BACKGROUND: This randomized controlled trial (RCT) evaluated the efficacy and safety of therapeutic plasma exchange (TPE) versus standard medical therapy (SMT) in acute-on-chronic liver failure (ACLF). APPROACH AND RESUL...BACKGROUND: This randomized controlled trial (RCT) evaluated the efficacy and safety of therapeutic plasma exchange (TPE) versus standard medical therapy (SMT) in acute-on-chronic liver failure (ACLF). APPROACH AND RESULTS: In this single-center, open-label RCT (February 2022-March 2025), we randomly (1:1) assigned 194 adult patients (aged 18-60 y) with ACLF [European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL CLIF-C) grades 1-3b] to receive SMT plus 5 sessions of TPE (n=97) or SMT alone (n=97). The primary outcome was all-cause mortality at 28 days. Secondary outcomes included 90-day mortality, changes in prognostic scores, resolution of organ failures, infections, and adverse events. Baseline characteristics were comparable between groups. Seventy-two (74.2%) patients completed 3 sessions of TPE, while 56 (57.7%) received all 5 sessions. Hemodynamic instability was the leading cause for discontinuation of TPE (18/41 patients, 43.9%). The 28-day mortality was significantly lower with TPE (43 patients, 44.3%; 95% CI: 34.2%-54.8%) than SMT (62 patients, 63.9%; 95% CI: 53.5%-73.4%), p =0.006; absolute risk reduction: 19.6% (95% CI: 5.8%-33.3%). Ninety-day mortality was similar between groups. TPE resulted in greater reductions in ammonia and higher rates of resolution of hepatic and coagulation failure by day 7 as compared with SMT. Subgroup analysis did not reveal significant heterogeneity across ACLF grade or etiology. Dyselectrolytemia and shivering were the most common complications after TPE. CONCLUSION: TPE significantly improves 28-day survival and organ failure resolution in patients with ACLF, but does not reduce 90-day mortality [CTRI/2022/01/039094].
BACKGROUND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) progresses from simple steatosis to metabolic dysfunction-associated steatohepatitis (MASH), yet its therapeutic development has been hamp...BACKGROUND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) progresses from simple steatosis to metabolic dysfunction-associated steatohepatitis (MASH), yet its therapeutic development has been hampered by pathological complexity and heterogeneity. APPROACH RESULTS: Bulk RNA-seq and diet-induced MASLD mouse models were employed to explore RNF128 expression patterns in MASLD livers. Hepatic RNF128 expression was characterized in single-cell RNA sequencing (scRNA-seq) and lipotoxicity-induced hepatocyte models. The impact of hepatocyte-specific RNF128 deletion and overexpression on MASLD progression was evaluated. Furthermore, the molecular mechanisms through which RNF128 exerts its functions were investigated, and both chemical and genetic approaches were employed to assess its potential as a therapeutic target.We found that the E3 ubiquitin ligase RNF128 is upregulated in human MASLD livers and in mice fed a high-fat, high-cholesterol diet. Hepatocyte-specific RNF128 knockout ameliorated MASLD, whereas its overexpression exacerbated disease phenotypes. Integrated proteomic and ubiquitinomic analyses identified stearoyl-CoA desaturase 1 (SCD1) as a direct target of RNF128. Mechanistically, RNF128 catalyzes K63-linked ubiquitination of SCD1 at lysine 30, which stabilizes SCD1 by blocking its autophagic-lysosomal degradation, thereby promoting lipid accumulation. Crucially, SCD1 overexpression reversed the effects of RNF128 loss, and SCD1 inhibition rescued RNF128-driven steatosis, both in hepatocytes and in vivo. Therapeutic inhibition of RNF128 with a GalNAc-conjugated antisense oligonucleotide (GalNAc-ASO) and a hepatocyte-specific TBG-promoter-driven shRNA-AAV alleviated MASLD in mice. CONCLUSIONS: Our study establishes the RNF128-SCD1 axis as a central mechanism in MASLD and highlights its therapeutic potential.
BACKGROUND AND AIMS: Acute liver failure (ALF) is a life-threatening disease with a high mortality rate and limited treatment options. Neutrophils rapidly infiltrate the injured liver, yet their functional heterogeneity...BACKGROUND AND AIMS: Acute liver failure (ALF) is a life-threatening disease with a high mortality rate and limited treatment options. Neutrophils rapidly infiltrate the injured liver, yet their functional heterogeneity and regulatory mechanisms remain poorly understood. We aimed to identify pathogenic neutrophil subsets in ALF and identify potential therapeutic targets. APPROACH AND RESULTS: Single-cell RNA sequencing of liver tissues from murine ALF revealed the expansion of Ifit1 + neutrophil subset, which was conserved across diverse etiologies. This subset exacerbates liver injury by amplifying inflammatory responses and inducing hepatocyte apoptosis. FGL2 was identified as the principal effector secreted by this subset. Mechanistically, IRF7 acted as an upstream transcriptional regulator of Ifit1 + neutrophil differentiation. Neutrophil-specific Irf7 deficiency reduced Ifit1 + neutrophil expansion, diminished FGL2 production, mitigated liver injury, and improved survival. Liver neutrophil-targeted lipid nanoparticles delivering the IRF7 small-molecule inhibitor HS38 selectively inhibited hepatic neutrophil Irf7, mitigating liver damage. Importantly, the translational relevance of this pathway is underscored by the significant expansion of Ifit1 + neutrophils in ALF patients, where their abundance correlated with disease severity. CONCLUSIONS: These findings delineate an IRF7-Ifit1 + neutrophil-FGL2 axis driving ALF pathogenesis and establish its targeted inhibition as a viable therapeutic strategy.
BACKGROUND AND AIMS: Alcohol-associated liver disease (ALD) is linked to intestinal barrier dysfunction, allowing microbial translocation that drives liver inflammation. The role of goblet cells (GCs) in maintaining inte...BACKGROUND AND AIMS: Alcohol-associated liver disease (ALD) is linked to intestinal barrier dysfunction, allowing microbial translocation that drives liver inflammation. The role of goblet cells (GCs) in maintaining intestinal homeostasis and regulating ALD has only recently been explored. Notably, the absence of mucin 2 (Muc2), the major secreted intestinal mucin, is protective against ALD, and GC-associated antigen passages (GAPs), gateway-like structures mediating antimicrobial immunity, play a critical role in prevention. We previously showed that intestinal epithelial gp130 signaling promotes duodenal GAP formation through activation of muscarinic acetylcholine receptor 4 (mAChR4), thereby protecting against ethanol-induced liver injury. Here, we aimed to define the contributions of Muc2 deficiency and mAChR4-formed GAPs to ALD prevention. APPROACH AND RESULTS: Duodenal transcriptomics from patients with alcohol use disorder revealed upregulation of GC-related genes involved in mucin glycosylation and secretion, while CHRM4 (encoding mAChR4 ) inversely correlated with mucin glycosylation, linking mucin dynamics to GAP formation. Consistently, Muc2 deficiency in mice promoted duodenal GAPs through reduced Myd88 expression and conferred protection against ethanol-induced liver injury. However, genetically induced GAP closure in Muc2-/- mice abolished protection, indicating mucin loss alone is insufficient. GC-specific mAChR4 deletion reduced GAPs, impaired intestinal immunity, increased bacterial translocation, and worsened steatohepatitis. Conversely, pharmacologic activation with an mAChR4-positive allosteric modulator restored GAPs, enhanced antimicrobial defense, and prevented liver injury. CONCLUSIONS: GAPs are central to gut-liver homeostasis. Muc2 deficiency enhances GAP formation and confers protection against ALD, whereas GAP closure exacerbates disease. Targeting GC-specific mAChR4 to restore GAPs represents a promising therapeutic strategy for ALD.
BACKGROUND AND AIMS: Forkhead Box Protein M1 (FOXM1) is an oncoprotein that plays an important role in liver inflammation and fibrosis. It is phosphorylated by multiple kinases at specific sites, leading to interaction w...BACKGROUND AND AIMS: Forkhead Box Protein M1 (FOXM1) is an oncoprotein that plays an important role in liver inflammation and fibrosis. It is phosphorylated by multiple kinases at specific sites, leading to interaction with peptidyl-prolyl isomerase NIMA-interacting 1 (PIN1) for further activation. The role of FOXM1 in alcohol-associated liver disease (ALD) is unknown and investigated here. APPROACH AND RESULTS: We used the NIAAA ALD protocol in wild-type, flox, and albumin-Cre Foxm1 knockout ( Foxm1Hep-/- ) mice, ethanol (EtOH)-treated human and mouse hepatocytes, and human ALD specimens, and examined the effect of FDI-6, a small molecule inhibitor of FOXM1. We found FOXM1 was upregulated in murine and human ALD, particularly in hepatocytes. FOXM1-PIN1 interaction increased in both cytosol and nuclei, along with increased total and nuclear levels of FOXM1, FOXM1-pT600 (marker of activation), cyclin D1, pERK, and pPKC. Total PIN1 level was unchanged, but nuclear PIN1 content increased. Silencing PIN1, cyclin D1, or inhibiting MEK alone blunted the EtOH-mediated increase in nuclear FOXM1 expression/activity, but the combination inhibited completely. FDI-6-treated and Foxm1Hep-/- mice were protected from EtOH-induced liver injury, the increase in triglyceride and proinflammatory cytokines. RNA-Seq analysis, validated in Foxm1Hep-/- livers and human ALD, revealed multiple novel Foxm1 targets, including granulin (GRN), cathepsins L/E, and importin-α5, which enhanced the nuclear translocation of PIN1. CONCLUSIONS: Taken together, FOXM1 is activated in hepatocytes in response to EtOH through a mechanism that involves PKCε, MEK/ERK, cyclin D1-CDK4/6, PIN1, and GRN. Targeting this pathway may represent a novel therapeutic strategy for ALD.
BACKGROUND AND AIMS: Effective non-invasive risk-stratification tools are essential for the early detection of individuals at high risk for cirrhosis, to enable timely intervention. We conducted a prospective, head-to-he...BACKGROUND AND AIMS: Effective non-invasive risk-stratification tools are essential for the early detection of individuals at high risk for cirrhosis, to enable timely intervention. We conducted a prospective, head-to-head comparison of fibrosis-based and outcome-driven routine blood-based risk scores for predicting cirrhosis-related morbidity in a large community-based cohort. APPROACH AND RESULTS: We first performed a systematic review to identify risk scores derived from routine liver blood tests, and then evaluated them in the UK Biobank. Severe cirrhosis-related morbidity was defined using International Classification of Diseases, Tenth Revision codes. Discrimination and clinical utility were assessed using the Wolbers C-index, time-dependent area under the receiver operating characteristic curve, area under the precision-recall curve (AUPRC), and cumulative incidence accounting for competing risks. The review identified 12 eligible risk scores (10 novel models plus APRI and FIB-4). Among 385,738 participants, the 10-year cumulative incidence of severe cirrhosis-related morbidity was 0.39% (1498 events). Most novel scores outperformed APRI and FIB-4. LiverRisk showed the highest discrimination at 5 years (C-index 0.847) and 10 years (C-index 0.812), closely followed by CORE (5-year C-index 0.839; 10-year C-index 0.811). In contrast, CORE achieved better enrichment of high-risk individuals, with an AUPRC of 0.088 compared with 0.063 for LiverRisk. At low referral proportions, increasing the CORE threshold yielded greater net benefit than a sequential CORE-LiverRisk referral strategy. CONCLUSIONS: CORE and LiverRisk are the most discriminative routine blood-based tools for predicting long-term cirrhosis-related morbidity in the community. When referrals are limited, a higher-threshold CORE-only strategy may outperform a sequential CORE-LiverRisk approach.
Huang Y, Xue H, He J
… +25 more, Fan R, Liu Y, Zhang M, Du Z, Shen Z, Zhang Q, Hu X, Zheng C, Xia Z, Jiang S, Jiang N, Zhu W, Wang J, Xu Z, Liao R, Zhao L, Zhang Y, Zheng J, Huang Y, Zhang J, Li G, Wang Z, Zhang Q, Zhang W, Qiu C
BACKGROUND AND AIMS: Hepatitis B virus (HBV) infection exhibits marked cellular heterogeneity, which conventional poly(A)-based single-cell RNA sequencing fails to resolve this heterogeneity owing to the overwhelming hos...BACKGROUND AND AIMS: Hepatitis B virus (HBV) infection exhibits marked cellular heterogeneity, which conventional poly(A)-based single-cell RNA sequencing fails to resolve this heterogeneity owing to the overwhelming host transcript background. To overcome this, we developed B-BEST (HBV can BE Seen on host Transcriptome), a targeted sc/snRNA-seq approach using custom beads conjugated with HBV-specific probes to simultaneously quantify 5 viral genomic regions (S, X, pgRNA, rcDNA, cccDNA). APPROACH AND RESULTS: We validated B-BEST in HepAD38 cells and integrated it with long-read sequencing, spatial transcriptomics, and in situ hybridization in liver tissues from treatment-naïve patients and antiviral-treated humanized liver-chimeric (Hu-URG) mice. B-BEST revealed significant heterogeneity among HBV-positive hepatocytes. In HBeAg-positive patients, HBV-positive subpopulations enriched for hepatic synthesis/metabolism and mitochondrial function were linked to active viral replication and transcription, with only a mild type I interferon response. Severe inflammation correlated with suppressed HBV replication. Long-read sequencing indicated that integrated HBV transcripts preferentially used host promoters and contributed to HBsAg persistence in HBeAg-negative patients. In Hu-URG mice, entecavir upregulated metabolic pathways, while peginterferon alfa-2b induced broad-spectrum antiviral programs. Notably, clonal expansion of hepatocytes diluted the intrahepatic viral reservoir when viral replication was inhibited, suggesting a proliferative dilution mechanism that may contribute to functional cure. CONCLUSIONS: In summary, our B-BEST platform provides resources for delineating the heterogeneous landscape of HBV infection, identifying host determinants and microenvironmental factors that govern viral replication and persistence, and highlighting hepatocyte proliferation as a potential clearance mechanism for antiviral therapy.
BACKGROUND AND AIMS: Since DNA sequencing alone faces challenges in variant interpretation during genetic diagnosis, RNA sequencing has recently gained attention in resolving these diagnostic gaps. This study aimed to ev...BACKGROUND AND AIMS: Since DNA sequencing alone faces challenges in variant interpretation during genetic diagnosis, RNA sequencing has recently gained attention in resolving these diagnostic gaps. This study aimed to evaluate the advantages of liver tissue RNA sequencing in the diagnosis of genetic liver diseases. APPROACH AND RESULTS: Liver tissue RNA sequencing was performed on 147 patients with prior DNA sequencing. We evaluated the role of RNA sequencing by analyzing aberrant gene expression, splicing, allele-specific expression, transcript-level similarity, and mosaic variants. Liver RNA-seq supported the molecular diagnoses in 56 patients diagnosed by DNA sequencing alone. Among 91 previously undiagnosed patients, incorporating RNA sequencing established a diagnosis in 17 (18.68%) patients. Among the 33 patients with indicative clinical phenotypes or prioritized variants, diagnosis was established in 15 (45.45%) patients with the help of RNA sequencing. This improvement was primarily (16/17) driven by the detection of aberrant splicing and allele-specific expression, instead of aberrant expression. RNA sequencing revealed ±50 bp of cryptic splicing sites as hotspot regions, characterized allele-specific expression at both the gene and variant levels, and revealed shared transcriptomic features in low-GGT cholestasis. CONCLUSIONS: While DNA sequencing demonstrates superior sensitivity in detecting clinically relevant variants, liver RNA sequencing significantly enhances genetic diagnosis, mainly by revealing aberrant splicing and allele-specific expression. These findings suggest that RNA sequencing is an essential complement to DNA sequencing.
BACKGROUND AND AIMS: Hepatic stellate cell (HSC) activation is central to liver fibrosis, but emerging evidence suggests HSC homeostatic activity. We compared HSC functions in parenchymal injury (CCl 4 -driven) versus me...BACKGROUND AND AIMS: Hepatic stellate cell (HSC) activation is central to liver fibrosis, but emerging evidence suggests HSC homeostatic activity. We compared HSC functions in parenchymal injury (CCl 4 -driven) versus metabolic dysfunction-associated steatohepatitis (MASH; choline-deficient, high-fat diet-CD-HFD) and identified therapeutic targets preserving HSC homeostatic functions. APPROACH AND RESULTS: Inducible HSC ablation was performed in Lrat-iDTR mice during active fibrogenesis. Multi-parametric analyses were conducted to assess roles of HSCs in 2 established fibrosis models, with a focus on elucidating the cellular origins of myofibroblasts and the alterations in regeneration and ductular reaction. RNA-seq from human biopsies validated mechanisms. HSC depletion in the CD-HFD model not only exacerbated MASH but also elevated a-SMA + myofibroblasts derived from PDGFRα + portal fibroblasts, impaired hepatocyte function (metabolic zonation and regeneration), and enhanced the ductular reaction. Conversely, HSC depletion in the CCl 4 model attenuated fibrosis without affecting hepatic regeneration or metabolic zonation. Strikingly, 85.5% of quiescent HSC-enriched genes remained upregulated in MASH-associated HSCs, unlike in CCl 4 fibrosis. RNA-seq followed by in vivo studies identified extracellular matrix protein 1 (ECM1) as a master regulator of HSC quiescence, and HSC-specific ECM1 overexpression suppressed CCl 4 -induced fibrosis. In human biopsies (MASH, HBV, PBC, PSC), ECM1 expression inversely correlated with fibrosis stage. CONCLUSIONS: HSCs exhibit dual roles contingent on disease context: in MASH with moderate inflammation, they maintain homeostasis, whereas in massive CCl 4 -driven injury, activated HSCs promote fibrogenesis. ECM1 enforces HSC quiescence and facilitates fibrosis resolution. Anti-fibrotic therapies based on general HSC ablation may be harmful.
O'Neill AF, Zeme EL, Abou-Alfa GK
… +18 more, Baretti M, Bondoc AJ, Church A, Ferrone CR, Fitzgerald M, Geller JI, Gill AE, Harris WP, Kim HB, Lee SS, Liu KX, Ortiz MV, Rangaswami A, Riehle KJ, Rosenberg AR, Torbenson MS, Yarchoan M, Gordan JD
BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction-associated steatohepatitis (MASH), can lead to significant morbidity and mortality in...BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease (MASLD) and its progressive form, metabolic dysfunction-associated steatohepatitis (MASH), can lead to significant morbidity and mortality in adults with type 2 diabetes (T2D) and obesity. This study evaluated whether participation in an individualized, nutrition-focused telemedicine care model emphasizing carbohydrate reduction (Virta Individualized Nutrition Therapy, VINT) was associated with reduced onset of MASLD, MASH, and advanced liver disease. APPROACH AND RESULTS: Adults with T2D, prediabetes, overweight,or obesity who enrolled in VINT (2015-2024) were identified in the Komodo Healthcare Map and matched 1:1 to usual care (UC) controls (n=5031 per group). Using 3 complementary analytic approaches, incidence and time-to-event analyses were performed for new-onset liver disease. Across all strategies, VINT participants consistently showed a lower incidence of any liver-related diagnosis (27.3 vs. 42.8 per 1000 person-years; HR=0.61, p <0.001), MASH-and-beyond (4.2 vs. 10.7; HR=0.38, p <0.001), advanced liver disease (2.8 vs. 8.7; HR=0.33, p <0.001), and any liver complications (2.0 vs. 7.7; HR=0.25, p <0.001). VINT participants who lost ≥15% body weight were at lower risk of new-onset liver disease (21.2 vs. 31.8 per 1000 person-years; HR=0.66, p =0.02) compared with VINT participants who lost less weight. CONCLUSIONS: Participation in individualized nutrition-focused telemedicine care was associated with significantly lower incidence and risk of new-onset MASLD, MASH, and advanced liver disease. These findings support lifestyle-first interventions that are potentially scalable to reduce liver disease burden in adults with T2D and obesity.
BACKGROUND AND AIMS: Understanding the mechanisms behind liver repair in acetaminophen (APAP)-induced liver injury (AILI) is crucial for developing effective treatments. Six-transmembrane epithelial antigen of the prosta...BACKGROUND AND AIMS: Understanding the mechanisms behind liver repair in acetaminophen (APAP)-induced liver injury (AILI) is crucial for developing effective treatments. Six-transmembrane epithelial antigen of the prostate 4 (STEAP4) is a metalloreductase involved in iron regulation. The roles of STEAP4 and endolysosomal iron in liver regeneration in AILI remain unclear. APPROACH AND RESULTS: Alb-Cre- Steap4flox/flox and liver-specific STEAP4 knockout (Alb-Cre+ Steap4flox/flox , L-STEAP4 KO) mice were given APAP for different periods. Deferiprone (DFP) was administered with or after APAP. Biochemical and histological analyses were performed to examine iron homeostasis and liver injury. STEAP4 expression decreased in human AILI livers. APAP treatment lowered hepatic STEAP4 expression in mice. L-STEAP4 KO mice showed similar hepatocyte death and serum ALT levels between 6 and 24 hours, but experienced delayed liver recovery at 48 hours after APAP compared with wild-type mice. Loss of STEAP4 led to iron buildup in endolysosomes, lysosomal membrane damage, and the release of cathepsin B following APAP treatment, which was correlated with lower hepatic mTOR activity, impaired mitophagy, and reduced hepatocyte proliferation 48 hours after APAP. DFP restored mitochondrial and lysosomal functions, providing protection against AILI. Overexpressing STEAP4 or TFEB (a key regulator of lysosomal biogenesis) or post-treatment with DFP repaired lysosomal membranes and inhibited AILI in both wild-type and L-STEAP4 KO mice. CONCLUSIONS: STEAP4 is not essential during the early injury phase but plays a critical role in liver regeneration by maintaining lysosomal iron homeostasis and function after APAP overdose. Targeting STEAP4-mediated endolysosomal iron overload may open new therapeutic avenues for AILI.
BACKGROUND AND AIMS: Increased circulating pro-inflammatory cytokine levels correlate with mortality in severe alcohol-associated hepatitis (AH), but their kinetics during disease progression or response to treatment rem...BACKGROUND AND AIMS: Increased circulating pro-inflammatory cytokine levels correlate with mortality in severe alcohol-associated hepatitis (AH), but their kinetics during disease progression or response to treatment remain unexplored. We longitudinally assessed circulating biomarkers in a severe AH cohort enrolled in a multicenter, double-blind clinical trial. APPROACH AND RESULTS: Eighty-nine patients with severe AH (MELD≥20) from 4 US sites were randomly assigned to treatment with IL-1 receptor antagonist (IL-1Ra) + pentoxifylline + zinc (anakinra: 47) or methylprednisolone + placebo (steroid: 42). Plasma levels of 43 indicators of AH pathology (inflammation, bacterial translocation, liver regeneration, tissue remodeling, and cell activation) were assessed on days 0, 7, 28, 90, and 180 after enrollment, and in 27 healthy controls. Baseline characteristics and cytokine levels were similar between treatment groups but significantly different compared with healthy controls. Consistent with anakinra administration, day 7 IL-1Ra levels were significantly increased in the anakinra group, accompanied by elevated levels of several other cytokines. IL-1β levels were increased in the steroid group on day 28. Strong correlations were observed between IL-1α and IL-17A, as well as IL-1β and IL-13, both before and during treatment. Although the dysregulated biomarkers demonstrated improving trends in survivors, most did not normalize by day 180. Markers associated with 90-day mortality were distinct between the treatment groups with few exceptions (IL-13-absolute level; sonic hedgehog and sTNF-R1-level change). CONCLUSIONS: Circulating cytokine and immune biomarkers dynamically change in AH during treatment, disease progression, and/or resolution. Our results highlight the importance of treatment-specific biomarkers in future clinical trials.
Slović N, Mishra S, Paul S
… +21 more, Oudot MA, Jühling F, Kanzaki H, Moehlin J, Charlot A, Denos M, Durand SC, Katz C, Gadenne C, Felli E, Ono A, Oka S, Higashi T, Nakagawa S, Akuta N, Goossens N, Chayama K, Lupberger J, Crouchet E, Hoshida Y, Baumert TF
BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) is the most common form of liver cancer and is a major global health burden, ranking sixth in incidence and third in cancer-related mortality. Despite therapeutic advan...BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) is the most common form of liver cancer and is a major global health burden, ranking sixth in incidence and third in cancer-related mortality. Despite therapeutic advances, treatment options for advanced liver disease and HCC are limited, and strategies to prevent HCC development are lacking. To address the urgent need for preventive strategies, we identified aripiprazole, an oral atypical antipsychotic, as a candidate for HCC chemoprevention. APPROACH AND RESULTS: Analyses of clinical liver tissues showed that aripiprazole targets are expressed in different liver cell compartments, including fibroblasts, macrophages, and epithelial cancer cells, and that target gene expression is associated with fibrotic liver diseases and HCC. In a rat model of MASH-induced HCC induced by choline-deficient L -amino acid-defined high-fat diet, aripiprazole prevents liver disease progression and HCC development by modulating fibrogenesis-related pathways and inflammation. Mechanistically, aripiprazole exerts antifibrogenic and anti-inflammatory effects by modulating the phenotype of liver fibroblasts and macrophages. Moreover, perturbation studies in cancer cell models showed that aripiprazole prevents tumor initiation and reduces cell proliferation via inhibition of the cMET and ERK pathways and perturbation of mitochondrial functions. Finally, treatment of patient-derived tumor spheroids demonstrated that aripiprazole modulates immune responses in the tumor microenvironment. CONCLUSIONS: Collectively, these findings suggest that treatment with aripiprazole is a clinically relevant approach for HCC chemoprevention.
BACKGROUND AND AIMS: Immune checkpoint blockade (ICB) shows therapeutic promise in hepatocellular carcinoma (HCC) but is associated with suboptimal responses in patients. Progenitor-exhausted T (Tpex) cells are key respo...BACKGROUND AND AIMS: Immune checkpoint blockade (ICB) shows therapeutic promise in hepatocellular carcinoma (HCC) but is associated with suboptimal responses in patients. Progenitor-exhausted T (Tpex) cells are key responders to ICB, but the regulatory mechanisms governing Tpex maintenance in HCC remain elusive. APPROACH AND RESULTS: Through an integrated analysis of HCC single-cell RNA-sequencing datasets, we constructed an exhausted CD8 + T-cell atlas and identified the kinase FYN as a marker of Tpex cells in ICB responders. FYN deficiency in CD8 + T cells induced LCK hyperactivation, which drove terminal exhaustion under high-affinity antigen stimulation. Mechanistically, LCK hyperactivation disrupted metabolic homeostasis by triggering excessive glycolysis and impairing mitochondrial function in Tpex cells. Conversely, LCK inhibition elevated compensatory FYN activity, restored mitochondrial fitness, and preserved Tpex cell stemness. In preclinical HCC models, transient LCK inhibition during T-cell expansion enhanced adoptive cell therapy efficacy by increasing Tpex cell persistence and stemness. Additionally, preemptive low-dose LCK inhibition before anti-PD-1 therapy expanded the Tpex cell pool, reduced terminal exhaustion, and improved therapeutic outcomes. CONCLUSIONS: This study establishes the FYN/LCK balance as a critical regulator of the terminal exhaustion of Tpex cells through metabolic reprogramming. These findings suggest that modulating the FYN/LCK kinase balance is a promising strategy to overcome immunotherapy resistance in HCC.