Hepatology

Background: Black patients and individuals with low socioeconomic status (SES) face significant disparities in accessing curative therapies for hepatocellular carcinoma (HCC), including liver transplantation. This study aimed to develop provider-co-created intervention prototypes in response to patient-identified barriers and recommendations. Methods: A human-centered design session with hepatology and transplant providers at a large academic medical center was conducted. Prior to the session, participants were presented with barriers and preliminary solutions identified through an earlier human-centered design session with Black and low-SES patients. Using structured ideation methods, including brainwriting, challenge mapping, and concept voting, providers co-created intervention prototypes. Final concepts were synthesized from patient insights, provider input, and design methods using affinity diagramming and concept modeling. Results: Nine providers participated in the session. They focused on three key areas for intervention: inefficiencies in transplant pre-evaluation, inadequate social support, and information overload. Solutions included: (1) a structured triage pathway to standardize referrals and reduce delays; (2) a peer navigator model to guide patients through the transplant process; and (3) a multimodal transplant education roadmap to improve comprehension and engagement. These prototypes addressed both patient- and system-level barriers. Conclusions: Protypes developed through provider-led design, grounded in patient-identified barriers and co-created ideas, can yield actionable, scalable strategies to advance equity in HCC care. Future work will refine these prototypes through patient feedback and pilot them in clinical settings.

BackgroundImmune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by restoring anti-tumor immunity. However, persistent antigen exposure drives T cell exhaustion, limiting the effectiveness of ICIs. Ignorant T cells are antigen-specific T cells that maintain a naive state by regaining stem-like properties, allowing them to remain fully responsive to subsequent immunization. Virus-related hepatocellular carcinoma (HCC) demonstrates superior responses to ICIs compared to non-viral HCC, prompting us to investigate whether immunologically ignorant T cells exist in HBV-associated HCC and represent a promising target for improving immunotherapy outcomes. MethodsSingle-cell RNA sequencing (scRNA-seq) was performed on tumor tissues from patients with HBV-associated HCC. For validation, immunostaining was conducted on the discovery cohort and an independent cohort of 16 non-B non-C HCC and 22 HBV HCC. The enrichment of TIGIT and NECTIN3 in the proposed ignorant T cell was further validated using the TCGA database. ResultsscRNA-seq identified distinct HBV-infected HCC populations and revealed NECTIN3 upregulation in HBV-enriched subsets. CellChat analysis uncovered a novel NECTIN3-TIGIT tumor-immune interaction in HBV-enriched subsets, which shifted toward TIGIT-NECTIN2 as viral transcription declines. Trajectory analysis revealed the emergence of ignorant CD8 T cells following T cell exhaustion. TIGIT-NECTIN2/3 interactions deliver a weak exhaustion signal. This allows T cells to survive and regain naive-like properties as ignorant cells. Integration of bulk RNA-seq data identified CD24, STMN1, and EZH2 as potential biomarkers of ignorant CD8 T cells. ConclusionsTIGIT-NECTIN2/3 interactions present a promising axis for preserving immunologically ignorant T cells and sustaining ICI responsiveness in HBV-associated HCC.

Background and AimsAcute-on-chronic liver failure (ACLF) is associated with high short-term mortality, but substantial heterogeneity among existing diagnostic and prognostic models results in inconsistent patient identification and risk assessment. We conducted a systematic head-to-head comparison of major ACLF diagnostic and prognostic models to evaluate concordance, short-term mortality prediction and clinical utility, with the goal of informing harmonization of ACLF assessment. MethodsWe analysed 3,370 patients with acute decompensation of cirrhosis in the COSSH cohort, with external validation in an independent Ambi-Spective cohort from India (n=2,055). Five ACLF diagnostic models were evaluated for identification of patients at risk of 28-day mortality. Reclassification was assessed using net reclassification improvement. Prognostic scores were compared using concordance index, integrated discrimination improvement, calibration, and decision-curve analysis. ResultsDiagnostic frameworks identified markedly different proportions of ACLF. A-TANGO and COSSH-ACLF classified the largest high-risk populations while maintaining substantial short-term mortality and balanced sensitivity-specificity profiles. Compared with COSSH-ACLF, A-TANGO improved net reclassification by 7.7%, with further gains versus EASL-CLIF (11.8%), APASL-ACLF (36.4%), and NACSELD-ACLF (45.9%). In the external cohort, A-TANGO and COSSH-ACLF showed similar discrimination and identified comparable proportions of patients. Combined application of the two models delineated three clinically meaningful strata, identifying a discordant intermediate-risk group with approximately 11% 28-day mortality. Among prognostic scores, COSSH-ACLF II and A-TANGO OF scores demonstrated strong and complementary performance across cohorts. ConclusionsOutcome-anchored ACLF definitions converge in identifying patients at highest short-term risk across diverse populations. Alignment between A-TANGO and COSSH-ACLF, together with identification of an intermediate-risk phenotype, supports a data-driven framework for improving consistency and advancing global harmonization of ACLF diagnosis and risk stratification.

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 and aimsPopulation screening for liver disease in high-risk groups is recommended. Community diagnosis of liver disease is a challenge due to the asymptomatic nature of disease until very advanced stages. Moreover, regional variation in testing availability can result in people with clinically significant liver disease being missed. Machine learning (ML) has been proposed as a method to reduce diagnostic error and automate screening. We present a novel machine learning derived algorithm (ID LIVER-ML) designed to predict the risk of clinically significant liver disease in a high-risk community population to identify those needing further investigations or specialist referral. MethodsUsing data from 2039 patients recruited to two UK cohorts, we created a parsimonious model using investigations that would be available in primary care using liver stiffness measurement as reference standard. The performance of ID LIVER-ML was compared against FIB-4 score in a second unseen hold out cohort (n=327). ResultsID LIVER-ML performed well at identifying patients at risk of clinically significant liver fibrosis (sensitivity 0.90, Specificity 0.43, PPV 0.54, NPV 0.86, AUC 0.83) and outperformed conventional risk scoring systems (FIB-4: AUC 0.65; NAFLD Fibrosis Score: AUC 0.66; APRI: AUC 0.53; BARD: AUC 0.58). ConclusionMachine learning derived algorithms can help screen high risk populations in a community setting for liver fibrosis. ClinicalTrials.gov ID: NCT04666402 Impact and ImplicationsThe prevalence of steatotic liver disease is rising globally and is an increasingly significant challenge for healthcare systems. Existing risk stratification scores are not validated in a real-world cohort where patients have risk factors for multiple aetiologies of liver disease. Our work shows that a machine learning model can predict the risk of clinically significant liver disease using routine primary care data, better than existing non-invasive risk stratification tools in a real-world cohort. This highlights a potential role for machine learning in the automation of fibrosis risk assessment in primary care. Highlights- Machine learning derived algorithms can predict the risk of clinically significant liver disease in an at risk community population with a mixed aetiology of liver diseases. - The performance of the ML algorithm (ID LIVER-ML) is not affected by metabolic, alcohol, or mixed aetiologies. - ID LIVER-ML outperforms traditional risk stratification scoring systems such as FIB-4 and NAFLD fibrosis scores. - Compared to the FIB-4 score, the use of Machine Learning can reduce the need for secondary care investigations by 59%.

Background Liver fibrosis (LF) represents a pivotal pathological phase in the advancement of chronic liver disorders toward cirrhosis. Amino acid metabolism reprogramming plays a pivotal role in its pathogenesis, yet the underlying molecular mechanisms remain incompletely understood. Methods Integrating three public datasets (GSE14323, GSE84044, and GSE136103) with amino acid metabolism-related gene sets, we performed consensus clustering, machine learning algorithms, functional enrichment analysis, immune microenvironment composition, regulatory network construction, and drug prediction. Results Fibrotic samples were classified into two amino acid metabolism-related subtypes with distinct immune landscapes and functional phenotypes. Through integrated analysis of differentially expressed genes (DEGs) common to both subtypes, fibrotic versus control comparisons, and amino acid metabolism-related gene sets, four biomarkers, GSTP1, LDHB, OXCT1, and PTGDS, were identified. These biomarkers were enriched in pathways related to epithelial-mesenchymal transition, interferon responses, and TNF/NF-{kappa}B signaling. Notably, GSTP1 and LDHB positively correlated with M1 macrophage infiltration and negatively with regulatory T cell abundance. Single-cell transcriptomic analysis revealed that cholangiocytes expressed all four biomarkers with elevated levels in fibrosis and interacted with macrophages/mesenchymal cells via MIF-CD74/CXCR4. Regulatory network analysis highlighted key modulators, including MALAT1, hsa-miR-3163, OXCT1, SMAD4, and RELA. Furthermore, 5-fluorouracil was predicted as a multi-target compound, with the strongest predicted binding affinity for OXCT1. In vitro validation confirmed the upregulation of GSTP1 and LDHB, aligning with the bioinformatics findings. Conclusion This study identified four amino acid metabolism-related biomarkers, revealing immune heterogeneity and cholangiocyte-centered intercellular communication in LF. These findings establish a foundation for biomarker-based diagnosis, subtype-guided patient stratification, and the development of cell-type-specific therapeutic strategies in LF.

Background and AimsHighly aggressive hepatobiliary tumours include gallbladder cancer (GBC), hepatocellular carcinoma (HCC), intrahepatic and extrahepatic cholangiocarcinoma (iCCA, eCCA) and ampulla of Vater cancer (AoV). We aimed to identify plasma biomarkers for the early diagnosis of hepatobiliary cancer by leveraging the metabolomic signatures of established clinical risk factors. MethodBased on 273,190 participants from the UK Biobank, we (1) identified metabolites associated with gallstone-related conditions (e.g. cholecystitis), primary sclerosing cholangitis (PSC) and metabolic liver diseases (e.g. cirrhosis), and (2) evaluated the relationship between the identified metabolites and the risk of GBC, HCC, iCCA, eCCA and AoV. Findings were validated in an independent group of 227,809 participants from the UK Biobank. We also derived metabolomic scores summarizing the three risk-factor signatures and evaluated their ability to stratify cancer risk. ResultsWe identified 27 metabolites associated with gallstone-related conditions, 11 with PSC, and 34 with metabolic liver diseases, some of which showed associations with inconsistent directions across risk factors, suggesting distinct pathogenic processes. Several metabolites were associated with cancer risk in both the discovery and validation datasets, independently of established risk factors, predominantly for HCC (16 signals) and for iCCA (4), with one for GBC and none for eCCA and AoV. Metabolomic scores clearly distinguished individuals at high risk for HCC and iCCA. ConclusionThe preselection of plasma metabolites associated with established risk factors facilitated the subsequent identification and validation of biomarkers for early cancer detection. The identified metabolites suggest specific pathogenic pathways for each type of hepatobiliary cancer. Wider replication is urgently needed to advance toward clinical implementation. What you need to knowO_ST_ABSBACKGROUND AND CONTEXTC_ST_ABSClinical risk factors for hepatobiliary cancers often progress silently, making early identification of high-risk individuals difficult and highlighting the need for biological markers detectable before clinical diagnosis. NEW FINDINGSRisk-factor-based serum metabolomic profiling identified circulating metabolites that predict specific hepatobiliary cancers years before diagnosis, with strongest and most consistent signals for hepatocellular and intrahepatic cholangiocarcinoma. LIMITATIONSClinical risk factors were assumed to be frequently underdiagnosed in UK Biobank, and event numbers were relatively small for some cancers, which may have reduced power and attenuated associations for less common endpoints. CLINICAL RESEARCH RELEVANCEThis study shows that serum metabolic profiles can identify individuals at increased risk for hepatobiliary cancers long before symptoms appear, particularly for hepatocellular and intrahepatic cholangiocarcinoma. These findings support the development of precision risk-stratification strategies that may ultimately enable earlier surveillance. BASIC RESEARCH RELEVANCEBy first identifying metabolites linked to specific liver and biliary clinical conditions, the study clarifies which metabolites are indirectly associated with hepatobiliary cancers through known disease pathways. Testing these metabolites again while adjusting for diagnoses of those conditions then reveals which ones also show direct, pathway-independent associations with individual hepatobiliary cancers, providing clearer insight into cancer-specific metabolic mechanisms.

BackgroundChronic hepatitis B virus (HBV) infection (CHB) affects nearly 300 million individuals globally and remains incurable with current antiviral therapies, which suppress viral replication but rarely achieve functional cure defined by sustained loss of hepatitis B surface antigen (HBsAg). CHB is characterized by profound virus-induced immune tolerance that limits the efficacy of conventional therapeutic vaccination strategies. ObjectiveTo evaluate the therapeutic efficacy and immunological mechanisms of HEPLISAV-B, a CpG-1018-adjuvanted HBsAg vaccine, in breaking immune tolerance and inducing functional cure-like responses in a murine model of CHB. DesignUsing the adeno-associated virus-HBV (AAV-HBV) mouse model, mice with high levels of persistent HBV viremia were vaccinated with two doses of HEPLISAV-B. Virological outcomes in the blood and liver, immune responses and mechanisms were assessed. ResultsHEPLISAV-B induced rapid and durable HBsAg clearance, markedly reduced circulating and intrahepatic HBV DNA and RNA, and suppressed viral replication without hepatocellular injury. Vaccination elicited robust, sustained anti-HBs IgG1 and IgA responses, enhanced HBsAg-specific T and B cell immunity, reduced CD4 regulatory T cells, and decreased PD-1 expression on CD4 T cells. Therapeutic efficacy was strictly dependent on CD4 T cells and the CD40/CD40L signaling pathway, but independent of CD8 T cells, indicating a CD4-driven, non-cytolytic antiviral mechanism critical for HEPLISAV-B induced HBV control. ConclusionHEPLISAV-B effectively breaks HBV-induced immune tolerance and restores coordinated antiviral immunity through a CD4 T cell-/CD40L-dependent pathway. The findings support its potential as a therapeutic vaccine in CHB patients. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSChronic HBV infection is marked by profound virus-induced immune tolerance, current antiviral therapies and vaccines fail to reliably induce HBsAg loss or restore effective antiviral immunity, highlighting the need for immune-based therapeutic strategies. What this study addsThis study demonstrates that the clinically approved vaccine HEPLISAV-B can break HBV immune tolerance in a chronic HBV mouse model, inducing durable HBsAg clearance and anti-HBs immunity, non-cytolytic depletion of intrahepatic HBV DNA, through a mechanism strictly dependent on CD4 T cells and CD40/CD40L signaling. How this study might affect research, practice or policyThese findings defined a CD4 T cell-CD40L/CD40 axis that is critical in CHB functional cure, and support testing HEPLISAV-B as a therapeutic vaccine in CHB patients. O_FIG O_LINKSMALLFIG WIDTH=165 HEIGHT=200 SRC="FIGDIR/small/711721v1_ufig1.gif" ALT="Figure 1"> View larger version (34K): org.highwire.dtl.DTLVardef@1d76f4dorg.highwire.dtl.DTLVardef@cc41cborg.highwire.dtl.DTLVardef@1f39288org.highwire.dtl.DTLVardef@192d0e_HPS_FORMAT_FIGEXP M_FIG Graphical Abstract C_FIG

Background & aimsConstitutive activation of the {beta}-catenin pathway is a determining feature in the pathogenesis of two primary liver cancers, namely HCC and hepatoblastoma (HB). Activating alterations in CTNNB1 gene and, to a lesser extent, inhibiting alterations in APC gene are observed in 30 to 40% of HCC cases and 80 to 90% of HB cases. For both tumours, therapeutic management is far from optimal. Therefore, relevant experimental models are needed to increase our knowledge and test new therapeutic approaches. MethodsOrganoids and tumouroids were established from APC{Delta}hep and {beta}cat{Delta}ex3 mouse models, which are clinically relevant models for {beta}-catenin-activated HCC and mesenchymal HB. We developed a new methodological approach based on a dynamic suspension culture in a rotating bioreactor. Morphological and molecular characteristics and sensitivity to WNTinib, a treatment already successfully tested on human HCC and HB tumouroids, were evaluated by histology, immunohistochemistry, immunofluorescence, and RT-qPCR. ResultsThis easy-to-implement methodology allows for the rapid generation of a large number of organoids and tumouroids that are uniform in size and show no signs of cell death in their core. The robustness of the methodology is illustrated by the maintenance of the histological architecture, cell diversity and gene expression in organoids and tumouroids in comparison with the native liver tissues. In addition, the value of the HCC-derived tumouroids for evaluating cancer treatment was assessed based on their responsiveness to the {beta}-catenin antagonist WNTinib. ConclusionsThe organoids and tumouroids that we present here are new reliable in vitro cancer models, recapitulating the main features of {beta}-catenin-driven HCC and mesenchymal HB. They can be integrated into an appropriate platform for drug screening and could enable the development of "a la carte" therapies that are urgently needed for these indications. Impact and implicationsThis study addresses the critical need for representative in vitro models to investigate {beta}-catenin-driven liver cancers. The organoids and tumouroids developed here are particularly valuable for researchers seeking robust, reproducible models that accurately reflect the cellular diversity and gene expression profiles of native liver tumours. These findings have practical applications in exploring cancer mechanisms, screening new drugs, optimizing personalized treatment strategies, and reducing reliance on animal models, which ultimately benefits patients. HighlightsO_LIEasy and rapid generation of mouse liver organoids and tumouroids from {beta}-catenin activated tumours using culture in a bioreactor C_LIO_LITumouroids preserve histology, cell diversity, and gene expression of native tissue C_LIO_LIHCC-derived tumouroids respond to {beta}-catenin inhibitor WNTinib C_LIO_LIThese reliable 3D models reduce reliance on animal experiments for drug testing C_LI

Background & AimsRare cases of non-hepatotropic virus (NHV) infection in humans can cause severe hepatitis and even acute liver failure. Clinically relevant animal models of NHV-induced hepatitis are limited, contributing to the incomplete understanding of pathological mechanisms. Murine norovirus (MNV) elicits hepatosplenomegaly in mice lacking the antiviral immune effector Signal Transducer and Activator of Transcription-1 (STAT1), providing a model to investigate mechanisms of NHV-induced hepatic pathology. MethodsSTAT1-sufficient and -deficient (Stat1Het, Stat1KO) littermates infected intravenously (i.v.) with MNV strain CR6 were assessed for hepatic inflammation and viral burden. Cell types and molecular pathways associated with hepatic pathology in CR6-infected Stat1KO mice were identified by flow cytometry and RNAseq of liver tissue. The relative importance of hematopoietic vs non-hematopoietic expression of STAT1 in restricting CR6 replication and maintaining tissue homeostasis was assessed in bone marrow chimeras. ResultsMNV CR6 Stat1KO mice developed severe hepatitis with patchy hepatocellular necrosis and localized enrichment of CR6-infected myeloid cells, particularly macrophages. Gene set enrichment analysis (GSEA) of hepatic biopsies isolated from CR6-infected Stat1KO mice suggested dysregulated myeloid cell activation and indicated similarities between murine and human hepatic pathologies. STAT1 expression in hematopoietic cells was protective against hepatic viral dissemination, but hematopoietic STAT1-deficiency permitted persistent hepatic MNV infection, facilitating dysregulated myeloid cell activation and hepatic fibrosis. ConclusionsThese results demonstrate that the role of STAT1 extends beyond restricting MNV dissemination and suggest that STAT1-dependent regulation of myeloid cell activation prevents acute hepatic necroinflammation and secondary fibrosis. This model of MNV-induced hepatitis may prove valuable in elucidating mechanisms of rare clinical complications. SynopsisMechanisms driving acute hepatitis caused by non-hepatotropic viruses are not well understood. We describe a model of non-hepatotropic murine norovirus infection that reliably induces liver pathology and identify a requirement for STAT1 expression in myeloid cells to promote antiviral immunity and hepatic tissue protection. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=81 SRC="FIGDIR/small/720966v1_ufig1.gif" ALT="Figure 1"> View larger version (24K): org.highwire.dtl.DTLVardef@4ef59forg.highwire.dtl.DTLVardef@1dfac58org.highwire.dtl.DTLVardef@1abe41dorg.highwire.dtl.DTLVardef@d59e9_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background and AimsSteatotic liver disease (SLD) is characterized by excessive lipid accumulation in hepatocytes, and alcohol consumption may modify the disease course, but the evidence is inclusive. This systematic review and meta-analysis aimed to holistically evaluate the impact of mild, moderate, and high levels of alcohol consumption on hepatic and extrahepatic outcomes in SLD. MethodsWe systematically searched EMBASE, MEDLINE, Web of Science, and the Cochrane Central Register of Controlled Trials for relevant studies. The study outcomes included liver related events, malignancy, mortality and cardiovascular disease among adults with SLD who consumed alcohol. ResultsOf 2228 records identified, twenty-six studies comprising 466611 adults with SLD were included. High alcohol consumption was associated with an increased risk of liver-related events compared with abstinence (2.97, 95% CI 1.61-5.50; p<0.001), and a similar association was observed among alcohol drinkers overall (HR 1.93, 95% CI 1.60-2.33; p<0.001). Moderate alcohol consumption was associated with a higher incidence of malignancy (HR 1.41, 95% CI 1.13-1.78; p=0.677). In contrast, mild alcohol consumption was associated with lower all-cause mortality compared with abstinence (HR 0.88, 95% CI 0.78-0.98; p=0.001). No association was observed between alcohol consumption and cardiovascular disease incidence or hepatocellular carcinoma ConclusionsAlcohol intake may increase the risk of liver-related complications and cancer risk in individuals with SLD. Mild alcohol consumption was associated with lower all-cause mortality, and alcohol intake showed no association with cardiovascular disease incidence. Further studies are needed to clarify the dose-dependent effects of alcohol on hepatic and extrahepatic outcomes in SLD.

Hepatocellular carcinoma (HCC) remains a leading cause of cancer-related mortality worldwide. Current treatments offer limited efficacy and no definitive cure, underscoring the urgent need for more selective and effective therapeutic strategies. This study investigated the synthetic lethality caused by co-targeting two metabolic genes, ATP citrate lyase (ACLY) and oxoglutarate dehydrogenase (OGDH), in HCC cells. Using valproic acid (VPA) and bempedoic acid (BA) as pharmacological inhibitors of OGDH and ACLY, respectively, we observed a strong synergistic effect in inhibiting the proliferation of HCC cell lines (Hep3B and Huh7), compared to using these drugs individually. Importantly, this combination treatment exhibited little increased cytotoxicity in the non-cancerous liver cell line THLE-2, indicating a degree of selectivity. Our findings are consistent with previous reports implicating USP13 as a metabolic regulator of ACLY and OGDH in various cancers, suggesting that the inhibition of USP13 may prevent HCC cell proliferation primarily through its downstream effects on ACLY and OGDH. By directly co-targeting ACLY and OGDH, our approach may offer a more precise and safer alternative to USP13 inhibition. Additionally, while both VPA and BA have been individually associated with beneficial effects in liver disease, their combined application in the context of HCC has not been previously investigated. Limitations include the reliance on cell line models, highlighting the need for validation in more physiologically relevant systems such as human organoids and animal models. Overall, this study provides a compelling rationale for further investigation into ACLY and OGDH as a synthetic lethal pair and the therapeutic potential of the VPA-BA combination treatment in HCC.

Background and AimsA major goal of personalised liver oncology is the ability to make targeted predictions about cancer-specific toxicity, however there are limited methods available. To address this, we validated the performance of our bioinformatics framework, TARGET-SL, through ex vivo drug screening. MethodsUsing TARGET-SL we predicted gain of function (GOF), loss of function (LOF) and synthetic lethal (SL) genetic events, and corresponding drug candidates. We validated drug predictions across hepatocellular carcinoma (HCC) cell lines, and a cohort of HCC and cholangiocarcinoma (CCA) patient-derived organoids (PDOs). ResultsFor HCC cells and PDOs we found 37.5% and 25% of the respective selected compounds induced unique target-specific growth inhibition based on genetic biomarkers, suggesting novel biomarker-driven drug sensitivities. ConclusionsOur analyses demonstrate TARGET-SLs potential to enhance personalized drug screening for liver cancer, by focusing on genetically informed targets. This will reduce experimental costs and accelerate the pace of therapeutic discovery. Impact and ImplicationsPrimary liver cancer (PLC) is a cancer with poor prognosis, and current therapies increase survival only for a minority of patients. Through the application of TARGET-SL we can predict, for each patient, the essential genes and corresponding small molecule inhibitors. These data support further investigation in larger patient cohorts and offer the possibility to specify new small molecule inhibitors and to repurpose current drugs for PLC treatment. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=81 SRC="FIGDIR/small/725819v1_ufig1.gif" ALT="Figure 1"> View larger version (28K): org.highwire.dtl.DTLVardef@10cb252org.highwire.dtl.DTLVardef@8f3049org.highwire.dtl.DTLVardef@ab4467org.highwire.dtl.DTLVardef@17f9d3_HPS_FORMAT_FIGEXP M_FIG C_FIG HighlightsO_LITARGET-SL can predict gene and drug sensitivities for cell lines and patient-derived organoids C_LIO_LIThis may reduce drug screening costs and accelerate the pace of therapeutic discovery. C_LIO_LITARGET-SL may assist in the repurposing of current drugs and their rapid translation for primary liver cancer C_LIO_LITARGET-SL is tumour-type agnostic, and therefore may have application in other cancers with poor prognosis C_LI

Background & Aims: ACLF is defined differently by APASL (acute hepatic dysfunction) and by organ failure-based frameworks including EASL-CLIF and the recently developed A-TANGO score. Whether these definitions identify competing populations or sequential stages of the same syndrome remains unresolved, with direct implications for the timing of intervention. We tested whether APASL-defined ACLF can be integrated into the A-TANGO framework to identify a clinically actionable patient population. Methods: 4,024 patients hospitalised with acute decompensation of cirrhosis in a multicentre cohort were classified simultaneously by APASL and A-TANGO criteria. Mortality, progression to A-TANGO ACLF among A-TANGO-negative patients, and reversal of ACLF were assessed using Fine-Gray competing-risk models with death as a competing event. EASL-CLIF analyses were performed as sensitivity analyses. Results: A-TANGO-negative/APASL-positive patients comprised 8.7% of the cohort and had higher 90-day mortality than A-TANGO-negative/APASL-negative patients (22.3% vs 14.4%, p=0.001), despite similar 28-day mortality. Once A-TANGO ACLF was established, 28-day mortality was high irrespective of APASL status (45.4% in APASL-positive and 56.0% in APASL-negative patients). Among A-TANGO-negative patients, 53.5% of APASL-positive vs 27.9% of APASL-negative patients progressed to A-TANGO ACLF within 28 days, with APASL positivity independently predicting progression (adjusted sHR: 2.30, 95%CI: 1.90-2.77). Within A-TANGO-negative/APASL-negative patients an A-TANGO OF score [&ge;]8 independently enriched for progression (52% vs 19%). A-TANGO reversal occurred in 17.1% and was independently reduced by APASL positivity (adjusted sHR: 0.756, 95%CI: 0.586-0.975), while APASL reversal was rare (4.0%). EASL-CLIF sensitivity analyses were directionally consistent. Conclusions: APASL-defined ACLF does not compete with A-TANGO; it occupies an upstream position on the same disease trajectory. A-TANGO-negative/APASL-positive patients and A-TANGO-negative/APASL-negative patients with A-TANGO OF [&ge;]8 represent complementary pre-ACLF populations suitable for prevention trials and enrichment strategies.

Background and aimsTherapeutic outcomes for advanced hepatocellular carcinoma remain inadequate, despite recent advances using immunotherapy. Long-term effectiveness of systemic therapies, including second-line multi-tyrosine kinase inhibitor sorafenib, is limited by resistance mechanisms and adverse effects. Upregulated deubiquitinase UCH-L1 is frequently correlated with poor prognosis in cancers. Here, we investigated the therapeutic potential of combining pharmacological UCH-L1-inhibition with sorafenib in HCC. MethodsUCH-L1 expression was analysed in TCGA-LIHC data and patient-derived HCC tissues. Sorafenib and LDN57444 effects were evaluated in vitro in cytotoxicity and invasion assays. Gene and protein expression were examined by RT-qPCR, Western blotting and immunohistochemistry. In vivo efficacy of drug synergy was assessed in an orthotopic xenograft mouse HCC model. ResultsIn silico data-analysis revealed significantly higher UCH-L1 levels in patient HCC tumours versus non-tumour, associated with reduced overall survival. Low-dose sorafenib upregulated UCH-L1 in HCC cell line Hep3B. Paradoxically, this also promoted invasiveness and sustained MEK1/2-ERK1/2-pathway activation. Combining low-dose sorafenib with LDN57444 produced strong synergistic cytotoxicity in vitro, reverted MAPK-activation and suppressed invasion. Consistently, at low sorafenib dose co-treatment with LDN57444 completely inhibited tumour growth of Hep3B xenografts and enhanced sorafenib efficacy. ConclusionLDN57444 sensitises HCC cells to low-dose sorafenib by reverting drug-induced pro-oncogenic signalling and thereby strongly synergises with sorafenib to enhance anti-tumour efficacy in a HCC mouse model. This presents UCH-L1 as a player in treatment-induced adaptive response and supports further exploring UCH-L1-targeting in combination with sorafenib as therapeutic avenue for advanced HCC. O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=144 SRC="FIGDIR/small/725527v1_ufig1.gif" ALT="Figure 1"> View larger version (37K): org.highwire.dtl.DTLVardef@176dc91org.highwire.dtl.DTLVardef@8acae8org.highwire.dtl.DTLVardef@f71bborg.highwire.dtl.DTLVardef@1f3c5aa_HPS_FORMAT_FIGEXP M_FIG C_FIG Lay summaryThis study explores a new treatment approach for hepatocellular carcinoma (HCC) by combining two drugs: LDN57444, which blocks the enzyme UCH-L1, and sorafenib, a FDA-approved multi-tyrosine kinase inhibitor. We evaluated the effect of this drug combination in vitro using a HCC cell line and in an mouse HCC-model. The drug combination displayed strong, synergy in lowering HCC cell viability, and greatly reduced invasiveness and in vivo tumour growth. LDN57444 sensitised HCC cells to low doses of sorafenib by preventing UCH-L1-mediated activation of pro-oncogenic signalling. These findings highlight the potential of this new drug combination for treating advanced HCC thereby potentially reducing side-effects and countering drug resistance. Impact and implicationsOur preclinical research introduces a novel combination strategy against advanced HCC that holds potential to improve existing therapies, particularly the second-line multi-tyrosine kinase inhibitor sorafenib. The proposed combination of sorafenib with an inhibitor of the deubiquitinase UCH-L1 not only enhances sorafenib efficacy but present promise to also counter resistance mechanisms. Moreover, because effective responses are achieved at lower drug doses, this may in addition reduce therapy-associated adverse effects further increasing potential impact. While sorafenib is FDA-approved, the UCH-L1 inhibitor LDN57444 needs further (clinical) development to bring our promising findings to full translational potential for HCC patients and physicians.

Background & AimsBulevirtide, a viral entry inhibitor used to treat chronic hepatitis delta virus (HDV) infection, targets the hepatic bile salt transporter Na+-Taurocholate Co-transporting Polypeptide (NTCP). As Bulevirtide displays preclinical potential to mitigate cholestatic liver injury, NTCP inhibition is currently explored as treatment for primary sclerosing cholangitis (PSC), a condition frequently associated with colitis. Here, we investigated the immunomodulatory effects of Bulevirtide in lipopolysaccharide (LPS)-induced inflammation and dextran sodium sulfate (DSS)-induced colitis in mice. MethodsThe immunomodulatory properties of the bile salt taurochenodeoxycholic acid (TCDC) were investigated in LPS-challenged mouse bone marrow-derived macrophages (BMDM) and human BLaER1 macrophages. The therapeutic efficacy of Bulevirtide against LPS-induced inflammation and DSS-induced colitis was evaluated in Slco1a/1b-/- FVB and C57BL/6J mice, which recapitulate human bile salt dynamics. ResultsIn BMDMs, TCDC reduced pro-inflammatory tumor necrosis factor alpha (TNF), increased anti-inflammatory interleukin (IL)-10, and suppressed inflammasome activation, as evidenced by reduced IL-1{beta}, IL-18 and cleaved-IL-1{beta} levels. Consistently, TCDC also reduced TNF and IL1B expression in human BLaER1 macrophages. In both FVB and C57BL/6J Slco1a/1b-/- mice, Bulevirtide increased plasma bile salt levels at least 30-fold. This systemic elevation of bile salts reduced plasma TNF and increased IL-10 in LPS-treated mice. Moreover, Bulevirtide attenuated DSS-induced colitis, evidenced by reduced disease scores and reduced intestinal Tnf expression. ConclusionThese findings highlight the anti-inflammatory effects of bile salts in preclinical models of colitis and support NTCP inhibition as a future therapeutic strategy to ameliorate both cholestasis and colitis in PSC. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=173 SRC="FIGDIR/small/719641v1_ufig1.gif" ALT="Figure 1"> View larger version (28K): org.highwire.dtl.DTLVardef@38efbeorg.highwire.dtl.DTLVardef@3e09borg.highwire.dtl.DTLVardef@8f1262org.highwire.dtl.DTLVardef@100179c_HPS_FORMAT_FIGEXP M_FIG C_FIG SynopsisInhibition of the Na+-Taurocholate Co-transporting Polypeptide using Bulevirtide induces systemic bile salt elevation and mitigates acute inflammation and colitis in mice. These findings support clinical evaluation of Bulevirtide in primary sclerosing cholangitis with protective effects against cholestasis and colitis.

Bile represents a clinically accessible biological fluid that can mitigates major limitations associated with tissue-based sampling for the generation of organoid models to study hepatobiliary disease, including biliary tract cancers where tissue availability is often limited. Importantly, bile can also enable the generation of non-malignant cholangiocyte organoids that are otherwise difficult to obtain. Here, we describe an operator-oriented, step-by-step protocol to generate organoids from fresh bile collected during endoscopic retrograde cholangiopancreatography (ERCP), together with two complementary workflows for siRNA delivery in 3D cultures. We detail critical control points that are often under-reported, yet considerably influence success and reproducibility. The protocol was optimized and applied in a real-world cohort of 21 patients undergoing ERCP, including benign biliary obstruction due to choledocholithiasis (n=5) and malignant strictures (n=16: cholangiocarcinoma n=13, gallbladder adenocarcinoma n=1, ampullary tumors n=2). Expandable organoids were established in 17/21 cases (81%), with establishment rates of 60% for choledocholithiasis and 85-100% across malignant entities. Anticipated results include organoid outgrowth within [~]2-3 weeks and morphological heterogeneity in cultures derived from malignant strictures, where normal-like and tumor-like populations may initially coexist and can drift toward a cystic phenotype under routine expansion, motivating optional manual handpicking when tumor-enriched lines are required. As downstream readouts, we show feasibility of DNA-based profiling in selected paired bile-organoid samples (targeted sequencing and ULP-WGS copy-number analysis) and demonstrate proof-of-concept gene silencing via siRNA in both dissociated cells prior to re-embedding, and intact fully formed organoids while preserving 3D architecture. Collectively, this workflow provides a practical and reproducible framework to establish, expand, characterize and functionally perturb bile-derived organoids from routine clinical procedures, facilitating standardized implementation across laboratories.

Regeneration depends on tightly coordinated transcriptional programs governed by a dynamic epigenetic landscape to regulate cell identity, proliferation, and tissue remodelling following injury. The livers highly regenerative due to the ability to rapidly upregulate genes that drive the cell cycle and other genes important for regeneration. Trimethylation of histone 3 lysine 27 (H3K27me3) is deposited by the polycomb repressive complex 2 (PRC2) and many genes occupied by H3K27me3 in their promoters in uninjured livers become induced following PH. Here we test the hypothesis that depleting H3K27me3 by hepatocyte-specific deletion of Embryonic Ectoderm Development (EedHepKO), a key component of PRC2, changes the regenerative response in the liver. We show that Eed eliminates H3K27me3 in hepatocytes, resulting in reduced liver size, increased hepatocyte death, proliferation and fibrosis associated with upregulation of cell cycle and fibrogenic genes. Though these mice are less likely to survive two-thirds partial hepatectomy than wildtype controls, those that do survive increase liver mass faster than WTs. Importantly the genes that are occupied by H3K27me3 in control uninjured livers are upregulated in EEDHepKO and become further induced following PH. These data show that modulation of PRC2 activity disrupts epigenetic patterning, induces liver injury, and alters regenerative outcomes, suggesting that precise control of PRC2 function could be harnessed to enhance regenerative capacity.

The use of decellularized diseased livers in regenerative medicine is a promising approach for eliminating organ shortages. Bioengineering studies have shown that ECM can impact cell physiology, inducing cell activation, function, and ECM deposition, which suggests that the ECM has a "memory" that is involved in the outcome after recellularization. However, the effect of diseased ECM memory on new cells in vitro and in vivo has not been thoroughly investigated. Since it has been increasingly recognized that liver ECM changes due to different factors, it is comprehensively that diseased ECM obtained from discarded organs will ensure a distinct environment and impact cell survival and physiology. Thus, we aimed at investigating the impact of the memory of diseased ECM obtained from metabolic dysfunction-associated steatohepatitis (MASH)-derived organs on steatohepatitis establishment. To address this aim, we explored decellularized ECM obtained from rats and humans with MASH in different contexts. First, MASH ECM was characterized and then submitted to transplantation to investigate whether a MASH-derived ECM could be used as a scaffold for transplantation and to promote steatohepatitis features in control animals. Histological analysis revealed that the MASH-ECM was completely recellularized after transplantation in both control and MASH recipient rats. However, steatosis and fibrosis were observed in MASH ECM after transplantation in both groups. Molecular analysis showed that MASH ECM stimulates de novo lipogenesis and fibrosis 30 days after transplantation. Untargeted metabolomic analysis revealed that cells grown on MASH ECM had a similar metabolic profile, even when transplanted into healthy or MASH recipient rats. In addition, we observed that MASH ECM promoted impaired lipid oxidation and mitochondrial dysfunction when transplanted into healthy recipients. Altered lipid turnover and inflammatory signaling were observed in MASH ECM transplanted in MASH recipients. In vitro analysis revealed that MASH ECM induced lipid accumulation in HepG2 cells after 10 days of culture. Calcium signalling experiments obtained from HepG2 cells cultured in MASH ECM showed a lower response to ATP, a reduced calcium signalling amplitude, and a distinct response profile than that observed in healthy ECM. On the other hand, a diseased human-derived ECM could still provide an environment that allows cell development. Taken together, our data showed that MASH ECM impacts cell metabolism, promoting steatohepatitis maintenance. In conclusion, our data confirm that diseased ECM memory can impact cell physiology contributing to disease progression.

BackgroundHepatocellular carcinoma (HCC) arises from diverse etiologies, but the balance between conserved and specific transcriptomic programs remains unclear. MethodsHBV and HCV cohorts were analyzed using GSVA to quantify Hallmark shifts. Biology was distilled into proliferation (ProlifHub) and hepatocyte-loss (HepLoss) modules, forming a composite HCCStateScore. An HBV injury axis was adjusted for proliferative state (E2F/G2M). Validation was performed using GSE14520 and GEPIA3. ResultsHallmark analysis revealed conserved proliferative activation and hepatocyte function suppression across etiologies. In HBV-HCC, the injury axis remained significantly elevated after adjusting for proliferation (p{approx}0.0147), indicating an injury component independent of the cell cycle. HCCStateScore robustly separated tumor from non-tumor tissue (AUC{approx}0.986, p=0). GEPIA3 confirmed concordant expression and survival associations for module genes. ConclusionsHCC features conserved opposing proliferation and hepatocyte-loss programs. HBV-associated tumors retain a distinct injury-linked component not fully explained by cell division. This validated score provides a framework for cross-cohort analysis and mechanistic prioritization in liver cancer research.