Histological assessment is foundational to multi-omics studies of liver disease, yet conventional fibrosis staging lacks resolution, and quantitative metrics like collagen proportionate area (CPA) fail to capture tissue...Histological assessment is foundational to multi-omics studies of liver disease, yet conventional fibrosis staging lacks resolution, and quantitative metrics like collagen proportionate area (CPA) fail to capture tissue architecture. While recent AI-driven approaches offer improved precision, they are proprietary and not accessible to academic research. Here, we present a novel, interpretable AI-based framework for characterising liver fibrosis from picrosirius red (PSR)-stained slides. By identifying distinct data-driven collagen deposition phenotypes (CDPs) which capture distinct morphologies, our method substantially improves the sensitivity and biological specificity of downstream transcriptomic and proteomic analyses compared to CPA and traditional fibrosis scores. Pathway analysis reveals that CDPs 4 and 5 are associated with active extracellular matrix remodelling, while phenotype correlates highlight links to liver functional status. Importantly, selected CDPs demonstrated prognostic associations in the discovery cohort, with attenuation of discrimination in the external validation cohort. All models and tools are made freely available to support transparent and reproducible multi-omics pathology research.
BACKGROUND AND AIMS: Unhealthy alcohol use is prevalent in chronic liver disease (CLD). This randomized controlled trial evaluated the efficacy of telehealth stepped alcohol treatment (SAT) in three healthcare systems. A...BACKGROUND AND AIMS: Unhealthy alcohol use is prevalent in chronic liver disease (CLD). This randomized controlled trial evaluated the efficacy of telehealth stepped alcohol treatment (SAT) in three healthcare systems. APPROACH AND RESULTS: Participants (N=157) with CLD and unhealthy alcohol use (>7 drinks/week or ≥4/day for women; >14/week or ≥5/day for men; or heavy episodic drinking, using timeline follow back), were enrolled at a safety-net and 2 Veterans Affairs hepatology clinics from 3/1/2022-2/28/2024. Participants were randomized to SAT (N=81; Step 1: three motivational interviewing sessions, Step 2: addiction medicine referral if no drinking reduction at month 3) or usual care (UC; N=76); evaluated at months 3 and 6. Alcohol use reduction was analyzed using bivariate tests and multivariable modeling. Baseline characteristics were: median age 61, 86% male, 48% with cirrhosis (37% decompensation), and 78% with alcohol use disorder. Compared to UC, SAT had no difference in percentage of alcohol use below moderate level (primary outcome) but had greater reduction in drinks/week from baseline to month 3 (estimate -0.66, P=0.03) and month 6 (estimate -0.67, P=0.03) (secondary outcome). The 6-month effect of SAT (vs UC) on alcohol use reduction remained significant (P=0.02), controlling for covariates. At month 6, 30-day abstinence rates were 29% for SAT and 18% for UC (P=0.14). Baseline motivation to reduce alcohol use was positively associated with treatment response. CONCLUSIONS: SAT was not superior on the primary outcome, yet reduced alcohol use more than UC at six months in this difficult-to-engage population and may be valuable in hepatology.
BACKGROUND AND AIMS: Liver transplantation is a lifesaving, standard of care intervention for infants, children, and adolescents with liver tumors, inborn errors of metabolism, and irreversible liver disease caused by a...BACKGROUND AND AIMS: Liver transplantation is a lifesaving, standard of care intervention for infants, children, and adolescents with liver tumors, inborn errors of metabolism, and irreversible liver disease caused by a wide spectrum of liver conditions. The American Association for the Study of Liver Diseases (AASLD) last published guidelines for the evaluation and selection of pediatric liver transplant candidates in 2014. This 2026 update aims to provide evidence-based recommendations that reflect current best practices and evolving clinical knowledge. METHODS: A multidisciplinary writing group of pediatric liver transplant experts and a medical librarian was convened by AASLD, with guidance by its Practice Guidelines Development Policy, and in collaboration with the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) and the American Society of Transplantation (AST). We conducted a systematic global literature review, formulated key clinical questions, and developed recommendations. Each recommendation was graded using the Oxford Centre for Evidence-Based Medicine framework and categorized by strength through a consensus voting process. CONCLUSION: This document provides clear, evidence-based guidelines on the transplant evaluation process and journey in infants, children, and adolescents. It outlines indications, contraindications, and barriers to transplantation based on robust, relevant published data. It offers best practices for pre-transplant assessment, organ allocation, and strategies to optimize survival, while allowing flexibility for individual clinical scenarios.
BACKGROUND AND AIMS: TREM2-expressing scar-associated macrophages (SAMs) are integral to the pathogenesis of hepatic fibrosis; however, the limited understanding of their differentiation and pro-fibrotic functions impede...BACKGROUND AND AIMS: TREM2-expressing scar-associated macrophages (SAMs) are integral to the pathogenesis of hepatic fibrosis; however, the limited understanding of their differentiation and pro-fibrotic functions impedes the advancement of targeted therapeutic strategies. APPROACH AND RESULTS: Integrated multi-omics analysis, including transcriptomics, 4D proteomics, CUT&Tag, and WGCNA of human and mouse fibrotic livers, coupled with single-cell RNA sequencing, identified SAMs with high TREM2 expression as key drivers of fibrosis. These TREM2high macrophage serves as essential mediators for the reception and transmission of TGF-β signaling. In the context of a fibrotic microenvironment, TGF-β activates HIF-1α-mediated glycolysis and lactate production, leading to an increase in histone lactylation, particularly the p300-catalyzed lactylation of histone H4 at lysine 12 (H4K12la). Importantly, the enrichment of H4K12la at the TREM2 promoter facilitates an upregulation of TREM2 transcription, thereby promoting the differentiation of monocytes into the pro-fibrotic TREM2high macrophage phenotype. Furthermore, TREM2 protein directly interacted with lactate dehydrogenase A (LDHA), stabilizing its expression and reinforcing lactate production, thereby establishing a complete TREM2/LDHA/H4K12la positive-feedback loop that promote the differentiation of TREM2high macrophages. In murine models, the knockout of TREM2, macrophage-specific knockdown and overexpression all disrupted this regulatory loop, inhibited glycolysis and H4K12la modification, and ultimately mitigated liver fibrosis. CONCLUSIONS: H4K12 lactylation facilitates the differentiation of monocytes into TREM2high macrophages within the context of liver fibrosis. This lactylation event enhances and maintains a crucial TREM2/LDHA positive feedback loop. Intervening in this H4K12la-TREM2 pathway significantly mitigates liver fibrosis, thus presenting a novel potential target for therapeutic intervention in hepatic fibrogenesis.
Systemic therapy for advanced hepatocellular carcinoma (HCC) has evolved from a linear, stepwise algorithm into a multidimensional and truly polyhedral process shaped by treatment response, liver function, and access to...Systemic therapy for advanced hepatocellular carcinoma (HCC) has evolved from a linear, stepwise algorithm into a multidimensional and truly polyhedral process shaped by treatment response, liver function, and access to therapy. This review integrates evidence from phase II and III trials and real-world studies, including more than 4,000 patients across different and diverse global regions, to outline how sequencing beyond first-line immunotherapy is redefining clinical practice. After immune-based combinations, tyrosine kinase inhibitors (TKIs) remain active and feasible options, achieving a median overall survival of approximately 10-11 months, while preservation of liver function consistently determines treatment eligibility and post-progression survival. Incorporation of the Barcelona Clinic Liver Cancer (BCLC) concept "upon response" (BCLC-UR) refines classification for patients achieving major responses or conversion and aligns staging with contemporary treatment dynamics. The CUSE framework-encompassing Complexity, Uncertainty, Subjectivity, and Emotion-reframes sequencing as an adaptive, patient-centered, and multifaceted process that integrates toxicity, feasibility, and patient values alongside efficacy. By structuring diverse clinical inputs into a unified interpretive model, CUSE supports multidisciplinary reasoning and enhances conceptual coherence in treatment sequencing. Conversion therapy and "drug-off" strategies following complete or major responses represent emerging frontiers, emphasizing that sequencing in HCC now extends beyond second-line therapy. Additionally, preserving hepatic function and applying polyhedral, data-informed decision frameworks are key to sustaining eligibility and optimizing outcomes across the continuum of care.
BACKGROUND AND AIMS: Metabolic dysfunction-associated steatohepatitis (MASH)-associated fibrosis is a pivotal stage toward end-stage liver disease. However, the immune mechanisms orchestrating the transition from inflamm...BACKGROUND AND AIMS: Metabolic dysfunction-associated steatohepatitis (MASH)-associated fibrosis is a pivotal stage toward end-stage liver disease. However, the immune mechanisms orchestrating the transition from inflammation to fibrosis remain elusive. We aimed to dissect the myeloid-cell crosstalk driving this transition and identify therapeutic targets. APPROACH AND RESULTS: Single-cell transcriptomic analysis of MASH mouse livers revealed expansion of infiltrating Selplg + macrophages and enhanced macrophage-neutrophil communication through the Selplg-Sell axis. This axis was consistently activated in CDAHFD- and WD+CCl 4 -induced MASH fibrosis models, and its cellular components were spatially enriched and associated with fibrosis severity in human MASLD liver tissues. Structural modeling showed that macrophage-derived Selplg engaged neutrophil Sell through a glycan-dependent interface involving sialyl-Lewis X (sLeX) recognition. In primary cell co-culture systems, Selplg-Sell engagement required direct cell-cell contact and activated neutrophil p38-MST1/2-YAP signaling, leading to YAP-dependent transcriptional activation of neutrophil extracellular trap (NET) effector programs. NETs subsequently acted as extracellular scaffolds that promoted integrin-dependent activation of latent TGF-β1, thereby driving hepatic stellate cell activation. Pharmacological blockade with the sLeX mimetic TBC-1269 or YAP inhibition attenuated hepatic inflammation, NET burden, and fibrosis under both preventive and therapeutic settings. Macrophage-lineage-specific Selplg deficiency further recapitulated these protective effects, confirming macrophage-derived Selplg as an upstream driver of this pathogenic circuit. CONCLUSIONS: This study defines a macrophage-neutrophil-HSC signaling axis linking metabolic inflammation to fibrotic remodeling in MASH. Macrophage-derived Selplg drives Sell-dependent YAP-mediated NETosis, while NETs further promote latent TGF-β1 activation and HSC activation. These findings support the axis as a therapeutic target for MASH-associated liver fibrosis.
BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease/steatohepatitis (MASLD/MASH) is a leading cause of liver disease. Despite recent drug approvals, there is a need for low-cost therapies. Poten...BACKGROUND AND AIMS: Metabolic dysfunction-associated steatotic liver disease/steatohepatitis (MASLD/MASH) is a leading cause of liver disease. Despite recent drug approvals, there is a need for low-cost therapies. Potential safety concerns regarding higher doses of vitamin E led to this study. APPROACH: Adults with suspected MASH, controlled attenuation parameter (CAP) score >280 dB/m on vibration-controlled transient elastography, and serum alanine aminotransferase (ALT) ≥60 U/L were randomized to 200, 400, or 800 IU of natural vitamin E (d-alpha tocopherol) or placebo once daily for 24 weeks. The primary aim was to determine the lowest effective dose of vitamin E that resulted in the greatest reduction in ALT levels from baseline to 24 weeks. Secondary aims were to assess improvements in other biomarkers of MASH, including liver fat and stiffness. RESULTS: Two hundred participants (age 47.0+13.9 y; 62% male) completed protocol-based visits. Serum ALT levels decreased similarly compared with placebo with all 3 doses of vitamin E: -38% (200 IU), -36% (400 IU), and -36% (800 IU) compared with -12% with placebo ( p ≤0.001 for all). ALT levels normalized in more patients taking vitamin E (49%, 37%, and 50%) than with placebo (22%). AST levels also decreased significantly. Mean reduction in CAP and liver stiffness was non-significantly greater in vitamin E-treated groups. Adverse events were mild to moderate, with no life-threatening events, and similar between vitamin E and placebo. CONCLUSIONS: Vitamin E administered at 200 IU/day was as effective as other doses tested in patients with MASLD and elevated aminotransferases. No safety signals were noted.
BACKGROUND AND AIMS: Whether HBsAg seroclearance provides further clinical benefit over complete viral suppression in nucleos(t)ide analogue (NA)-treated patients with chronic hepatitis B with cirrhosis remained unclear....BACKGROUND AND AIMS: Whether HBsAg seroclearance provides further clinical benefit over complete viral suppression in nucleos(t)ide analogue (NA)-treated patients with chronic hepatitis B with cirrhosis remained unclear. We aimed to compare the risk of HCC and hepatic decompensation in treated patients with cirrhosis with complete viral suppression versus HBsAg seroclearance. APPROACH AND RESULTS: All adult patients with chronic hepatitis B and cirrhosis receiving entecavir/tenofovir between January 2005 and September 2020 were identified. Patients with HCC before or within the first 6 months of baseline, other cancers or liver transplantation before baseline, liver transplantation before HBsAg loss, and without complete viral suppression were excluded. One-year landmark analyses were performed; patients with clinical outcomes or follow-up <1 year were excluded. Of 5149 patients (mean age 60.1±12.6 y, 66.3% male) included in the 1-year landmark analysis, 456/4988 (9.1%) and 5/161 (3.1%) of patients with complete viral suppression alone and HBsAg seroclearance developed HCC, respectively, at a median (25th-75th percentile) follow-up of 4.1 (2.5-5.0) years; 334/4777 (7.0%) and 10/153 (6.5%) patients with complete viral suppression and HBsAg loss developed hepatic events. HBsAg seroclearance was associated with a lower risk of HCC (adjusted subdistribution HR: 0.37, 95% CI 0.15-0.91, p =0.030) but not hepatic events (adjusted subdistribution HR: 1.01, 95% CI: 0.52-1.95) than complete viral suppression. Similar results on HCC were observed in a 2-year landmark analysis (adjusted subdistribution HR: 0.37 [0.14-1.04]). CONCLUSIONS: HBsAg seroclearance is associated with a lower risk of HCC but not first/further hepatic decompensation in NA-treated patients with chronic hepatitis B and cirrhosis with complete viral suppression.
BACKGROUND AIMS: Radiofrequency ablation (RFA) is becoming a standard treatment for early-stage hepatocellular carcinoma (HCC). However, high rates of postoperative recurrence, particularly following insufficient RFA (iR...BACKGROUND AIMS: Radiofrequency ablation (RFA) is becoming a standard treatment for early-stage hepatocellular carcinoma (HCC). However, high rates of postoperative recurrence, particularly following insufficient RFA (iRFA), remains a clinical obstacle. iRFA contributes to the formation of an immunosuppressive tumor microenvironment and facilitates tumor progression, though the molecular mechanisms driving these processes are not fully elucidated. This study seeks to comprehensively characterize the spatial architecture and cellular interactions within iRFA HCC, and to identify key transcriptional mechanisms through which sublethal heat stress promotes immune evasion and recurrence. APPROACH RESULTS: We integrated high-definition spatial transcriptomics (Visium HD) with single-cell RNA sequencing data to map the cellular heterogeneity and communication networks in samples from 6 HCC patients who underwent surgical resection after iRFA. Functional validation was performed using in vitro heat stress models, co-cultured assays, and orthotopic mouse models. We provided a high-resolution spatial atlas of iRFA HCC and the ablation zone, identifying a subpopulation of tumor cells exhibiting activation of the transcription factor CEBPD in response to sublethal heat stress. CEBPD directly bound to the promoter of CXCL2 and drove its expression. Up-regulation of CXCL2 diminished immune checkpoint inhibitors response in iRFA HCC through promoting SPP1+ TAM accumulation via the CXCL2/STAT3/SPP1 axis, and enhanced tumor cell invasion through autocrine signaling. CONCLUSIONS: Our study provides a comprehensive spatial characterization of HCC following iRFA, identifies the heat stress-CEBPD-CXCL2 axis as a key driver of tumor progression post-RFA, and demonstrating the therapeutic potential of CXCR2 inhibition for preventing tumor recurrence following RFA.
Li Y, Lu L, Tu J
… +16 more, Zhang J, Xiong T, Fan W, Wang J, Li M, Chen Y, Steggerda J, Peng H, Chen Y, Wh Li T, Zhou ZG, Mato JM, Seki E, Liu T, Yang H, Lu SC
Sposito C, Berardi G, Viganò M
… +15 more, Serenari M, Mazzarelli C, Paoletti M, Muttillo EM, De Giorgio M, Mosconi C, Solcia M, Chiesa C, Belli LS, Cescon M, Fagiuoli S, Lanocita R, Crocetti L, Ettorre GM, Mazzaferro V
BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) with tumoral portal vein thrombosis (PVTT) is considered a contraindication to liver transplantation (LT). Transarterial radioembolization (TARE) may induce sustained r...BACKGROUND AND AIMS: Hepatocellular carcinoma (HCC) with tumoral portal vein thrombosis (PVTT) is considered a contraindication to liver transplantation (LT). Transarterial radioembolization (TARE) may induce sustained regression of PVTT and achieve downstaging in selected patients, potentially enabling LT. The aim of this study is to assess post-LT oncological and survival outcomes in patients with HCC and PVTT who were successfully downstaged with TARE. APPROACH AND RESULTS: Consecutive patients with HCC and PVTT treated with TARE (2010-2023) at 5 Italian transplant centers were included. Successful downstaging required a sustained radiological response for at least 6 months with a complete or partial response of the PVTT component, together with fulfillment of center-specific morphological criteria and AFP thresholds. Survival analyses were conducted for the overall cohort from TARE and the transplanted patients. Among downstaged patients, cancer-related death according to transplant status was assessed using competing-risk analysis. Among 240 patients, 61 (25.4%) achieved sustained downstaging after TARE, and 37 patients (15.4%) eventually underwent LT. In competing-risk analysis, LT was associated with a lower risk of cancer-related death (60-month cumulative incidence: 15.8% vs. 45.2%; sHR 0.221, 95% CI 0.071-0.683; p =0.0087). The median time from TARE to LT was 17 months. In the 37 transplanted patients, post-LT 3-year and 5-year OS and RFS were 67.2%/61.6% and 79.3%/79.3%, respectively. Pathology showed complete tumor necrosis in 56.7% explants. CONCLUSIONS: Radioembolization downstaged ~1 in 4 PVTT patients to transplant eligibility. After downstaging, LT conferred markedly superior oncological outcomes. TARE in PVTT associated with HCC represents a valid, transplant-oriented option with a distinct efficacy profile.