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State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany

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A special issue of Biomedicines (ISSN 2227-9059). This special issue belongs to the section "Molecular and Translational Medicine".

Deadline for manuscript submissions: closed (15 December 2025) | Viewed by 14760

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Prof. Dr. Christa Büchler

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Department of Internal Medicine I, Regensburg University Hospital, 93053 Regensburg, Germany
Interests: adipose tissue; obesity; non-alcoholic fatty liver disease; adiponectin; chemerin
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Dear Colleagues,

Hepatic and gastrointestinal diseases are a broad category of conditions that affect the digestive system and the liver. Inflammatory bowel disease, irritable bowel syndrome, gastro-oesophageal reflux, celiac disease, and liver diseases, such as fatty liver disease, primary sclerosing cholangitis, and hepatocellular carcinoma, are caused by a variety of pathomechanisms that are not yet fully understood. The development of diagnostic tools, therapies, and interventions for the wide range of liver and gastrointestinal diseases requires an understanding of the cellular and molecular mechanisms. The discovery of non-invasive biomarkers for early diagnosis and prognosis is another challenge. We continue to learn more about the mechanisms underlying liver and gastrointestinal diseases thanks to developments in molecular and cellular biology, which are also driving innovation in medical research and healthcare. Pathomechanisms, diagnostics, and treatment aspects of liver and gastrointestinal diseases in Germany are the main topics of this Special Issue. Manuscripts on other topics related to liver and gastrointestinal diseases not covered here will also be considered. Studies on the course of the various diseases and on their prevalence and trends over the last few years in Germany are also very welcome. We invite original research and review articles on all novel aspects of the diagnosis and treatment of hepatic and gastrointestinal diseases in Germany.

Prof. Dr. Christa Büchler
Guest Editor

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Keywords

biomarker
prevalence
Germany
inflammatory bowel disease
cancer

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Research

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13 pages, 3122 KB

Open AccessArticle

Combined Single-Session Stereotactic Biopsy and Microwave Ablation of Primary and Secondary Liver Tumors

by Liang Zhang, Anthony Ngu, Laura Sophia Kupke, Vinzenz Mayr, Quirin Strotzer, Moritz Brandenstein, Christian Stroszczynski and Ingo Einspieler

Biomedicines 2025, 13(12), 2865; https://doi.org/10.3390/biomedicines13122865 - 24 Nov 2025

Viewed by 274

Abstract

Objective: To evaluate the safety, diagnostic yield, and ablation efficacy of a single-session workflow combining stereotactic percutaneous core-needle biopsy (CNB) immediately followed by microwave ablation (MWA) for liver tumors. Methods: We retrospectively reviewed consecutive patients (December 2021–May 2025) who underwent stereotactic CNB followed by MWA in the same procedure. Primary endpoints were primary technique efficacy (PTE) and complications. Secondary endpoints were 6-month local tumor progression (LTP) and diagnostic yield. Six-month LTP was summarized using a Kaplan–Meier (KM) point estimate with Greenwood 95% CIs. Results: Thirty-three patients underwent single-session biopsy and ablation (33 biopsied; 41 lesions ablated). PTE was 95.1% (39/41); two residual tumors were successfully re-ablated. Six-month LTP was 3.6% (patient level; KM 95% CI 0.0–10.5%) and 2.8% (lesion level; KM 95% CI 0.0–8.2%). There was one major complication (3%, post-ablation abscess) and no minor complications. Adequate tissue was obtained in all biopsies; a definitive diagnosis was established in 88% (29/33): malignancy in 73% (24/33) and benignity in 15% (5/33); 12% (4/33) were nondiagnostic. In the hepatocellular carcinoma (HCC)-suspected subgroup (LI-RADS LR-3 to LR-5; n = 24), all LR-5 lesions were HCC (11/11). Among LR-4 lesions (n = 7), histology showed HCC in 1/7 (14%) and cholangiocarcinoma in 2/7 (29%); 4/7 (57%) were benign or nondiagnostic. Among LR-3 lesions (n = 6), 2/6 (33%) were HCC and 4/6 (67%) were benign or nondiagnostic. In the metastasis-suspected subgroup (n = 9), malignancy was confirmed in 8/9 (89%); 1/9 (11%) was nondiagnostic. Conclusions: Single-session stereotactic CNB followed by MWA is feasible and safe, yields diagnostically useful tissue, and achieves high ablation efficacy. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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18 pages, 3832 KB

Open AccessArticle

Human Hepatocytes in Experimental Steatosis: Influence of Donor Sex and Sex Hormones

by Lena Seidemann, Carolin Marie Rohm, Anna Stilkerich, René Hänsel, Christina Götz, Daniel Seehofer and Georg Damm

Biomedicines 2025, 13(11), 2770; https://doi.org/10.3390/biomedicines13112770 - 12 Nov 2025

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Abstract

Background/Objectives: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a sexually dimorphic condition, with higher prevalence in men than in women. Sex differences in hepatic lipid metabolism and the modulatory role of sex hormones have been described but are still insufficiently understood. The aim of this study was to introduce the variables sex and sex hormones into a human in vitro model of hepatic steatosis. Methods: Primary human hepatocytes (PHHs) were isolated from male and female donors, treated with free fatty acids (FFA) to induce steatosis, and further exposed to physiological concentrations of estrogen, progesterone, or testosterone. Intracellular triacylglyceride (TAG) content, lipid droplet (LD) formation, FFA uptake, and very-low-density lipoprotein (VLDL) excretion were assessed. In parallel, the expression of lipid metabolism-related genes was quantified by qPCR. Results: FFA treatment induced comparable uptake and intracellular TAG storage in both sexes. However, female PHHs secreted approximately twice as many VLDL particles as male cells. Steatosis significantly increased expression of LDLR, CPT2, and PLA1A only in male PHHs. Sex hormones exerted distinct, sex-specific effects: estrogen reduced TAG accumulation in female PHHs; whereas testosterone reduced TAG in male but increased it in female PHHs after prolonged treatment. LD characterization confirmed sex- and hormone-dependent differences in lipid storage patterns. In male PHHs, progesterone promoted lipid storage and increased apoB-100 secretion, accompanied by reduced LDLR and APOA5 expression, and testosterone increased the FFA-mediated CPT2 even further. Conclusions: Sex and sex hormones distinctly shape hepatocellular lipid handling under steatotic conditions. While female PHHs demonstrated greater lipid excretion capacity, male PHHs exhibited stronger transcriptional responses. Sex-specific responses to estrogen and testosterone resembled clinical observations on sex hormone effects. These findings highlight the need to account for sex-specific differences in MASLD pathophysiology and therapeutic strategies. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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12 pages, 461 KB

Open AccessArticle

Long-Term Clinical and Endoscopic Outcomes of Crohn’s Disease Following Liver Transplantation: A Multicenter Cohort Study

by Ebru Ar, Irini Solomonidou, Henrike Lenzen, Miriam Wiestler, Claudia Veltkamp, Katharina Willuweit, Jassin Rashidi-Alavijeh, Hartmut H. Schmidt, Richard Vollenberg, Phil-Robin Tepasse, Jonel Trebicka, Stefanie Tischendorf, Carsten Elfers, Karim Hamesch and Arne Bokemeyer

Biomedicines 2025, 13(9), 2200; https://doi.org/10.3390/biomedicines13092200 - 8 Sep 2025

Viewed by 945

Abstract

Patients with Crohn’s disease (CD) may require liver transplantation (LT) due to advanced liver diseases, including primary sclerosing cholangitis (PSC), autoimmune hepatitis, or other etiologies. However, data on CD activity and the use of advanced therapies following LT are limited. This study aimed to assess CD activity before and after LT and to evaluate the use of advanced therapies in this setting. Methods: In this multicenter retrospective cohort study, we analyzed 40 patients with CD who underwent LT between 2000 and 2022 at four university hospitals in Germany. Clinical and endoscopic disease activity, as well as the use of advanced therapies, were evaluated before and after transplantation. Results: Before LT, 89.7% of patients were in clinical remission, which remained stable after LT (85.7%; p = 0.650). Nevertheless, 22.6% of these patients demonstrated moderate to severe mucosal inflammation on endoscopy during long-term follow-up. The use of advanced therapies remained low after transplantation (pre-LT: 11.7%, post-LT: 7.5%; p = 0.532) even among those with endoscopic disease activity. Conclusions: Although clinical remission of CD is usually maintained following LT, endoscopic evidence of persistent mucosal inflammation is common and may be underrecognized. Despite this, advanced therapies are not frequently used in the post-transplant setting. These findings suggest that individualized treatment strategies are needed to address subclinical disease activity while balancing therapeutic effectiveness with transplant-specific risks. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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17 pages, 2533 KB

Open AccessArticle

Novel Coating Approaches for Polyethylene Biliary Stents to Reduce Microbial Adhesion, Prevent Biofilm Formation, and Prolong Stent Patency

by Laura Wagner, Philipp Stolte, Stephan Heller, Dina Schippers, Dominik Pförringer, Jutta Tübel, Roland M. Schmid, Rainer Burgkart, Jochen Schneider and Andreas Karl-Werner Obermeier

Biomedicines 2025, 13(8), 1950; https://doi.org/10.3390/biomedicines13081950 - 9 Aug 2025

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Abstract

Background: Occlusion of plastic biliary stents is a common complication in biliary drainage, often requiring exchange procedures every 2–4 months due to microbial colonization and sludge formation. This study aimed to evaluate diamond-like carbon (DLC) coatings, with and without silver nanoparticle additives, for preventing stent occlusion. Methods: Polyethylene (PE) stents were coated with DLC using PlasmaImpax for DLC-1 and pulsed laser deposition for DLC-2. Silver ions (Ag) were incorporated into the DLC-2 coatings. To simulate in vivo conditions, a co-culture of Enterococcus faecalis (E. faecalis), Escherichia coli (E. coli), and Candida albicans (C. albicans) was used for microbial colonization. Standardized human bile simulated physiological conditions. Adhesion tests, weight measurements, and scanning electron microscopy (SEM) quantified bacterial adherence to stents. Results: DLC-1 coatings demonstrated higher bacterial growth than uncoated PE stents with E. faecalis (adhesion assay difference: 0.6 log [p = 0.19] and 0.1 log [p = 0.75] in rounds 1 and 2, respectively). In the bile incubation model, DLC-1 did not significantly reduce bacterial counts at 5 days (0.4 log [p = 0.06]) or 14 days (0.2 log [p = 0.44]). DLC-2 showed no significant reduction either. DLC-2-Ag significantly reduced bacterial adhesion (5 days: −0.3 log [p = 0.00]; 14 days: −0.4 log [p = 0.16]) and exhibited inhibition zones against E. faecalis (2.3 mm), E. coli (2.1 mm), and C. albicans (0.6 mm). SEM revealed cracks and flaking in the coating. Conclusions: DLC coatings alone did not prevent microbial adhesion. Tendencies of anti-adhesive properties were seen with Ag-doped DLC coatings, which were attributed to the antibacterial effects of Ag. Optimization of the DLC-coating process is needed to improve stent performance. Future studies with larger samples sizes are needed to confirm the observed trends. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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15 pages, 1420 KB

Open AccessArticle

Malignancy and Inflammatory Bowel Disease (IBD): Incidence and Prevalence of Malignancy in Correlation to IBD Therapy and Disease Activity—A Retrospective Cohort Analysis over 5 Years

by Agnieszka Jowita Kafel, Anna Muzalyova and Elisabeth Schnoy

Biomedicines 2025, 13(6), 1395; https://doi.org/10.3390/biomedicines13061395 - 6 Jun 2025

Cited by 1 | Viewed by 1421

Abstract

Background/Objectives: Patients with inflammatory bowel disease (IBD) are at an increased risk of various cancers; such as colorectal cancer; skin cancer; bile duct cancer; or lymphoma; with IBD itself not being the sole cause. Inappropriate or ineffective IBD therapy with a continuous inflammatory burden within the gut leads to an increased risk of malignancy. Our study aimed to investigate the risk of malignancy in our patient cohort; focusing on concomitant therapy; disease duration; and inflammatory burden. Methods: A total of 333 consecutive adult patients with IBD (Crohn’s disease; ulcerative colitis; and IBD unclassified) were included in this study. Data from patients were collected retrospectively using patient charts. The patients were treated in the gastroenterological outpatient clinic of the University Hospital of Augsburg; Germany; between 1 January 2014 and 31 December 2018. Results: The study group included 333 patients; 32 (9.61%) of whom suffered from malignancy (any form). Men (n = 21; 65.62%) tended to develop malignancy more often than women (n = 11; 34.38%, p = 0.051). It was also observed that the probability of developing cancer was 2.40 times higher in male patients than in female patients in our cohort. However, this trend was non-significant (HR = 2.412; p = 0.075). Furthermore; the probability of developing cancer increased with the increasing age at the time of the first diagnosis of IBD (HR = 1.088; p < 0.025). A total of 20 patients (6.00%) received their cancer diagnosis after being diagnosed with IBD. The majority of those patients had skin (n = 6; 30.00%) or colon cancer (n = 5; 25.00%). Other diseases such as CML; NHL; HL; HCC; liver sarcoma; prostate cancer; breast cancer; seminoma; thyroid cancer (a second cancer in one of the patients); or CUP syndrome/lung cancer were diagnosed in single patients. Patients with IBD and colon cancer (n = 5; 25.00%) shared some of the known risk factors for tumour development; such as a long-lasting IBD (n = 5; 100.00%), diagnosis at a young age (under 30; n = 3; 60.00%), and the coexistence of PSC (n = 1; 20.00%). The cancer prevalence rate was relatively low in our cohort despite the use of diverse biologics and immunosuppressive drugs. Faecal calprotectin was confirmed as a relevant tool for inflammation monitoring in this cohort. Conclusions: In our study cohort; we could show a low prevalence rate of malignancy in IBD. There were more malignancies in men and in patients who were diagnosed with IBD at later ages. It can be observed that the prevalence rate of cancer was relatively low despite the use of diverse biologics and immunosuppressive drugs; which is the major conclusion of this study. Additionally; the known correlation between elevated levels of faecal calprotectin and gut inflammation was confirmed through our statistical analysis. The use of calprotectin as a non-invasive screening tool for gut inflammation is advised. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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14 pages, 2973 KB

Open AccessArticle

The Presence and Significance of Bacteria and Fungi in Bile Aspirated During ERC—A Retrospective Analysis

by Sylvia Weigand, Arne Kandulski, Ina Zuber-Jerger, Marcus Scherer, Jens Werner, Jan Bornschein and Kilian Weigand

Biomedicines 2025, 13(5), 1255; https://doi.org/10.3390/biomedicines13051255 - 21 May 2025

Cited by 1 | Viewed by 1149

Abstract

Background: Infections of the biliary tract are found frequently in pathologically or surgically altered bile ducts. Mostly these infections result from the ascent of bacteria or fungi from the small bowel, although hematogeneous infections of the biliary system may also occur. The biliary sphincter and the continuous flow of bile are thought to prevent or limit ascending infections. Obstructive alterations in the biliary system are the most frequent indication of endoscopic retrograde cholangiography (ERC). The aim of this study was to analyze the spectrum and frequency of microbes within the bile, and discover the influence of earlier sphincterotomy. Methods: In our department, we routinely aspirate bile for microbiologic culture during ERC. For this study, all ERC performed in 2014–2018 were retrospectively analyzed, including all microbiological reports. Indications for the endoscopic examination were also recorded. In addition, the findings were correlated with whether or not a sphincterotomy had been previously performed, and whether or not there had been antibiotic treatment prior to the examination. Results: A total of 2253 successful standard ERC procedures were performed between 2014 and 2016. In 486 cases, bile was aspirated and sent for microbiologic culture. In total, 1220 bile samples were analyzed, and bacteria or fungi were found in 1029 (86.0%). Enterococci and Enterobacter were found most commonly, but E. coli, streptococci, klebsiella, and staphylococci were also found. In 11.2% of positive cultures, multiresistant pathogens were identified. In up to 29% Candida spp., most commonly, Candida albicans (68%) were also found, either alone or in conjunction with bacteria. Neither prior sphincterotomy nor the use of peri-interventional antibiotics had a major influence on the frequency with which positive bile cultures were detected. Conclusions: Aspiration of bile during ERC is of high clinical relevance, because microbiological analysis reveals the frequent presence of bacteria and fungi, knowledge of which may be useful for deciding on anti-infective treatment. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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13 pages, 7297 KB

Open AccessArticle

Stereotactic Percutaneous Electrochemotherapy as a New Minimal Invasive Treatment Modality for Primary and Secondary Liver Malignancies

by Lukas Luerken, Andrea Goetz, Vinzenz Mayr, Liang Zhang, Alexandra Schlitt, Michael Haimerl, Christian Stroszczynski, Hans-Jürgen Schlitt, Matthias Grube, Arne Kandulski and Ingo Einspieler

Biomedicines 2024, 12(12), 2870; https://doi.org/10.3390/biomedicines12122870 - 17 Dec 2024

Cited by 1 | Viewed by 1333

Abstract

Background and Objectives: To report on the first results of safety, efficacy, and outcome of CT-navigated stereotactic percutaneous electrochemotherapy (SpECT) in patients with primary and secondary liver malignancies. Methods: This retrospective study included 23 consecutive lesions in 22 patients who underwent SpECT for primary and secondary malignant liver lesions with locally curative intention. The endpoints were primary technique efficacy (PTE), local tumor progression (LTP), time to progression (TTP), and occurrence of adverse events. Results: The mean maximum diameter of the treated lesions was 42 mm (range: 16 mm–72 mm). Eight lesions were hepatocellular carcinoma (34.8%), five lesions were colorectal liver metastases (21.7%), three lesions were cholangiocellular carcinoma (13.0%), and the other seven lesions were liver metastases from different primary cancers (30.4%). PTE was achieved for 22 lesions (95.7%). The mean follow-up time was 15 months (0–39 months). No LTP was observed. In six patients (27.3%), hepatic tumor progression was observed during follow-up with a mean TTP of 3.8 months (2–8 months). In 10 procedures (43.5%), minor complications (1 CIRSE Grade 2) and side effects occurred, but no major complications were observed. Conclusions: SpECT seems to be a safe and effective new local treatment modality for primary and secondary liver malignancies. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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12 pages, 1831 KB

Open AccessArticle

Fecal Nervonic Acid as a Biomarker for Diagnosing and Monitoring Inflammatory Bowel Disease

by Claudia Kunst, Tanja Elger, Johanna Loibl, Muriel Huss, Arne Kandulski, Sabrina Krautbauer, Martina Müller, Gerhard Liebisch, Hauke Christian Tews and Christa Buechler

Biomedicines 2024, 12(12), 2764; https://doi.org/10.3390/biomedicines12122764 - 4 Dec 2024

Cited by 4 | Viewed by 2177

Abstract

Background/Objectives: Inflammatory bowel disease (IBD) is a chronic immune-mediated pathology associated with the dysregulation of lipid metabolism. The administration of nervonic acid, a very long-chain fatty acid, has been shown to improve colonic inflammation in a mouse model of colitis. Our study aimed to quantify fecal levels of nervonic acid, as well as the very long-chain fatty acids, lignoceric acid, and pentacosanoic acid, to identify associations with IBD activity. Methods: Stool samples were collected from 62 patients with IBD and 17 healthy controls. Nervonic acid, lignoceric acid, and pentacosanoic acid were quantified by gas chromatography coupled with mass spectrometry (GC-MS). Lipid levels, normalized to the dry weight of fecal homogenates, were used for calculations. Results: Patients with IBD exhibited elevated fecal nervonic acid levels compared to healthy controls, with no significant differences observed between ulcerative colitis and Crohn’s disease. A fecal nervonic acid concentration of 0.49 µmol/g distinguished IBD patients from controls, achieving a sensitivity of 71% and a specificity of 82%. Fecal nervonic acid levels showed a positive correlation with both C-reactive protein and fecal calprotectin and increased proportionally with rising fecal calprotectin levels. IBD patients treated with corticosteroids or interleukin-12/23 antibodies had higher levels of fecal nervonic acid than those in other therapies, with no difference in serum C-reactive protein and calprotectin levels between these groups. Conclusions: In summary, this analysis indicates that fecal nervonic acid may emerge as a novel specific biomarker for IBD diagnosis and disease monitoring. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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23 pages, 2469 KB

Open AccessReview

Esophageal Lichen Planus—Contemporary Insights and Emerging Trends

by Wolfgang Kreisel, Rebecca Diehl, Annegrit Decker, Adhara Lazaro, Franziska Schauer and Annette Schmitt-Graeff

Biomedicines 2025, 13(11), 2621; https://doi.org/10.3390/biomedicines13112621 - 26 Oct 2025

Viewed by 680

Abstract

Background: Lichen planus (LP) is a common inflammatory disease affecting skin, mucous membranes, hairs, and nails, with an unpredictable course involving remissions and relapses. LP is a Type-I-Inflammation disease involving IFN-γ and IL-17 as key inflammatory mediators. Materials and Methods: We searched PubMed/MEDLINE and Google Scholar search engines for studies on the esophageal manifestation of lichen planus over an unlimited time frame. Articles were searched with combinations of Medical Subject Heading (MeSH) terms. Given the limited number of publications, no exclusion criteria were applied. Results: Esophageal lichen planus (ELP) is an underreported manifestation of LP that primarily affects middle-aged women. Its prevalence among LP patients remains to be defined. Though potentially clinically silent, ELP can significantly impact patient wellbeing and serve as a precursor to esophageal squamous cell carcinoma. While dysphagia is the primary symptom, the condition may also remain subclinical. The endoscopic hallmarks of ELP are mucosal denudation and tearing, trachealization, and hyperkeratosis. Chronic disease progression may lead to scarring esophageal stenosis. Histologically, ELP shows mucosal detachment, T-lymphocytic infiltrations, epithelial cell apoptosis (Civatte bodies), dyskeratosis, and hyperkeratosis. Fibrinogen deposits along the basement membrane zone distinguish ELP from various immunological esophageal diseases. There is currently no standardized therapy available. Topical steroids lead to symptomatic and histologic improvements in two-thirds of patients. Severe or refractory cases require immunosuppressive therapy, whereas JAK-inhibitors represent a promising emerging option. Endoscopic dilation helps symptomatic stenosis. Considering ELP’s precancerous potential, timely diagnosis and treatment are crucial in preventing complications, such as stenosis or invasive esophageal squamous cell carcinoma. Conclusions: ELP is an underdiagnosed and underreported manifestation of LP. While it may remain clinically silent, it can nevertheless significantly affect patients’ wellbeing and life expectancy. This narrative review aims to initiate multidisciplinary cooperation among gastroenterologists, dermatologists, oral health professionals, and histopathologists to support clinical diagnosis and management. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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19 pages, 990 KB

Open AccessReview

Acute-on-Chronic Liver Failure—Current Management and Future Perspectives

by Benedict Allhoff, Christoph Neumann-Haefelin and Philipp Kasper

Biomedicines 2025, 13(9), 2193; https://doi.org/10.3390/biomedicines13092193 - 8 Sep 2025

Viewed by 3882

Abstract

Acute-on-chronic liver failure (ACLF) is a distinct clinical syndrome characterized by an acute decompensation of chronic liver disease in association with extrahepatic organ failure(s) and a high short-term mortality. Despite its increasing clinical relevance, there is no internationally standardized definition of ACLF to date. This review provides a comprehensive overview of current ACLF definitions, underlying pathogenic mechanisms, frequent precipitating events, and current treatment strategies. While liver transplantation remains the only curative treatment option, its role in the setting of ACLF is controversially debated, and patient selection remains complex due to high perioperative risk. Thus, the review article describes the current role of liver transplantation in patients with ACLF and describes novel prognostic scoring systems (e.g., TAM core, SALT-M model) that may be helpful in selecting suitable transplant candidates. Further emerging treatment options for ACLF include extracorporeal liver support systems, therapeutic plasma exchange, and immune-modulating approaches targeting toll-like receptor signaling that offer promising adjunctive strategies, though clinical evidence remains limited. Given the high burden and complexity of ACLF, harmonized definitions and evidence-based therapeutic frameworks are urgently needed to improve patient care and optimize transplant prioritization. Full article

(This article belongs to the Special Issue State-of-the-Art Hepatic and Gastrointestinal Diseases in Germany)

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