Introduction

Alpha-1-antitripsin deficiency (AATD) is a codominant autosomal hereditary condition that predisposes patients to the development of pulmonary and/or hepatic disease, with Pi*Z mutation being the most clinically relevant.

Aims & Methods

Our aim was to evaluate the impact of AATD and Pi*Z allele in hepatic fibrosis.
Prospective, cohort, single-centred study including adult patients with AATD followed in Pneumology or Hepatology consultation. A control group was created with patients without liver disease. Liver fibrosis was assessed through non-invasive methods via serum tests, NAFLD fibrosis score (NFS) and Fibrosis-4 (FIB-4) index, and transient elastography.

Results

A total of 98 patients were included, 69 with AATD (70.4%) and 29 controls (29.6%). In the AATD group, the median value of alpha-1-antitripsin (AAT) at diagnosis was 67 mg/dL and the presence of at least one Pi*Z allele occurred in 55 patients (79.7%).
Patients with AATD regardless of genotype had a significantly higher liver stiffness measurement (LSM) compared to controls, although in both groups without significant liver fibrosis (median 5.0 vs 3.8kPa, p<0.001). Additionally, patients with AATD had significantly higher aspartate-transaminase (AST) (median 25 vs 17 UI/L, p<0.001) and alanine-transaminase (ALT) (median 29 vs 18 UI/L, p<0.001), with the two groups having values within normal range. The same occurred with alkaline phosphatase (ALP) (median 71 vs 59 UI/L, p<0.001) and gamma-glutamyl transferase (GGT) (median 25 vs 20 UI/L, p=0.007).
AAT values at diagnosis showed a negative and weak correlation with NFS (s=-0.327, p=0.007), as well as with FIB-4 index (s=-0.309, p=0.011). AAT value at diagnosis equal or superior to 77 had a sensitivity of 0.944 and specificity of 0.646 in predicting a NFS value that excludes advanced liver fibrosis (AUC 0.681; p=0.025).
In patients with at least one Pi*Z allele, the presence of diabetes mellitus was associated with 8 times higher likelihood of significant liver fibrosis with LSM≥7.1kPa (p=0.035). Furthermore, patients with at least one Pi*Z associated with both metabolic syndrome and alcohol consumption (>25 grams daily) had significantly higher NFS values (-1.18±1.45 vs -2.43±1.30, p=0.006) and FIB-4 index values (median 1.41 vs 1.0, p=0.011), being 6.55 times more likely to have an intermediate to high risk of advanced fibrosis, according to NFS (p=0.008).

Conclusion

Patients with alpha-1-antitripsin deficiency had higher liver stiffness and higher levels of serum transaminases, ALP and GGT. Alpha-1-antitripsin values at diagnosis were associated with NFS and FIB-4 index during follow-up. In patients with Pi*Z mutation, the presence of diabetes mellitus, metabolic syndrome and alcohol consumption was significantly associated with significant liver fibrosis, highlighting the need for controlling these coexisting comorbidities in this subset of patients.

Introduction

Patients with decompensated cirrhosis have high mortality rates. Several prognostic scores have been developed, based on clinical and laboratory parameters, to assess the prognosis of patients with cirrhosis. However, to date, there is no consensus on the best prognostic model. The MELD 3.0 score was recently published with the aim of refining the MELD score to contemporary data.

Aims & Methods

The objective of this study was to evaluate and compare models based on the hepatic severity index to investigate their predictive performance in mortality.
A retrospective cohort study was conducted, including consecutively admitted patients to a Gastroenterology Department for first admission due to decompensated cirrhosis. MELD, MELD-Na, MELD 3.0, and Child-Pugh scores were calculated upon admission. Mortality at 6 weeks and 180 days was the main outcome studied.

Results

109 patients admitted for the first episode of decompensated cirrhosis were included, 82.6% with alcoholic aetiology. Mean age was 61.8 ±10.8 years, 73.4% were men and 26.6% were women. Of the included patients, 11% died within the first 6 weeks and 25.7% died within the first 180 days after admission.
All models showed good accuracy in predicting mortality at 6 weeks and 180 days, with slight superiority of the MELD 3.0 score (AUC 0.693, 95% CI 0.598-0.778 at 6 weeks; AUC 0.712, 95% CI 0.617-0.795 at 180 days), although statistically significant differences between the different prognostic models were not observed.

Conclusion

The use of models based on hepatic severity indices accurately predicts the risk of mortality at 6 weeks and 180 days in patients with decompensated cirrhosis. The new MELD 3.0 score showed superior predictive performance in mortality, although without statistically significant differences.

Introduction

Metabolic Associated Steatotic Liver Disease (MASLD) affects 25-30% of the European population and is projected to rise further. These patients are at increased risk for liver-related complications and higher overall mortality, emphasizing the need for early detection to improve outcomes. While abdominal ultrasound serves as the primary imaging modality for suspected liver disease, its sensitivity for diagnosing mild steatosis is inadequate, and gold-standard methods for quantifying liver steatosis infiltration, such as magnetic resonance imaging or liver biopsy are impractical for widespread use.

Aims & Methods

This study aimed to assess the diagnostic accuracy of the Attenuation Coefficient (ATT) as a complementary method to B-mode ultrasound for early detection of hepatic steatosis. Consecutive patients referred for transient elastography were prospectively enrolled. Liver steatosis was graded using a 4-point scale (normal, mild, moderate, or severe) in B-mode ultrasound for each patient, and ATT was measured in accordance with manufacturer quality criteria instructions (Fujifilm®). Additionally, the Hepato-Renal Index (HRI) was calculated for each patient, and Controlled Attenuation Parameter (CAP, Fibroscan®) was measured.

Results

A total of 128 patients, 61.7% male, with a mean age of 56.8±12.8 years, were included. Among them, 78.1% exhibited at least one cardiometabolic risk factor. The main referral indications were fibrosis assessment in viral hepatitis (42.2%), MASLD (21.9%), and alcoholic liver disease (11.7%). The median vibration-controlled elastography result was 5.8kPa. B-mode ultrasound steatosis assessment classified 44.5% as normal, 10.2% with mild steatosis, 21.1% with moderate steatosis, and 24.2% with severe steatosis. The area under the ROC curve for steatosis detection was 0.796 for HRI, 0.894 for ATT, and 0.896 for CAP, highlighting robust diagnostic performance, particularly for the latter two methods. There was a strong correlation between ATT and CAP (r=0.710). Using a CAP>248dB/m to define steatosis, the area under the ROC curve for ATT was 0.890. For an ATT cutoff value ≥0.66, Sensitivity, Specificity, Negative Predictive Value, and Positive Predictive Value were 82.7%, 77.3%, 72.3%, and 86.1%, respectively. The sensitivity of B-mode ultrasound for steatosis detection was 79.5%, increasing to 90.4% when combined with ATT measurement.

Conclusion

ATT demonstrated excellent accuracy for steatosis detection, comparable to CAP and superior to HRI. Importantly, combining B-mode ultrasound with ATT significantly improved the diagnostic sensitivity. These findings suggest that ATT has the potential to become a valuable non-invasive tool alongside ultrasound for early detection of hepatic steatosis, aiding in earlier intervention and improved patient outcomes.

References

Tamaki N, Koizumi Y, Hirooka M, et al. Novel quantitative assessment system of liver steatosis using a newly developed attenuation measurement method. Hepatol Res. 2018;48(10):821-828. doi:10.1111/hepr.13179
Bozic D, Podrug K, Mikolasevic I, Grgurevic I. Ultrasound Methods for the Assessment of Liver Steatosis: A Critical Appraisal. Diagnostics. 2022;12(10):2287. doi:10.3390/diagnostics12102287

Introduction

The treatments for liver fibrosis are still in need so far. As the crucial initiators, activated hepatic stellate cells (aHSCs) undergo a series of epigenetic changes. The study intends to explore transcription factors (TFs) that facilitate HSCs activation and provide novel therapeutic targets for liver fibrosis.

Aims & Methods

Three distinct HSCs activation models were established in present study. Firstly, in vitro activation involved isolating primary HSCs from normal Sprague-Dawley rats and culturing them for two days (n=5) and seven days (n=5), namely natural activation model. Secondly, in vivo activation entailed isolating primary HSCs from bile duct ligated rats (n=4) and normal controls (n=4), followed by culturing until the next day. Lastly, transforming growth factor-β (TGF-β, 2.5ng/ml) (n=10) or control buffer (n=10) were added to the human HSCs cell line LX2 and cultured for 24 hours. Subsequently, assay for transposase-accessible chromatin using sequencing (ATAC-seq) was conducted on the abovementioned cells, along with motif enrichment and footprint analysis. Pathway enrichment analysis was performed on differentially accessible genes (DAGs). RNA sequencing (RNA-seq) was employed to analyze gene expression profiles of primary HSCs in the natural activation model (n=4). The integration of ATAC-seq and RNA-seq further identified potential key TFs. RT-qPCR and differential expression analysis of public datasets was utilized to confirm the dysregulation of TFs in primary HSCs, fibrotic liver and fibrotic model of induced pluripotent stem cells. Finally, enrichment at enhancers and promoters of these genes was validated by H3K27Ac and H3K4me3 chromatin immunoprecipitation followed by sequencing (ChIP-seq) of human HSCs.

Results

For ATAC-seq, primary HSCs exhibited higher chromatin accessibility after activation compared with the controls. After peak annotation, the up-regulated peaks were mainly located in the promoter region in all comparison groups, uncovering the dynamic transcriptional regulation during HSC activation. In the motif enrichment analysis, 150 aHSCs related TFs and 54 quiescent HSCs (qHSCs) related TFs were identified in the in vitro activation model. The three models shared 12 aHSCs related TFs, namely Runx-aml, Runx1, Runx2, Runx, Ets:Runx, Atf2, Atf4, Atf7, c-Jun-Cre, Creb5, Smad3 and CArG; and 19 qHSCs related TFs, including Foxf1, Foxo3, Foxk1, Foxp1, Hoxa1, Hoxa2, Stat3, Hnf4a, Hnf6, Elk1, Elk4, Cux1, Crx, Duxbl, Vdr, Tr4, Ebf2, Gata2, Gata6. Footprint analysis validated the alteration of accessibility in Atf2, Atf4, Atf7, Creb5, Hnf6 and Gata2. Actin filament organization, Ras protein signal transduction and intrinsic apoptotic signal pathways were enriched in DAGs. Integration of ATAC-seq and RNA-seq showed that gene expression was significantly correlated with chromatin accessibility, among which Runx2, Creb5, and Smad3 were significantly upregulated in aHSCs at transcription level. The dysregulation of these three genes was verified in primary HSCs, fibrotic liver and fibrotic model of human induced pluripotent stem cells. Finally, enrichment at active enhancers and promoters of these TFs was validated by H3K27Ac and H3K4me3 ChIP-seq of human HSCs, revealing the crucial role of genes in the transcription.

Conclusion

We generated chromatin accessibility profiles of different HSCs activation models, highlighting the significance of Runx2, Creb5, and Smad3 as key TFs mediating HSCs activation. These findings proposed these TFs as promising targets for future liver fibrosis treatment.

Disclosure

The author declare no competing interests and financial relationships with commercial interests.

Introduction

Metabolic-dysfunction-associated-steatotic liver disease (MASLD) affects more than half of obese subjects. To date, weight reduction by diet and physical activity is recommended to improve liver injury. Recent studies have shown that bariatric surgery induces stable weight loss and ameliorates metabolic parameters.

Aims & Methods

The aim of this study is to evaluate the effect of bariatric surgery on liver steatosis and fibrosis.
This is a monocentric prospective study including all patients with severe obesity and MASLD candidates for bariatric surgery in a single Italian-center. Other causes of chronic liver disease were an exclusion criteria. Clinical and biochemical data were collected. Liver fibrosis and steatosis were non-invasively assessed with Liver Stiffness Measurements (LSM) and Controlled Attenuation Parameter (CAP) by Fibroscan at three time-points: before surgery, 6- and 12-months after surgery.

Results

A total of 112 patients (63.4% female, mean age 41.5 years) were enrolled. Before bariatric surgery, the BMI was 43.6±6.2kg/m², the LSM was 8±5.8kPa and the CAP was 319.7±57.8dB/m. Ninety-six patients continued follow-up up after surgery. These patients demonstrated a significant reduction in BMI and CAP as early as 6-months post-surgery, while a significant decrease in LSM was observed only after 12-months. Specifically, the mean BMI was 31.9±5.1kg/m² after 6 months and 28.0±3.5kg/m² after 12-months, representing an overall decrease of 35.9% from baseline (p<0.0001). The mean CAP was 264.5±57dB/m after 6-months and 214.8±47.8dB/m after 12-months, reflecting an overall decrease of 32.8% from baseline (p<0.0001). Finally, the mean LSM was 6.3±2.5kPa after 6-months and 5.8±1.9kPa after 12-months, showing an overall decrease of 21.6% from baseline (p=0.02).

Conclusion

This study demonstrated a significant weight loss and liver steatosis decrease already at 6-months after surgery, while liver fibrosis reduction takes longer at 12-months after surgery. Therefore, in adults with MASLD and severe obesity, bariatric surgery should be considered as a valid therapeutic option for improving the liver damage.

Introduction

Noninvasive assessment of liver fibrosis is essential in the management of chronic liver diseases. APRI and FIB-4 are simple, low-cost tools widely used for this purpose. This study aimed to evaluate the diagnostic performance of APRI and FIB-4 in identifying significant fibrosis (≥F2) and cirrhosis (F4), using transient elastography (FibroScan) as the reference standard, and to explore their clinical and biochemical correlations.

Aims & Methods

We conducted a cross-sectional study at the Institute of Gastroenterology and Hepatology, Iași, Romania, between January 1^st, 2024 and April 1^st, 2025. A total of 106 patients with chronic liver disease were included. Laboratory tests were used to calculate APRI and FIB-4 scores, and liver stiffness was measured by FibroScan. For diagnostic accuracy we performed ROC curve analysis and Pearson correlation coefficients were used to assess relationships between noninvasive scores and clinical-biological variables. Statistical analysis was performed using MedCalc® Statistical Software version 23.2.1 (MedCalc Software Ltd, Ostend, Belgium).

Results

For the detection of significant fibrosis (≥F2), the area under the ROC curve (AUC) was 0.748 for APRI (p < 0.001) and 0.752 for FIB-4 (p < 0.001). In diagnosing cirrhosis (F4 ≥12.5 kPa), FIB-4 demonstrated superior diagnostic accuracy (AUC 0.836, p < 0.001) compared to APRI (AUC 0.797, p < 0.001). A FIB-4 threshold of 1.45 provided a sensitivity of 68.6% and a specificity of 83.3% for detecting significant fibrosis. High cut-offs (≥2.0 for APRI and ≥4.0 for FIB-4) were associated with a specificity exceeding 96%. A significant positive correlation was observed between APRI and FIB-4 (r = 0.96, p < 0.001). Moreover, FIB-4 correlated moderately with FibroScan values (r = 0.514), while APRI showed a weaker correlation (r = 0.423).

Conclusion

The results of this study confirm that both APRI and FIB-4 are effective noninvasive tools for the staging of liver fibrosis, with FIB-4 demonstrating superior diagnostic accuracy, particularly for cirrhosis. The moderate correlation between FIB-4 and FibroScan (r = 0.514) supports its potential role as a reliable surrogate marker, especially in settings where access to elastography is limited, outperforming the weaker correlation of APRI (r = 0.423) that suggests a lower predictive power, aligning with findings from previous studies that emphasized FIB-4's stronger association with liver stiffness and histological fibrosis progression. The high specificity associated with elevated cut-off values enhances the clinical applicability of these scores for ruling in advanced fibrosis and cirrhosis, minimizing the need for unnecessary imaging or biopsies. Overall, integrating FIB-4 and APRI into routine clinical practice could improve early identification of at-risk patients, optimize resource allocation, and facilitate timely therapeutic interventions.

References

1. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on non-invasive tests for evaluation of liver disease severity and prognosis - 2021 update. J Hepatol. 2021 Sep;75(3):659-689. doi: 10.1016/j.jhep.2021.05.025. Epub 2021 Jun 21. PMID: 34166721.
2. Gür-Altunay D, Yürük-Atasoy P. How Successful Are APRI and FIB-4 Scores in Predicting Liver Fibrosis in Chronic Hepatitis B Patients? Infect Dis Clin Microbiol. 2023 Dec 29;5(4):332-340. doi: 10.36519/idcm.2023.276. PMID: 38633858; PMCID: PMC10986711.
3. Rungta S, Kumari S, Deep A, Verma K, Swaroop S. APRI and FIB-4 performance to assess liver fibrosis against predefined Fibroscan values in chronic hepatitis C virus infection. J Family Med Prim Care. 2021 Nov;10(11):4082-4088. doi: 10.4103/jfmpc.jfmpc_666_21. Epub 2021 Nov 29. PMID: 35136771; PMCID: PMC8797084.

Introduction

MAESTRO-NASH is an ongoing 54-month, randomized, double-blind, placebo-controlled Phase 3 trial evaluating the efficacy of resmetirom in patients with biopsy-confirmed nonalcoholic steatohepatitis (NASH/MASH) and fibrosis. 966 patients with biopsy-confirmed NASH were randomized 1:1:1 to resmetirom 80 mg, resmetirom 100 mg, or placebo administered once daily.
Histologic endpoints were assessed after 52 weeks. Dual primary endpoints at Week 52 were achieved with both resmetirom 80 mg and 100 mg: NASH resolution with no worsening of fibrosis (NR) or ≥1-stage reduction in fibrosis with no worsening of NAS (FI). In this analysis, we examined the impact of baseline PNPLA3, TM6SF2 and MBOAT7 genotypes on the response to resmetirom on serial liver biopsy and MRI-PDFF (magnetic resonance imaging proton density fat fraction).

Aims & Methods

In the Phase 3 study (MGL-3196-11), PNPLA3 rs738409, TM6SF2 rs58542926 and MBOAT7 rs6141738 were genotyped in patients consenting to DNA collection and genetic testing for the response to
resmetirom on serial liver biopsy and MRI-PDFF. The NASH resolution and fibrosis improvement responses on liver biopsy and the MRI-PDFF (median percent change from baseline at Week 52) response were analyzed within each treatment arm, comparing wild type, heterozygote and homozygote for each genetic risk allele.

Results

Across three treatment arms, 740 patients had genotyping and serial liver biopsy data. The frequency of PNPLA3 GG (wild type), PNPLA3 CG (heterozygous), and GG (homozygous) genotypes across 3
treatment arms were 30-32%, 45-50% and 20-24% respectively. The frequency of TM6SF2 CC (wild type), TM6SF2 CT (heterozygous), and TM6SF2 TT (homozygous) genotypes were 79-82%, 15-21% and 0-3%
across 3 treatment arms. The frequency of MBOAT7 CC (wild type), MBOAT7 CT (heterozygous) and MBOAT7 TT (homozygous) genotypes were 28-29%, 47-50%, and 21-24% across 3 treatment arms. There were no differences observed in the level of response on biopsy or MRI-PDFF to resmetirom or placebo treatment in patients with genetic risk alleles for PNPLA3 and TM6SF2 (Table) or TMC4 (not shown).

Conclusion

MASH risk alleles were prevalent in the MAESTRO-NASH population and did not influence the treatment response to resmetirom.

Disclosure

This study was funded by Madrigal Pharmaceuticals, Inc.