms underlying CALCA overexpression in FLC, and assess whether PCT-guided monitoring can predict prognosis, improve patient outcomes or clinical trial design in this rare malignancy

BackgroundChronic infection with hepatitis C virus (HCV) is a leading cause of liver-related mortality. Direct-acting antivirals (DAAs) have revolutionised treatment by offering profound improvements in sustained viral clearance (SVR) and tolerability resulting in rapid expansion of treatment for individuals for whom HCV treatment had previously been less feasible, such as those with advanced liver disease or with drug and/or alcohol-related substance use. Given these clinical policy shifts, the primary objective of this study was to assess the impact of SVR on liver-related death among important clinical groups and the secondary objective was to explore changes in predictors of liver-related death by treatment era using real-world data from a large population-based cohort. MethodsWe conducted a population-based, linked cohort study of all Ontario residents with HCV viremia between January 1st, 1999, and December 31st, 2018, with follow up to 31st May 2021 (N=73,411). Population-level health administrative, clinical, and demographic data were accessed at ICES. Cause-specific hazard models were used to explore the impact of SVR on liver-related death and to identify factors associated with the rate of liver-related death in the DAA and pre-DAA treatment eras. The moderating effects of liver disease severity and substance-use disorder on the relationship between SVR and liver-related-mortality was explored by stratification. ResultsAmong Ontario residents diagnosed with living with HCV, the achievement of SVR was associated with a significant reduction in liver related mortality (adjusted hazard ratio [aHR] 0.22, 95%CI: 0.20-0.24 vs. no SVR). This was also observed across progressive liver disease severity levels (aHR 0.13, 95%CI: 0.10-0.17 for individuals without cirrhosis; aHR 0.11, 95%CI: 0.06-0.17 for those with compensated cirrhosis, and aHR 0.24, 95%CI: 0.22-0.27 for those with advanced liver disease vs. no SVR) and by substance use status (aHR 0.24, 95%CI: 0.21-0.27 for those with a history of substance use disorder; and aHR 0.21, 95%CI: 0.18-0.24 for those without vs. no SVR). Additionally, factors such as age at diagnosis, sex, liver disease severity, immigration status, birth year, substance use, HBV-coinfection, viral genotype, and markers of social marginalisation were independent predictors of liver-related mortality. However, sex, and viral genotype no longer displayed significant associations with liver-related death in the DAA era as was observed in the earlier treatment era. ConclusionsThis study provides real-world evidence showing profound impact of SVR on liver-related mortality in a population-based sample of individuals with CHC and highlights the importance of early diagnosis and treatment. This study further demonstrates significant mortality benefits of SVR regardless of substance use status highlighting the importance of supporting marginalised individuals in treatment access.

1)Nonalcoholic fatty liver disease (NAFLD) is a common cause of liver disease worldwide, and is characterized by the accumulation of fat in the liver. Nonalcoholic steatohepatitis (NASH), an advanced form of NAFLD, is a leading cause of liver transplantation. Fibrosis is the histologic feature most associated with liver-related morbidity and mortality in patients with NASH, and treatment options remain limited. In previous studies, we discovered that acid ceramidase (aCDase) is a potent antifibrotic target using human hepatic stellate cells (HSCs) and models of hepatic fibrogenesis. Using two dietary mouse models, we demonstrate that depletion of aCDase in HSC reduces fibrosis without worsening metabolic features of NASH, including steatosis, inflammation, and insulin resistance. Consistently, pharmacologic inhibition of aCDase ameliorates fibrosis but does not alter metabolic parameters. The findings suggest that targeting aCDase is a viable therapeutic option to reduce fibrosis in patients with NASH.

BackgroundImmune checkpoint inhibitors (ICI) have revolutionized the treatment of many malignancies in recent years. However, immune-related adverse events (irAE) are a frequent concern in clinical practice. The safety profile of ICI for the treatment of malignancies in patients diagnosed with autoimmune liver disease (AILD) remains unclear. Due to this uncertainty, these patients were excluded from ICI clinical trials and ICI are withheld from this patient group. In this retrospective multicenter study, we assessed the safety of ICI in patients with AILD. MethodsWe contacted tertiary referral hospitals for the identification of AILD patients under ICI treatment in Europe via the European Reference Network on Hepatological Diseases (ERN RARE-LIVER). Fourteen centers contributed data on AILD patients with malignancies being treated with ICI, another three centers did not treat these patients with ICI due to fear of irAEs. ResultsIn this study, 22 AILD patients under ICI treatment could be identified. Among these patients, 12 had primary biliary cholangitis (PBC), five had primary sclerosing cholangitis (PSC), four had autoimmune hepatitis (AIH), and one patient had an AIH-PSC variant syndrome. Eleven patients had hepatobiliary cancers and the other 11 patients presented with non-hepatic tumors. The applied ICIs were atezolizumab (n=7), durvalumab (n=5), pembrolizumab (n=4), nivolumab (n=4), spartalizumab (n=1), and in one case combined immunotherapy with nivolumab plus ipilimumab. Among eight patients who presented with grade 1 or 2 irAEs, three demonstrated liver irAEs. Cases with grades [&ge;] 3 irAEs were not reported. No significant changes in liver tests were observed during the first year after the start of ICI. ConclusionsThis European multicenter study demonstrates that PD-1/PD-L1 inhibitors appear to be safe in patients with AILD. Further studies on the safety of more potent dual immune checkpoint therapy are needed. We conclude that immunotherapy should not categorically be withheld from patients with AILD.

BackgroundMetabolic dysfunction-associated steatotic liver disease (MASLD) is the fastest-growing etiology of hepatocellular carcinoma (HCC). A mechanistic understanding of the metabolic heterogeneity of MASLD-driven tumors is crucial to inform strategies for future treatment options. MethodsPaired tumor (n=8) and adjacent non-tumor tissue (n=8) were collected from patients with steatohepatitic HCC at the University of Kentucky Markey Cancer Center. Hematoxylin and eosin (H&E) staining was used for pathological determination of tumor and adjacent nontumor tissue by a board-certified pathologist. Lipidomic, metabolomic, and transcriptomic analyses were performed, and data were integrated across platforms to identify novel relationships across tumor and adjacent nontumor tissue. ResultsHistological analysis by H&E showed significant lipid vacuole accumulation and inflammatory foci in HCC tumors relative to nontumor tissue. Across omics platforms, we identified 1,679 genes, 1,696 metabolites, and 292 lipids that were significantly (padj<0.01) increased or decreased in tumors relative to nontumor tissue. We identified significant reductions in total ceramides and increases in fatty acyl chain saturation in tumor tissue. Furthermore, metabolites involved in amino acid and fatty acid metabolism were largely decreased in tumors relative to nontumor tissue. We also identified a total of 303 highly significant and novel transcript-metabolite associations (117 gene-metabolite; 186 gene-lipid) across tumor and nontumor tissue. ConclusionsTaken together, this integrative analysis reveals novel relationships between steady-state gene transcripts and specific metabolites in steatohepatitic tumors, thereby identifying new pharmacological targets that may be exploited for therapeutic benefit.

BackgroundLiver transplantation (LT) offers a curative option for early-stage hepatocellular carcinoma (HCC). Its role in intrahepatic cholangiocarcinoma (ICC) remains controversial, with limited comparative evidence on long-term outcomes, especially for early-stage disease. MethodsThis retrospective population-based study utilized the SEER database (2004-2015). Patients with AJCC 6th edition Stage I HCC or ICC who underwent LT were included. Cancer-specific survival (CSS) and overall survival (OS) were primary endpoints. Kaplan-Meier ana lysis, log-rank tests, and Cox proportional hazards regression were used for survival comparison and identification of prognostic factors. ResultsAmong 944 eligible patients, 925 had HCC and 19 had ICC. The 5-year OS and CSS rates were significantly higher for HCC patients (OS: 95.1%; CSS: 97.7%) compared to ICC patients (OS: 82.3%; CSS: 82.3%). Multivariate Cox analysis for HCC identified age and marital status as independent risk factors for OS, and tumor size for CSS. For ICC, only tumor size was associated with OS in univariate analysis; no independent risk factors for CSS were identified due to the small sample size. ConclusionsLT provides excellent long-term survival for patients with early-stage HCC. In contrast, outcomes for early-stage ICC patients after LT are significantly inferior. Prognostic factors differ between the two histological types, underscoring the need for distinct LT selection criteria and management strategies. The findings highlight the limited utility of LT for ICC based on current selection paradigms and emphasize the necessity for larger studies incorporating molecular pro filing to identify potential ICC subpopulations that may benefit from LT.

Background and ObjectivesBariatric surgery is a highly effective obesity treatment, yet it may predispose individuals to alcohol-related liver injury. While altered ethanol metabolism following procedures like Roux-en-Y gastric bypass (RYGB) is well described, the long-term hepatic consequences, particularly the risk of portal hypertension in patients who develop alcohol-related hepatitis (AH,) remain poorly defined. MethodsUsing the TriNetX US Collaborative Network, we identified adult patients diagnosed with AH or alcohol-related cirrhosis. We compared outcomes between patients with a history of RYGB or sleeve gastrectomy (SG) who subsequently developed AH (Bariatric+AH group) and those with AH and no history of bariatric surgery (AH-only group). Propensity score matching was performed on over 44 demographic, clinical, and laboratory variables. Cox proportional hazards models and Kaplan-Meier survival curves were used to estimate the risk of clinically significant portal hypertension (PH) events, liver transplantation, and all-cause mortality at three-, five-, and seven-year follow-ups. ResultsAfter matching, 772 patients were included in each cohort. At 7 years post-index event, the Bariatric + AH group exhibited a significantly higher risk of PH-related complications compared to the AH-only group (HR 1.519; 95% CI, 1.15-2.005; p = 0.003). No significant differences were observed in liver transplantation (HR 1.412; 95% CI, 0.850-2.346; p = 0.181) or all-cause mortality (HR 1.085; 95% CI, 0.904-1.303; p = 0.381). These findings were consistent across all follow-up intervals. ConclusionBariatric surgery is associated with an increased long-term risk of portal hypertension in patients who develop alcohol-related hepatitis despite similar mortality and transplantation rates. These findings underscore the need for targeted postoperative counseling, liver-focused surveillance strategies, and integration of hepatologic risk assessment into metabolic surgery care pathways.

Background & AimsAlterations in the glycosylation of blood proteins affect protein functionality and have been linked to various diseases. Metabolic dysfunction- associated steatotic liver disease (MASLD) is a silent disease, of which progression to advanced disease stages including metabolic dysfunction-associated steatohepatitis (MASH), fibrosis and cirrhosis often goes unnoticed. As current non- invasive diagnostic tests lack specificity, the purpose of this work was to study total blood protein N-glycosylation in individuals with MASLD and various degrees of fibrosis as compared to healthy controls. MethodsIn two independent cross-sectional cohort studies, blood N-glycosylation analysis was performed by mass spectrometry on released glycans of overall 132 MASLD patients and 99 age- and sex-matched healthy controls. Relationships between glycosylation traits and the disease spectrum of MASLD including fibrotic MASLD were investigated in comparison to healthy controls. Furthermore, publicly available transcriptomics datasets were used to explore glycosyltransferase expression in patients with MASLD. ResultsGlobally lower 2,3-sialylation distinguished MASLD from healthy controls (OR [CI]=0.36; [0.18-0.67]; p-value=0.019, and 0.11 [0.04-0.24]; p-value<0.000001), as well as non-fibrotic MASLD from its fibrotic counterparts (OR: 0.13 [0.06-0.26]; p- value<0.0001), but showed no association with steatohepatitis activity. Hepatic ST3GAL6, a sialyltransferase responsible for N-glycan 2,3-sialylation, negatively associated with fibrosis progression, similar to the observed glycomic signature. Both glycomic and transcriptomic signatures were replicated in independent cohorts. ConclusionsFibrotic MASLD is characterized by a global decrease of blood protein 2,3-sialylation and according decrease in hepatic 2,3-sialyltransferase expression, associating with disease progression. These findings suggest alterations in the N- glycan biosynthetic pathway and are potentially useful in the early diagnosis of fibrosis in MASLD. Lay SummaryNon-invasive markers of fibrotic MASLD perform suboptimal. This research identified that changes in blood protein glycosylation coincide with fibrosis development, offering blood-based markers that could potentially replace a liver biopsy. What You Need to KnowO_ST_ABSBACKGROUND AND CONTEXTC_ST_ABSThe majority of the plasma glycoproteins is synthesized in the liver and changes to their glycosylation are known to affect their function and to associate with liver disorders. NEW FINDINGSMASLD patients exhibit lower 2,3-sialylation on the complete range of their blood protein N-glycans, which coincides with the histological appearance of fibrosis, mediated likely via downregulation of hepatic ST3GAL6. LIMITATIONSWhile the findings of this study has could have implications for diagnosing fibrotic MASLD, the identified glycomic signature needs to be confirmed in a larger, ideally prospective patient cohort. CLINICAL RESEARCH RELEVANCEBy identifying specific signatures in the blood protein N-glycome, this research offers potential non-invasive markers for early diagnosis and monitoring of fibrosis in MASLD. Non-invasive diagnosis could potentially lessen the need for liver biopsies, and allow for timely intervention and improved disease management, ultimately leading to improvement of patient outcomes and the reduction of liver-related morbidity and mortality. BASIC RESEARCH RELEVANCEThe observed glycomic and transcriptomic signatures offer molecular-level insights into fibrosis development in MASLD. This paves the way for future research at the intersection of glycoscience and hepatology, that will offer deeper insights into the pathophysiology of this liver disease.

BackgroundLiver failure is a debilitating disease and a major cause of morbidity and mortality. It has a wide spectrum of aetiological factors that lead to different clinical outcomes. Data on the clinical outcomes of liver failure in low income settings are scanty. We set out to evaluate the clinical outcomes and predictors of mortality in liver failure at the main referral and teaching hospital in Zambia. MethodsWe consecutively enrolled patients with liver failure at the University Teaching Hospital, Lusaka, Zambia from May 2020 to May 2021. This was an observational cohort study and patients were prospectively followed up for 30 days or until death. Demographics, clinical findings and laboratory investigations were recorded and summary statistics were used to describe data. Predictors of mortality were determined by Cox regression. ResultsOut of 59 adult patients whom we evaluated, we enrolled 51 patients who fulfilled the inclusion criteria. The mean age was 43{+/-}14 years with 39 (77%) being males. The majority had liver failure whose cause was unknown (27; 53%). Hepatitis B virus was positive in 9 (18%) patients, hepatitis A antibodies were positive in 4 (8%) patients while the antibodies to hepatitis C were positive in 2 (4%) patients. Antituberculosis therapy was suspected to cause liver failure in 9 (18%) patients. Predictors of mortality were low albumin (HR 0.909 [95% CI 0.849-0.973], P=0.006), low neutrophils (HR 0.9928 [95% CI 0.866-0.995], p=0.036), low Karnofsky performance status score (HR 0.417 [95% CI 0.290-0.599], P<0.001), low platelet count (HR 1.002 [95% CI 1.0004-1.00041], P=0.015) and cirrhosis (HR 0.453 [95% CI 0.209-0.979], P=0.044). Mortality rate was 69% (35/51). ConclusionPatients with liver failure had high mortality rate within the 30-day follow-up. Low albumin, neutrophil count, platelet count and low Karnofsky performance status score including cirrhosis predicted mortality.

BackgroundAutoimmune hepatitis (AIH) is a chronic immune-mediated liver disease associated with substantial morbidity and mortality. Diagnosis and monitoring typically rely on liver biopsy, despite its invasiveness and limitations. Liquid biopsies hold potential as non-invasive alternatives, but their utility in AIH remains underexplored. ObjectiveTo evaluate whether plasma-based chromatin immunoprecipitation followed by sequencing (cfChIP-seq) can detect hepatocyte-specific transcriptional activity in AIH and serve as a diagnostic and monitoring biomarker. DesignWe profiled circulating cell-free nucleosomes marked by H3K4me3--a histone modification marking active and poised promoters--in plasma samples from AIH patients (43 pediatric, 49 adult), healthy controls (6 pediatric, 1240 adults), and patients diagnosed with other liver diseases (15 pediatric, 175 adult). ResultscfChIP-seq revealed immune-related hepatocyte transcriptional signatures representing intrahepatic activity unique to AIH patients. RNA-seq of matched liver biopsies further corroborates these findings. A score trained on cfChIP-seq profiles from AIH and metabolically associated steatohepatitis (MASH) patients discriminated liver autoimmune diseases (including AIH) from other liver conditions, including MASH and drug-induced liver injury (DILI), with high accuracy on independent validation cases (AUC = 0.94; 95% CI 0.84-1). Combined with a second cfChIP-seq-based classifier for AIH vs. PSC/PBC, we distinguish between AIH and biliary autoimmune diseases (AUC = 0.92; 95% CI 0.83-1). ConclusionPlasma cfChIP-seq captures hepatocyte disease-specific gene activity in AIH patients and offers a non-invasive, accurate method for diagnosing and monitoring AIH. This approach has the potential to reduce the reliance on liver biopsy, improve diagnostic precision, and provide novel insights into AIH pathogenesis. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSAutoimmune hepatitis (AIH) is a chronic liver disease diagnosed and monitored primarily through liver biopsy, an invasive procedure with associated risks and sampling errors. Non-invasive alternatives are urgently needed but have shown limited disease specificity to date. What this study addsThis study shows that cfChIP-seq,a plasma-based assay detecting gene activity in turned over cells including from liver, can accurately distinguish AIH from other liver conditions. The cfChIP-seq signal in AIH patients reflects intrahepatic immune activity and correlates with findings from liver biopsy. How this study might affect research, practice or policyBy capturing disease-specific intrahepatic disease activity, cfChIP-seq provides positive indication of disease etiology. As such, cfChIP-seq has the potential to reduce the need for liver biopsies in AIH by providing a specific, non-invasive diagnostic tool. Its application in clinical practice could improve patient monitoring, support earlier intervention, and guide personalized management.

BackgroundPrimary liver cancer (PLC) remains a global health challenge. Understanding trends in the disease burden and survival is crucial to inform decisions regarding screening, prevention and treatment. MethodsPopulation-based cohort study using UK primary care data from the Clinical Practice Research Datalink (CPRD) GOLD (2000 to 2021), replicated in CPRD Aurum. PLC incidence rates (IR), period prevalence (PP) and survival at one, five and ten years over the study period were calculated, and stratified by age, sex and diagnosis year. ResultsThe crude IR of PLC was 4.56 (95%CI 4.42-4.70) per 100,000 person-years between 2000 and 2021, with an increase over time across age and sex strata. Sex-specific IR for males was higher than females, 6.60 (95%CI 6.36-6.85) vs. 2.58 (95%CI 2.44-2.74) per 100,000 person-years. Crude PP showed a 7-fold increase over the study period, with PP 0.02% (95%CI 0.019%-0.022%) in 2021, and a 2.8-fold higher PP in males. Survival at one, five and ten years after diagnosis was 41.7%, 13.2% and 7.1%, respectively, for both sexes. One-year survival increased only in men, from 33.2% in 2005-2009 to 49.3% in 2015-2019. ConclusionOver the past two decades, there has been a significant increase in the number of patients diagnosed with PLC. Despite a slight improvement in median and one-year survival in men, prognosis remains poor. To improve the survival of PLC patients, it is necessary to understand the epidemiological changes and address the preventable risk factors associated with liver disease and promote early detection and access to care. LAY SUMMARYThis population-based cohort study shows that the incidence and prevalence of primary liver cancer in the UK has increased in the last 20 years across both sexes and age groups, with a 7-fold increase in crude period prevalence over the study period. One-year survival has improved only in males over the study period and, regrettably, no increases in long-term survival were observed. Our findings are a call for awareness to stimulate further research and public health actions on liver cancer.

Background and aimsTo examine the associations between Steatotic liver disease (SLD), its subtypes (MASLD, MetALD, ALD), fibrosis stages and mortality from a broad spectrum of diseases. MethodsWe analysed 486156 UK Biobank participants. We summarised the causes of death during follow-up, by SLD status and subtypes. Multivariable Cox models estimated associations between SLD, SLD subtypes, FIB4 score, and cause-specific mortality outcomes across ICD10 disease categories. ResultsAmong 178336 participants with SLD, 20766 died over a median follow up of 13.8 years. The leading causes of deaths were neoplasm (46.4%), circulatory disease (24.2%), respiratory disease (7.0%), and digestive disease (4.8%). Compared to participants without SLD (n=307820), those with SLD had significantly higher mortality from neoplasm (HR 1.24 (1.20, 1.28)), circulatory (1.57 (1.50, 1.64)), and digestive disease (1.85 (1.67, 2.05)), as well as from metabolic, and genitourinary diseases, across all FIB4 score levels. Elevated risks were also observed for mortality from diabetes (3.40 (2.59, 4.46))), Covid-19 (1.97 (1.76, 2.21)), myocardial infarction (1.69 (1.53, 1.86)), stroke (1.24 (1.04, 1.48)), and several cancers, such as breast (1.50 (1.35, 1.68)), colorectal (1.22 (1.11, 1.34)), and prostate cancer (1.22 (1.09, 1.37)). SLD subtypes exhibited distinct patterns of cause-specific mortality. ConclusionSLD is associated with increased mortality across a wide range of disease categories, with extrahepatic cancers and circulatory diseases being the primary contributors. These findings underscore the importance of multidisciplinary management strategies targeting liver fibrosis, cardiometabolic burden, and cancer prevention in individuals with SLD. Graphic abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=131 SRC="FIGDIR/small/25342903v1_ufig1.gif" ALT="Figure 1"> View larger version (34K): org.highwire.dtl.DTLVardef@1ee89c0org.highwire.dtl.DTLVardef@195a679org.highwire.dtl.DTLVardef@1e45af3org.highwire.dtl.DTLVardef@10f4503_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundCirrhosis is the main risk factor for the development of Hepatocellular carcinoma (HCC). Six-monthly screening with ultrasound is advocated for the surveillance of cirrhotic patients. We recently showed that a glycomics-based test (GlycoCirrhoTest [GCT]) can provide additional information regarding the risk of HCC development in cirrhotic patients. AimsIndependent clinical validation of the GCT for the assessment of the risk of HCC development in cirrhosis and exploration of additional clinical parameters to assess HCC risk. MethodsValidation study on serum samples of patients with established compensated cirrhosis (CHILD Pugh A & B) in a tertiary liver centre. Serum N-glycan profiling was performed and GCT was calculated at baseline. During the follow up period, patients were screened for the presence of HCC every 6 months with ultrasound. ResultsA total of 198 cirrhotic patients were followed in clinical routine for the development of HCC. 29 patients developed HCC and one died during follow up. At baseline, the mean GCT value was significantly higher in patients who developed HCC within 3 years compared to patients who did not develop HCC (Welchs t-test, p-value 3 years: 0.034). A high GCT at baseline was associated with increased HCC incidence with a HR of 5.8 (95% CI: 0.7 - 48), 4.8 (95% CI: 1.4 - 16) and 3.6 (95% CI: 1.2 - 11) at 3, 5 and 7 years post sampling respectively. Results from this study are in agreement with previous results1, as shown in a meta-analysis. Moreover, we also identified albumin as an independent predictor for developing HCC in a multivariate analysis revealing that low albumin blood levels (< 4g/dL) are also associated with increased HCC incidence with a HR at 7 years of 2.3 (95% CI: 1.1 - 4.9). For subjects with both high GCT and low albumin we found a HR of 9.8 (95% CI: 3.5 to 27) at 7 years. ConclusionsGCT is a glycomics-based test that provides additional information for risk assessment of HCC development in cirrhosis. This information could be used to develop personalised HCC screening programs in cirrhotic patients according to the value of GCT. Serum albumin levels could provide additional and GCT-independent information which may add to the utility of the test.

Background & AimsA cholestatic pattern of liver enzymes is associated with progressive liver disease and major adverse liver-related outcomes (MALO) among patients with Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD). We aimed to authenticate the efficacy of a newly formulated liver function test (LFT) score for distinguishing patients with cholestatic vs. hepatocellular patterns and to evaluate its prognostic utility in MASLD patients. MethodsA retrospective longitudinal study on a dataset of over 250,000 individuals diagnosed with MASLD and/or obesity with cardiovascular risk factors. Patients were categorized into cholestatic (C), mixed (M), or hepatocellular (H) patterns according to the LFT score, or the well-known R score. Long-term MALO, major adverse cardiovascular events (MACE), and all-cause mortality were tracked. ResultsThe LFT score excelled in differentiating patients into C, M, or H groups accurately. While about two-thirds of our cohort initially showed a low FIB4 (<1.3), patients in the C category experienced a higher incidence of MALO and MACE compared to those in the H category (0.5% vs. 0.2% and 7.1% vs. 3.6%, respectively) over the span of 10 years post-diagnosis. Additionally, the 15-year overall survival rate was notably lower for C patients compared to their H counterparts (63% vs. 77%, p<0.0001). The LFT score was more effective than the R score in distinguishing between H and C patients for prognostic purposes, and a baseline cholestatic pattern indicates poorer outcomes regardless of subsequent LFT changes. ConclusionsThe LFT score accurately categorizes cholestatic MASLD patients and may serve as a useful prognostic tool.

IntroductionPost-hepatectomy liver failure (PHLF), driven by insufficient volume and quality of the remnant liver following an operation, is a significant clinical problem that is currently underserved by pre-operative assessment methods. Clinical management and a patients recovery from post-operative liver related complications results in a protracted stay in hospital. Methods91 patients with colorectal liver metastasis being considered for liver resection were recruited onto the Precision1 trial. The imaging report from an additional non-quantitative multiparametric MRI (mpMRI) scan was examined and used to alter surgical decision making. Patient outcomes were monitored and evaluated against a standard of care comparator dataset blinded to mpMRI scan results. ResultsPreviously undiagnosed liver disease activity or elevated liver fat was detected using mpMRI in 23% of patients, whereas the liver health was unexpectedly good in 7% of patients; this resulted in a change to surgical plan in 29% of cases. The incidence of protracted (over 14 days) length of stay was reduced from 5% to 1% following the introduction of mpMRI reports into surgical decision-making process. ConclusionmpMRI is a safe method to evaluate liver health in patients being considered for liver resection. Surgical decision making can be altered to achieve a safer treatment strategy resulting in shorter hospital stays for patients.

BackgroundPrevious research has suggested potential links between amino acids and metabolic dysfunction-associated steatotic liver disease (MASLD), but the precise roles of amino acids in MASLD development are not well understood. This study aimed to obtain insights into the relationships between circulating amino acids and MASLD. MethodsUtilizing data from the UK Biobank, we examined the observational associations of ten amino acids with MASLD in a cohort of 72,626 MASLD cases and 128,102 controls. Bi-directional two-sample Mendelian randomization (MR) was conducted using genome-wide association study data to investigate the causal relationships between amino acids and MASLD. Multiple MR methods comprising MR-Egger and MR-PRESSO were applied to assess pleiotropy and heterogeneity, and multivariable MR was conducted to evaluate the impacts of body mass index (BMI) on these associations. Survival analysis assessed the link between baseline amino acid levels and the risk of major outcomes. ResultsWe identified nine amino acids significantly associated with MASLD in the observational study. The genetic predisposition towards higher leucine (odds ratio (OR) [95% confidence interval (CI)]: 2.1 [1.4, 3.2]), valine (OR [95% CI]: 1.8 [1.3, 2.7]), and alanine (OR [95% CI]: 1.4 [1.1, 1.8]) levels were significantly associated with MASLD. By contrast, the genetic predisposition for increased MASLD risk was significantly associated with phenylalanine (beta = 0.05, p = 4.0x10-4). Further analysis showed that valine may mediate the association between BMI and MASLD, and may also have an exclusive effect on MASLD in addition to the effect of obesity (beta = 1.3, p = 1.9x10-4). Elevated phenylalanine levels in MASLD patients were linked with an increased risk of metabolic dysfunction-associated steatohepatitis (MASH), hepatocellular carcinoma, cirrhosis, heart failure, stroke, and mortality. ConclusionWe found genetic associations between circulating branched-chain amino acids, particularly leucine and valine, and MASLD, independent of obesity. Phenylalanine was identified as a potential biomarker for MASLD prognostic complications. These results highlight the importance of amino acid metabolism in MASLD as well as suggest new possibilities for research and therapeutic intervention.

Background and aimsRare, pathogenic variants can cause severe liver disease, requiring transplantation in childhood, but it is unclear how common variants in the same genes affect adults. Here, we aimed to establish population-level genetic evidence for whether monogenic diseases are associated with liver injury in adulthood. MethodsWe identified 99 genes where pathological mutations cause significant liver disease in children. For each, we used data from over 1.8 million adults to identify associations with biomarkers of liver injury. Observations were validated in multiple cohorts of adults with clinical liver disease and transcriptomics. Finally, we illustrated the importance of the JAG1-NOTCH pathway on the ductular reaction using immunohistochemistry. ResultsMost genes (56% (55/99)) had at least moderate evidence of association with liver-related traits at a population level. We identified 82 genome-wide (p<5x10-8) associations with markers of liver injury in 41% (41/99) of genes. Loss of function variants in these genes had a ten-fold greater effect on liver enzymes and well-established variants in PNPLA3 had a three-fold greater effect. Variants in ABCC2, ASL, BCS1L, HFE, and SERPINA1 were linked with presence of clinical liver disease in adults. Aggregated effects of 35 variants as polygenic risk score (PRS) was associated with 0.6% lower prevalence of MASLD between highest and lowest PRS groups. Transcriptional expression of 30% of genes was associated with severity of MASLD. Expression of JAG1-NOTCH2 pathway was associated with severity of PSC. JAG1 and NOTCH2 were expressed in injured bile ducts but not adjacent unaffected ducts. ConclusionsOnset and severity of liver disease in adulthood is influenced by genes that also cause severe monogenic liver disease in children.

Background & AimsTransarterial chemoembolization (TACE) is the most common treatment for hepatocellular carcinoma (HCC) worldwide; however, response rates and durability vary widely. With the growing armamentarium of therapies for HCC patients, identifying predictors of response to TACE has become increasingly important for a patient population with limited hepatic reserve. We hypothesized that a distinct metabolic phenotype associated with {beta}-catenin pathway mutations render HCC tumors more susceptible to TACE-induced ischemia. Material and MethodsHCC patients referred for TACE were enrolled in a prospective cohort study at two academic medical centers from April 2016 to October 2021. Liver biopsies were acquired at the time of TACE, and mutational profiles were determined using next generation sequencing. Tumor response was determined by MRI using modified Response Evaluation Criteria in Solid Tumors. HCC cell lines with and without B-catenin mutations were grown in standard and ischemic cell culture conditions (1% O2, low nutrient media). Cell viability was measured by WST-1 reagent and Annexin-V PI assay. ATP concentration and metabolites were measured using CellTiter Glo and a YSI biochemical analyzer, respectively. Mitochondrial function was assessed through Seahorse XF Mito Stress Test. Results53 HCC tumors from 50 HCC patients were biopsied prior to TACE, including 22/53 (41.5%) tumors with {beta}-catenin pathway mutations. Despite larger tumor size (4.9 cm vs 3.0 cm p=0.01), tumors with these mutations demonstrated increased rates of complete response after TACE at first imaging (9/22, 40.9% vs 6/31, 19.4%, p=0.06) and best response (12/22, 54.5% vs 7/31, 22.6%, p=0.02), as well as a longer time to tumor progression (median not yet reached vs 8.3 months, p=0.02). In vitro modeling confirmed that {beta}-catenin mutant HCC cells have reduced viability (21.4% vs 59.9%, p<0.01) and ATP levels (8.47 vs 4.26 pM/cell, p<0.001) under ischemic conditions compared to {beta}-catenin wild type HCC cells. {beta}-catenin mutant HCC cells had a dramatic increase in their susceptibility to glycolysis inhibition that was not seen in wild type HCC cells (0.09 vs 0.79 IC50 ration for ischemic vs standard conditions, p=0.004), suggesting a change from predominantly aerobic to anaerobic metabolism under ischemia specific to {beta}-catenin mutant. This was further supported by increased sensitivity of {beta}-catenin mutant cells to inhibition of the electron transport chain (43.9% vs 59.5%, p=0.02,) as well as significantly higher basal oxygen consumption rates (0.74 vs 0.39 pmoles/min, p=0.04), maximal respiratory capacity (1.46 vs 0.51 pmoles/min, p=0.01) and ATP-linked respiration (0.58 vs 0.29 pmoles/min, p=0.04). ConclusionsHCC tumors with activating B-catenin pathway mutations demonstrate a superior response to TACE, driven by enhanced susceptibility to ischemia due to a greater dependence on oxidative phosphorylation for bioenergetic homeostasis. These findings hold the potential to provide a molecular basis for treatment selection in patients with HCC. IMPACT AND IMPLICATIONSWith the growing armamentarium of locoregional and systemic therapies for patients with HCC, identifying predictors of response to individual therapies has become increasingly important for a patient population with limited hepatic reserve. Current treatment guidelines fail to incorporate molecular biomarkers to inform therapy. In a prospective clinical study of HCC patients undergoing transarterial chemoembolization (TACE), we demonstrated that tumors with activating mutations in the Wnt/B-catenin pathway have increased rates of complete response and longer time to local progression. We further characterized this finding in vitro by modeling the post-TACE ischemic environment and demonstrated that B-catenin mutant HCC cells have a distinct metabolic phenotype that renders this subtype more susceptible to ischemia. These findings provide the rationale for genotype-based strategies to enable precision medicine for patients with HCC patients.

ObjectivesThis study assessed the contribution of five genes previously known to be involved in cholestatic liver disease in British Bangladeshi and Pakistani people in the United Kingdom as they are an understudied genetic ancestry group with disproportionate disease burden. MethodsFive genes (ABCB4, ABCB11, ATP8B1, NR1H4, TJP2) were interrogated by low/mid whole exome sequencing data of 5236 volunteers. Included were non-synonymous or loss of function (LoF) variants with a minor allele frequency <5%. Variants were filtered and annotated. Rare variant burden analysis was conducted. Variants associated with a phenotype or predicted to be likely pathogenic (LP) underwent protein structure and modelling analysis in silico. ResultsOut of 314 non-synonymous variants, 180 fulfilled the inclusion criteria and were mostly heterozygous unless specified. 90 were novel and unique to this cohort and not previously reported in the GnomAD database. Of those novel variants, 22 were considered LP and 9 pathogenic. We identified variants in volunteers with gallstone disease (n=31), intrahepatic cholestasis of pregnancy (ICP, n=16), cholangiocarcinoma and cirrhosis (n=2). Fourteen novel LoF variants were identified: 7 frameshift, 5 introduction of premature stop codon and 2 splice acceptor variants. The rare variant burden was significantly increased in ABCB11. A total of 73 variants were assessed for impact at the protein level. Protein modelling demonstrated variants that appeared to likely cause significant structural damage. ConclusionsThis study highlights the significant genetic burden contributing to cholestatic liver disease. Novel likely pathogenic and pathogenic variants were identified addressing the underrepresentation of diverse ancestry groups in genomic research. WHAT IS KNOWNCholestatic liver diseases encompass a broad range of conditions. Intrahepatic cholestasis of pregnancy (ICP) is the commonest gestational liver disease. Genetic and environmental factors contribute to the aetiology of cholestatic disease. South Asian populations are disproportionally affected. WHAT IS NEW HEREExome sequencing analysis in a British Pakistani and Bangladeshi population discovered new genetic mutations. Pathogenic variants were identified that increase risk of cholestatic liver disease. Novel variants that contribute to ICP were identified.

Background & AimsClonal hematopoiesis of indeterminate potential (CHIP) has been linked to chronic liver disease progression, yet its role across the full spectrum of metabolic dysfunction-associated steatotic liver disease (MASLD), from its initial development to end-stage complications, remains unclear. We aimed to comprehensively investigate the association of CHIP and its major subtypes with both the incidence and progression of MASLD. MethodsWe conducted a prospective cohort study of 353,218 UK Biobank participants, stratified into a healthy cohort free of MASLD at baseline (Cohort 1; n=230,270) and a prevalent MASLD cohort (Cohort 2; n=122,948). CHIP was ascertained from whole-exome sequencing data. We used multivariable Cox regression, competing risk models, and mediation analyses to assess the associations of CHIP (overall, by driver gene, and by clone size) with incident MASLD, cirrhosis, hepatocellular carcinoma (HCC), and liver-related death. ResultsIn Cohort 1, CHIP was associated with an increased risk of incident MASLD (HR 1.25, 95% CI 1.08-1.44) and cirrhosis (HR 1.57, 95% CI 1.10-2.25). These associations were driven by non-DNMT3A mutations, particularly TET2, and showed a linear dose-response relationship with clone size. In Cohort 2, non-DNMT3A CHIP was associated with progression to cirrhosis (HR 1.82, 95% CI 1.28-2.58). The associations were more pronounced in males and in individuals without obesity or diabetes. C-reactive protein partially mediated the CHIP-MASLD association. ConclusionCHIP, driven predominantly by non-DNMT3A mutations (particularly TET2) is an independent risk factor for both the development and progression of MASLD. These findings position CHIP as a novel player in the pathophysiology of MASLD and suggest potential avenues for risk stratification and targeted anti-inflammatory intervention. Impact and ImplicationsThis large-scale, prospective study establishes clonal hematopoiesis of indeterminate potential (CHIP) as a novel and independent risk factor for the entire spectrum of metabolic dysfunction-associated steatotic liver disease (MASLD), from its initial development to its progression to cirrhosis and liver-related death. For hepatologists and hematologists, these findings identify a genetically defined, high-risk subpopulation, particularly individuals with non-DNMT3A mutations, who may benefit from enhanced liver surveillance. The identification of systemic inflammation as a partial mediator of the CHIP-MASLD association suggests that anti-inflammatory therapies currently under development for liver disease could represent a targeted treatment strategy for this growing patient population.