Livers, Volume 5, Issue 1 (March 2025) – 14 articles

Artificial intelligence (AI) has emerged as a transformative field in computational research with diverse applications in medicine, particularly in the field of liver transplantation (LT) given its ability to analyze and build upon complex and multidimensional data. This literature review investigates the application of AI in LT, focusing on its role in pre-implantation biopsy evaluation, development of recipient prognosis algorithms, imaging analysis, and decision-making support systems, with the findings revealing that AI can be applied across a variety of fields within LT, including diagnosis, organ allocation, and surgery planning. As a result, algorithms are being developed to assess steatosis in pre-implantation biopsies and predict liver graft function, with AI applications displaying great accuracy across various studies included in this review. Despite its relatively recent introduction to transplantation, AI demonstrates potential in delivering cost and time-efficient outcomes. However, these tools cannot replace the role of healthcare professionals, with their widespread adoption demanding thorough clinical testing and oversight. Full article

Introduction: We describe the first reported case of auto-brewery syndrome complicating liver transplantation, wherein a patient was temporarily removed from a liver transplant list not due to ethanol consumption but rather spontaneous ethanolic fermentation within the gastrointestinal tract. Auto-brewery syndrome (ABS) is a rare metabolic condition where gastrointestinal microbiota dysbiosis leads to spontaneous microbial ethanolic fermentation under anaerobic, high carbohydrate conditions. Because no alcohol is directly consumed by the patient, this alcohol is often referred to as “endogenous”. Methods: We present a case where a patient awaiting orthotopic liver transplantation was removed from the transplant list due to significantly elevated blood alcohol levels. However, an upper endoscopy revealed Candida esophagitis, and the diagnosis of ABS was made. Results: With antifungal fluconazole treatment, the patient’s blood alcohol biomarkers decreased, and the patient underwent a successful liver transplantation. Discerning between patient exogenous alcohol consumption and endogenous alcohol production with ABS remains a significant challenge for clinicians, and this knowledge could have serious implications for a patient awaiting a life-saving liver transplant. Conclusions: This case highlights the importance of listening to the patient and carefully assessing potential liver transplant recipients who consistently deny alcohol consumption, specifically for gut dysbiosis and ABS. Full article

Introduction: The significant impact of nonalcoholic fatty liver disease (NAFLD) on public health, combined with the limitations of current diagnostic approaches, demands a more comprehensive and accurate method to identify NAFLD cases in large general populations. Methods: In this cross-sectional study, we recruited 3733 individuals (average age 51.8 years) who underwent health check-ups between October 2015 and October 2016. NAFLD was diagnosed using ultrasound; 114 serum metabolites were measured using gas chromatography–mass spectrometry. We adopted the least absolute shrinkage and selection operator (LASSO) method to build a metabolomic-based diagnostic model. Results: NAFLD was diagnosed in 826 participants. While each metabolite exhibited a limited diagnostic ability for NAFLD when used individually, compared with BMI, the model constructed using the LASSO demonstrated adequate diagnostic power (area under the curve [AUC] 0.866, 95% confidence interval 0.847–0.885 in test set) and even for lean (BMI < 23) populations (AUC for LASSO 0.828, for BMI 0.78). Moreover, the LASSO model-derived ‘pre-NAFLD’ condition showed a potential association with insulin resistance and elevated triglycerides. Conclusions: Our metabolomic-based approach provides a comprehensive evaluation of NAFLD or ‘pre-NAFLD’, both considered parts of a hypothetical ‘NAFLD spectrum’, independent of body type. Metabolomics could offer additional diagnostic benefits and potentially expand the disease concept. Full article

Non-alcoholic fatty liver disease (NAFLD), recently redefined as metabolic dysfunction-associated steatotic liver disease (MASLD), is the most common cause of chronic liver disease worldwide. Characterized by excessive hepatic fat accumulation, this disease encompasses a spectrum from simple steatosis to more severe forms, including steatohepatitis, fibrosis, and cirrhosis. Emerging evidence highlights the pivotal role of gut dysbiosis in the pathogenesis of MASLD. Dysbiosis disrupts the gut–liver axis, an intricate communication network that regulates metabolic, immune, and barrier functions. Alterations in gut microbiota composition, increased gut permeability, and translocation of pro-inflammatory metabolites/factors have been shown to trigger liver inflammatory and fibrotic cascades, exacerbating hepatic inflammation and injury. Recent studies have identified microbiome signatures associated with MASLD, offering promise as non-invasive diagnostic biomarkers and paving the way for new potential therapeutic strategies targeting gut dysbiosis. This review explores the crucial role of the gut microbiota in MASLD pathogenesis and highlights the need for further targeted research in this field to validate microbial biomarkers and optimize therapeutic strategies. Comprehensive understanding of the gut–liver axis may enable innovative diagnostic and therapeutic approaches, transforming the clinical management of MASLD. Full article

Background/Objectives: Transarterial chemoembolization (TACE) is the most widely used bridging treatment for hepatocellular carcinoma (HCC) before liver transplantation (LT) but may be associated with dropout and post-LT HCC recurrence. We aimed to identify a subgroup of HCC LT candidates at high risk of TACE-to-LT strategy failure (TLSF). Methods: All consecutive HCC LT candidates with French AFP-scores ≤ 2 who underwent at least one bridging TACE at Paul Brousse Hospital in 2013–2018 were included (n = 173). Dropout for HCC progression during waiting list and post-LT HCC recurrence was defined TLSF. Results: The one-year TLSF cumulative incidence was 15%. According to univariate analysis, pre-TACE AFP > 15 ng/mL was the only factor associated with decreased overall survival (OS) and TLSF-free survival (TLSF-FS) after the first TACE. The absence of complete radiological response (CRR) or pre-TACE AFP > 15 ng/mL were associated with reduced OS and TLSF-FS after a second TACE (n = 118). The cumulative incidence of TLSF reached 41% one year after the second TACE in patients with both AFP > 15 ng/mL and no CRR, while it was 7% for others (p < 0.001). Conclusions: HCC patients receiving bridging TACE, with pre-TACE AFP > 15 ng/mL and no CRR after two TACEs, are at high risk of delisting for HCC progression or of post-LT recurrence. Alternative therapeutic strategies should be proposed early for this better-defined population. Full article

Conventionally, drug-induced liver injury (DILI) exists in two types: idiosyncratic and intrinsic. Both types are classified as non-immune disorders, thereby ignoring that some iDILI cases may have an immune or autoimmune background that requires a different therapeutic approach because steroids may be helpful. The purpose of this analysis was to analyze and classify the subtypes of iDILI which, indeed, show autoimmune or immune features among four cohorts, namely idiosyncratic DILI type 1: idiosyncratic drug-induced autoimmune hepatitis (DIAIH), to be differentiated from the classic drug-unrelated idiosyncratic autoimmune hepatitis (AIH); idiosyncratic DILI type 2: human leucocyte antigen-based idiosyncratic drug-induced autoimmune hepatitis; idiosyncratic DILI type 3: anti-cytochrome P450-based idiosyncratic drug-induced autoimmune hepatitis; and idiosyncratic DILI type 4: immune-based idiosyncratic drug-induced liver injury associated with Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). In conclusion, the traditional non-immune and non-autoimmune iDILI, as well as the four immune or autoimmune iDILI subtypes, are now well classified and clinically characterized by the broadly applied Roussel Uclaf Causality Assessment Method (RUCAM), facilitating additional immunology and therapy studies for the four subtypes, all of which could benefit from steroid treatment. Full article

Liver transplantation (LT) in the United States is evolving in response to shifting disease patterns, innovative therapies, and technological advancements. Metabolic-associated fatty liver disease (MAFLD) and alcohol-associated liver disease (ALD) now are the most common indications for LT, reflecting the impact of the obesity epidemic and increased alcohol consumption. Advances in pharmacotherapy for MAFLD and tailored protocols for ALD management are reducing disease progression and improving outcomes. The inclusion of colorectal liver metastases (CRLM) and intrahepatic cholangiocarcinoma (iCCA) as transplant indications highlights progress in chemotherapy and patient selection. Technologies like normothermic machine perfusion (NMP) are expanding the donor pool, while xenotransplantation and organ rehabilitation offer transformative solutions to organ shortages. As the population ages, LT programs must address challenges in older patients and explore minimally invasive approaches for donors and recipients. By integrating innovation and multidisciplinary expertise, LT will continue to provide life-saving care while adapting to the needs of diverse patient populations. Full article

The global burden of liver metastases from different primary lesions is increasing, resulting in significant challenges for public health systems. Accordingly, colorectal cancer (CRC) remains a leading cause of cancer-related mortality, with a high incidence of liver metastases. Although surgical resection is considered the standard curative treatment, it is only viable for a limited subset of patients. This review aims to describe a potential alternative nonsurgical intervention, such as electrochemotherapy (ECT), in the treatment of CRC oligometastatic liver disease. ECT has been largely used for the treatment of cutaneous and subcutaneous lesions, while its visceral use is currently a novel approach. ECT consists of the administration of intravenous anticancer drugs, followed by the application of intralesional electrode needles, which release localized electrical pulses to induce electroporation, a process that transiently increases cell membrane permeability, thereby facilitating the intracellular delivery of otherwise membrane-impermeable drugs. The main topics of this review focus on the technical and clinical applications, efficacy, safety, and possible complications of ECT for CRC liver metastases. A comparison with other locoregional treatments is also performed, highlighting possible advantages and disadvantages. Full article

Liver fibrosis is a very complicated dynamic process where several immune cells are involved. Both innate and adaptive immunity are implicated, and their interplay is always present. Multi-directional interactions between liver macrophages, hepatic stellate cells (HSCs), immune cells, and several cytokines are important for the induction and perpetuation of liver fibrosis. Detailed studies of proteomics and transcriptomics have produced new evidence for the role of individual cells in the process of liver fibrosis and cirrhosis. Most of these cells are controlled by the various immune checkpoints whose main function is to maintain the homeostasis of the implicated immune cells. Recent evidence indicates that several immune checkpoints are involved in liver fibrosis. In particular, the role of the programmed cell death protein 1 (PD-1), the programmed death-ligand 1 (PD-L1), and the role of the cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) have been investigated, particularly after the availability of checkpoint inhibitors. Their activation leads to the exhaustion of CD4+ve and CD8+ve T cells and the promotion of liver fibrosis. In this review, the current pathogenesis of liver fibrosis and the immunological abnormalities are discussed. The recent data on the involvement of immune checkpoints are identified as possible targets of future interventions. Full article

Metabolic dysfunction-associated steatotic liver disease (MASLD) is the novel terminology encompassing liver disease associated with metabolic dysfunction, replacing the previous terminology of non-alcoholic fatty liver disease (NAFLD). This disease is strongly associated with metabolic disorders such as obesity, type 2 diabetes, and dyslipidemia. MASLD and dyslipidemia are deeply interconnected, driven by shared pathophysiological mechanisms. Emerging evidence suggests that statins, a class of lipid-lowering medications, may have beneficial effects on MASLD beyond their primary role in reducing cholesterol levels through several mechanisms, including anti-inflammatory, antioxidant, anti-fibrosis, and immunomodulatory effects. This review aims to summarize the efficacy of statins in the management of MASLD and provide insights into their potential mechanisms of action. It discusses the pathophysiology of MASLD and the role of statins in targeting key aspects of the disease. Additionally, the review examines the clinical evidence supporting the use of different statins in MASLD treatment and highlights their specific effects on liver enzymes, inflammation, and fibrosis. Furthermore, an algorithm for statin therapy in MASLD is proposed based on the current knowledge and available evidence. Full article

The authors of this study focused their research on developing cap geometries for the FibroScan^® elastograph (FibroScan, EchoSens, Paris, France) measuring head aimed at a non-invasive assessment of liver condition for transplantation using a pig animal model. Numerical models were created to simulate the propagation of a mechanical wave through a biological medium induced by the FibroScan^® elastograph measuring head. The designed caps were intended to replicate the skin–muscle–rib–liver structures to minimize the risk of damage caused by mechanical wave excitation when directly applied to liver tissue. The construction process of numerical models for the liver and surrounding tissues is presented, along with simulations reflecting the mechanical and acoustic properties of the wave propagation process. The results obtained from in vivo measurements on pigs were validated through a numerical analysis, confirming a high level of agreement between the test results and the numerical model. Full article

Chronic liver disease poses significant challenges to healthcare systems, which frequently struggle to meet the needs of end-stage liver disease patients. Early detection and management are essential because liver damage and fibrosis are potentially reversible. However, the implementation of population-wide screenings is hindered by the asymptomatic nature of early chronic liver disease, along with the risks and costs associated with traditional diagnostics, such as liver biopsies. This study pioneers the development of innovative, minimally invasive methods capable of improving the outcomes of liver disease patients by identifying liver disease biomarkers using quantification methods with translational potential. A targeted mass spectrometry assay based on stable isotope standard protein epitope signature tags (SIS-PrESTs) was employed for the absolute quantification of 108 proteins in just two microliters of plasma. The plasma profiles were derived from patients of various liver disease stages and etiologies, including healthy controls. A set of potential biomarkers for stratifying liver fibrosis was identified through differential expression analysis and supervised machine learning. These findings offer promising alternatives for improved diagnostics and personalized treatment strategies in liver disease management. Moreover, our approach is fully compatible with existing technologies that facilitate the robust quantification of clinically relevant protein targets via minimally disruptive sampling methods. Full article

Background: This study addresses a particular aspect of the biological behavior of the Spike subunit S1 of SARS-CoV-2. Researchers observed S1 acting freely in the human organism during and after COVID-19 and vaccination. One of its properties is that it interacts one-to-one with human proteins. S1 interacts with 12 specific human proteins in the liver. Methods: We used these proteins as seeds to extract their functional relationships from the human proteome through enrichment. The interactome representing the set of metabolic activities in which they are involved shows several molecular processes (KEGG), including some linked to HBV (hepatitis B) and HCC (hepatocellular carcinoma) with many genes/proteins involved. Reports show that, in some COVID patients, HBV reactivated or progressed to cancer. Results: We analyzed the interactome with several approaches to understand whether the two pathologies have independent progressions or a common progression. All our efforts consistently showed that the molecular processes involving both HBV and HCC are significantly present in all approaches we used, making it difficult to extract any useful information about their fate. Through BioGRID, we extracted experimental data in vivo but derived it from model cell systems. The lack of patient data in STRING results prevents diagnosis or prediction of real disease progression; therefore, we can consider them “aseptic” model data. Conclusion: The interactome tells us that genes involved in HCC and HVB-related pathways have the potential to activate disease processes. We can consider them as a gold standard. It is the comparison with similar molecular interactions found in individual human phenotypes that shows us whether the phenotype favors or hinders their progression. This also suggests how to use these features. These sets of proteins constitute a molecular “toolkit”. In fact, if we compare them with similar molecular sets of the patient, they will provide us with information on the level of the phenotypic state that is driving the disease. The information derived from the composition of an entire group of proteins is broader and more detailed than a single marker. Therefore, these protein compositions can serve as a reference system with which doctors can compare specific cases for personalized molecular medicine diagnoses. Full article