Zhen Tian

Background: Maternal total bile acids (TBA) guide management of intrahepatic cholestasis of pregnancy (ICP), but the relationship of hepatic injury markers with fetal growth restriction (FGR) remains uncertain. Methods: We analyzed 110 ICP and 110 non-ICP pregnancies in a retrospective single-center cohort. Clinically recorded FGR was verified against source medical records, including ultrasound reports, but not against standardized fetal-growth percentiles. TBA at ICP diagnosis and the highest TBA during pregnancy were analyzed separately. An exploratory Firth-penalized logistic model assessed alanine aminotransferase (ALT), IVF-coded conception and diagnostic TBA. Two induction-only records were excluded from the main preterm analysis. Results: Recorded FGR occurred in 16/110 ICP versus 1/110 control pregnancies (14.5% vs 0.9%; Fisher P< 0.001). Mean birth weights were 2695 versus 3281 g (P< 0.001). Within ICP, median ALT was 195 versus 46 U/L with and without FGR (P=0.016); AST showed a nonsignificant unadjusted difference (P=0.062). Recorded FGR rose across data-derived ALT quartiles (10.0%, 4.0%, 14.3% and 29.6%; ordinal trend P=0.030). In the exploratory Firth model (16 events), ALT had an odds ratio (OR) of 1.046 per 10 U/L (95% CI 1.018– 1.079; P=0.001), but exclusion of the highest 5% of ALT values attenuated the association (P=0.079). FGR was 13/81 versus 3/29 across pregnancy-peak TBA strata (P=0.553). Preterm births were 33/80 versus 16/28 (OR 1.899, 95% CI 0.795– 4.537; P=0.149); the diagnosis-time TBA preterm trend was also nonsignificant (OR 1.395, 95% CI 0.807– 2.411; P=0.233). Conclusion: Hepatocellular injury markers, primarily ALT with AST secondary, showed fragile, hypothesis-generating associations with recorded FGR in this selected cohort, whereas total bile acid severity did not track recorded FGR; absent TBA associations establish neither a null effect nor marker superiority. Larger prospective studies with standardized FGR ascertainment and timed blood tests are required.

Background Esophageal variceal bleeding (EVB) is a life-threatening complication of cirrhosis, necessitating accurate risk stratification. Current non-invasive methods lack sensitivity to dynamic hemodynamic changes. This study aimed to develop a VExUS ultrasound-based model integrating renal venous congestion and superior mesenteric artery (SMA) hemodynamics for noninvasive EVB risk prediction. Materials and Methods This retrospective study enrolled 161 patients with liver cirrhosis. Based on endoscopic findings, participants were stratified into two groups: those receiving endoscopic band ligation (EBL) (±pharmacotherapy) (n=78, 48.4%) and those managed conservatively (n=83, 51.6%). VExUS parameters, including renal vein Doppler patterns and superior mesenteric artery (SMA) peak systolic velocity (PSV), were analyzed alongside liver function markers. Using endoscopic results as the reference standard, we developed a predictive model for high-risk esophageal varices.The study protocol was approved by the Institutional Ethics Committee (No. XJTU1AF2024LSYY-339) and complied with the Declaration of Helsinki. Results The combination model (renal venous congestion + SMA-PSV + ALT) achieved an AUC of 0.931 (95% CI: 0.8916–0.9703), significantly outperforming individual parameters (p<0.01). Renal venous congestion alone showed an AUC of 0.841 (95% CI: 0.7745–0.9066). Conclusion The VExUS-based model provides a noninvasive, accurate tool for EVB risk stratification, potentially reducing reliance on endoscopy.

Background: Intrahepatic cholestasis of pregnancy (ICP) is characterized by skin pruritus, elevated liver enzymes, and increased serum total bile acids. Several previous studies have revealed that the fasting and ejection volumes of the gallbladder in cholestasis of pregnancy are greater than those in normal pregnancy. The goal of this study was to explore the gallbladder volume and evaluate the diagnostic and prognostic value of ultrasound in ICP. Methods: We prospectively recruited a cohort of 60 ICP patients at the First Affiliated Hospital of Xi’an Jiaotong University, Shaanxi, China from January 2020 to December 2021 and compared their data with those from healthy pregnant women (n = 60). The gallbladder volume was evaluated by real-time ultrasound examination after overnight fasting and at 30, 60, 120, and 180 min after a liquid test meal of 200 mL, and the ejection fraction was calculated. Continuous data between two groups were compared by Student’s t test. Differences were considered significant for p < 0.05. The diagnostic and prognostic value of the volume and ejection function of the gallbladder was analyzed by the receiver operating characteristic (ROC) curve. Results: The ICP group had significantly higher gallbladder basal volume (43.49 ± 1.34 cm³ vs. 26.66 ± 0.83 cm³, p < 0.01) and higher ejection fraction compared with the healthy group. The ejection fraction higher than 54.55% at 120 min might predict ICP diagnosis with 96.67% sensitivity and 88.33% specificity, and an AUC of 0.9739 (95% CI 0.9521–0.9956), while the gallbladder volume higher than 12.52 cm³ at 60 min might predict ICP severity with 59.18% sensitivity and 72.73% specificity, and an AUC of 0.7319 (95% CI 0.5787–0.8852). Conclusion: Our results indicate abnormal volume and ejection function of the gallbladder in patients with ICP. The ejection fraction at 120 min can assist in the diagnosis if ICP exists, and the gallbladder volume at 60 min may assess the degree of severity of ICP.

There is an increasing evidence indicating the involvement of the sympathetic nervous system (SNS) in liver disease development. To achieve an extensive comprehension of the obscure process by which the SNS alleviates inflammatory damage in non-parenchymal liver cells (NPCs) during acute liver failure (ALF), we employ isoproterenol (ISO), a beta-adrenoceptor agonist, to mimic SNS signaling. ISO was administered to C57BL/6J mice to establish an acute liver failure (ALF) model using LPS/D-GalN, which was defined as ISO + ALF. Non-parenchymal cells (NPCs) were isolated from liver tissues and digested for tandem mass tag (TMT) labeled proteomics to identify differentially expressed proteins (DEPs). The administration of ISO resulted in a decreased serum levels of pro-inflammatory cytokines, e.g., TNF-α, IL-1β, and IL-6 in ALF mice, which alleviated liver damage. By using TMT analysis, it was possible to identify 1587 differentially expressed proteins (DEPs) in isolated NPCs. Notably, over 60% of the DEPs in the ISO + ALF vs. ALF comparison were shared in the Con vs. ALF comparison. According to enrichment analysis, the DEPs influenced by ISO in ALF mice were linked to biological functions of heme and fatty acid metabolism, interferon gamma response, TNFA signaling pathway, and mitochondrial oxidation function. Protein-protein interaction network analysis indicated Mapk14 and Caspase3 may serve as potentially valuable indicators of ISO intervention. In addition, the markers on activated macrophages, such as Mapk14, Casp1, Casp8, and Mrc1, were identified downregulated after ISO initiation. ISO treatment increased the abundance of anti-inflammatory markers in mouse macrophages, as evidenced by the immunohistochemistry (IHC) slides showing an increase in Arg + staining and a reduction in iNOS + staining. Furthermore, pretreatment with ISO also resulted in a reduction of LPS-stimulated inflammation signaling markers, Mapk14 and NF-κB, in human THP-1 cells. Prior treatment with ISO may have the potential to modify the biological functions of NPCs and could serve as an innovative pharmacotherapy for delaying the pathogenesis and progression of ALF.

Background. Inflammation plays a critical role in the progression of acute-on-chronic liver failure (ACLF). Atg13 is a vital regulatory component of the ULK1 complex, which plays an essential role in the initiation of autophagy. Previously, hepatic stellate cells (HSCs) were considered to be noninflammatory cells that contribute only to hepatic fibrosis. Recently, it has been found that HSCs can secrete inflammatory cytokines and participate in hepatic inflammation. Autophagy and proteasome-mediated degradation constitute two major means of protein turnover in cells. Autophagy has been shown to regulate inflammation, but it is unclear whether ubiquitin (Ub)-proteasome system (UPS) is involved in inflammatory responses in HSCs during ACLF. Methods. Clinical data were collected from ACLF patients, and surgically resected paraffin-embedded human ACLF liver tissue specimens were collected. The expression of Atg13 was assessed by quantitative real-time polymerase chain reaction (qRT-PCR) and Western blotting. Secretion of IL-1β was assessed by ELISA. Atg13 was knocked down by siRNA in LX2 cells. Coimmunoprecipitation assay was used to detect protein binding and polyubiquitination of Atg13. In vitro tests with LX2 cells were performed to explore the effects and regulation of p38 MAPK, Atg13, UPS, autophagy, and inflammation. Results. Serum lipopolysaccharide (LPS) was positively associated with disease severity in ACLF patients, and p38 MAPK was overexpressed in ACLF liver tissue. We evaluated the role of Atg13 in HSC inflammation and explored the possible underlying mechanisms. Inflammatory factors were upregulated via activation of p38 MAPK and inhibition of autophagy in LX-2 cells. Expression of Atg13 was decreased in LPS-incubated LX2 cells. Atg13 knockdown markedly inhibited autophagy and promoted LPS-induced inflammation in LX2 cells. Our in vitro experiments also showed that LPS induced depletion of Atg13 via UPS, and this process was dependent on p38 MAPK. Conclusions. LPS induces proteasomal degradation of Atg13 via p38 MAPK, thereby participating in the aggravation of LPS-induced autophagy inhibition and inflammatory responses in LX2 cells. Atg13 serves as a mediator between autophagy and proteasome. Modulation of Atg13 or proteasome activity might be a novel strategy for treating HSC inflammation.

Background and Aim: Fewer than 50% of patients with acute-on-chronic liver failure (ACLF) recover spontaneously, and without liver transplantation, ACLF is associated with high death rates. Nitric oxide (NO) has a role in the pathogenesis of various liver disorders. We investigated if serum NO level could be used as a biomarker to predict the severity and prognosis of patients with ACLF. Methods: Between January 2018 and September 2020, a retrospective cohort of 120 ACLF patients, as well as healthy and cirrhotic controls, was investigated. The serum NO levels were measured using a commercial ELISA kit, and Kaplan–Meier survival analysis was conducted. Results: ACLF patients had significantly higher serum NO levels than healthy and cirrhotic controls. Multivariate analysis indicated that the serum NO level (HR=1.078, 95% CI 1.031– 1.126, P< 0.01), as well as the Model for End-stage Liver Disease (MELD) score, may be an affordable, easily available, and significant independent predictive marker for mortality. In ACLF patients, a serum NO level of > 53.5 μmol/L was associated with a significant increase in the risk of mortality or liver transplantation. A combination of serum NO level and MELD score to assess the severity and prognosis of ACLF patients showed enhanced performance. Conclusion: Based on serum NO levels at the time of hospital admission, ACLF patients may be divided into high-risk and low-risk groups. The combination of serum NO level and MELD score is more closely linked to the patient’s outcome than either value alone. This method might be used to evaluate patient prognoses and select candidates for liver transplantation.

Background: Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is the most prevalent type of ACLF in China. The mortality rate of HBV-ACLF has decreased in recent years due to advances in treatment therapies; however, it is still above 50%. Many cases of HBV-ACLF are caused by HBV reactivation due to discontinuation of nucleoside analog treatment. The present study focused on plasma levels of superoxide dismutase (SOD) in HBV-ACLF patients and investigated whether the plasma level of SOD is a useful biomarker in assessing disease severity and predicting outcomes of HBV-ACLF patients, including patients treated with Entecavir (ETV) and patients who were withdrawn from ETV treatment. Methods: Plasma samples and clinical data from 200 HBV-ACLF patients and from age- and sex-matched cirrhotic and healthy controls were collected and analyzed. Plasma levels of SOD were measured using an ELISA commercial kit. Results: Among the HBV-ACLF patients, in the ETV withdrawal group, the mortality rate was higher than in the ETV group (69.95% vs 46.71%, P < 0.05). Moreover, HBV-DNA and SOD plasma levels were higher in the ETV withdrawal group than in the ETV group (Log₁₀(HBV-DNA): 6.49 ± 0.24 vs 4.79 ± 0.14, P < 0.01; SOD: 463.1 ± 27.61 U/mL vs 397.2 ± 10.97 U/mL, P < 0.05). The mortality and liver transplantation rates were significantly higher in HBV-ACLF patients with plasma levels of SOD > 428 U/mL than in patients with plasma SOD levels ≤ 428 U/mL. Conclusions: Reactivation of HBV and elevated oxidative stress caused by discontinuation of ETV treatment are crucial factors in the pathogenesis of HBV-ACLF. Plasma level of SOD may serve as a useful biomarker in estimating disease severity and predicting outcomes of HBV-ACLF patients who stop ETV treatment.

Background. Inflammation is a critical factor in the development and progression of myocardial infarction and cardiac fibrosis. Thymosin β4 (Tβ4) alleviates the disease process via protective antioxidant and anti-inflammatory mechanisms. Although Tβ4 has been shown to have a protective effect in myocardial infarction, its impact on cardiac fibrosis has not been well reported. In this study, we evaluated the influence of exogenous Tβ4 on myocardial infarction and cardiac fibrosis and explored the possible underlying mechanism. Methods. Real-time quantitative reverse-transcription PCR (qRT-PCR), immunohistochemistry (IHC), and Western blot were used to analyze Tβ4 expression in acute myocardial infarction (AMI) cardiac tissues. The effects of intraperitoneal adeno-associated virus-Tβ4 (AAV-Tβ4) on ligation-induced AMI in mice were studied using cardiac function parameters, and RT-PCR, Western blot, HE staining, Masson staining, and IHC were used to assess the degree of myocardial fibrosis. The effects of Tβ4 were confirmed in vitro using mouse cardiac myocytes and myofibroblasts. Results. Tβ4 was shown to be significantly elevated in mice AMI cardiac tissues. In mice, AAV-Tβ4 induced exogenous expression of Tβ4 significantly reduced oxidative damage, inflammation, cardiac dysfunction, and fibrosis. H₂O₂ inhibited mitophagy and increased inflammation in mouse cardiac myocytes via oxidative stress, and Tβ4 substantially reduced mitophagy inhibition and inflammasome activation in myocytes caused by H₂O₂. Furthermore, Tβ4 decreased cardiac myofibroblast growth and reduced TGF-β1-induced activation. Conclusions. AAV-Tβ4 induced expression of Tβ4 reduced inflammation, heart damage, and eventual fibrosis in vivo. Tβ4 helped to reduce oxidative stress, promote mitophagy, and alleviate inflammation and fibrosis. Exogenous supplementation of Tβ4 might be a promising therapeutic agent for treating myocardial infarction as well as cardiac fibrosis.

Background: Intrahepatic cholestasis of pregnancy (ICP) is characterized by skin pruritus and impaired liver function. Hepatitis B virus (HBV) infection increases the risk of developing ICP. HBV infection is associated with oxidative stress, which has been proven to participate in the development of ICP. The goal of this study was to explore the relationship among HBV, oxidative stress, and ICP, and investigate whether a biomarker of oxidative stress may predict the diagnosis and severity of ICP. Methods: We induced a retrospective cohort of 70 ICP patients from January 2019 to December 2020, and compared their data with those from healthy pregnant women (n = 70). Serum levels of an oxidative stress marker superoxide dismutase (SOD) were examined using an enzyme-linked immunosorbent assay (ELISA). Diagnostic and prognostic values of serum SOD were analyzed by receiver operating characteristic (ROC) curve. Results: Pregnant women in the ICP group had significantly higher level of serum SOD (243.24 ± 12.57 U/L vs 98.70 ± 2.95 U/L, p < 0.01) and a higher rate of HBV infection (51.53% vs 25.71%, p < 0.05) compared with the control group. HBsAg-positive ICP patients had a higher levels of serum SOD (287.24 ± 19.21 U/L vs 196.65 ± 11.75 U/L, p < 0.01) compared with HBsAg-negative ICP patients. A serum SOD level > 121.4 U/mL might be used to predict ICP, while a serum SOD level > 274.6 U/mL might predict ICP severity. Conclusion: HBV infection promotes oxidative stress during the pathogenesis of ICP. Serum levels of SOD could be used to predict ICP diagnosis and severity. Modification of oxidative stress might be a treatment target for ICP.

Background: Hemorrhagic fever with renal syndrome (HFRS) is a disease with increased systemic inflammation and a high fatality rate. Oxidative stress is crucial for inflammation in the pathogeneses of various diseases. We aimed to identify biomarkers of oxidative stress that may assess the severity and disease outcomes of patients with HFRS. Methods: Between January 2015 and September 2018, we analyzed a retrospective cohort of 149 HFRS patients and 30 healthy individuals. Serum levels of SOD were measured using an ELISA commercial kit, and survival analysis was carried out using the Kaplan–Meier method. Results: Patients with HFRS had significantly lower serum SOD levels compared with healthy controls (108.40 ± 2.47 U/mL vs 164.23 ± 3.82 U/mL, P < 0.01). SOD levels in patients were lower at acute than at convalescent stage (108.40 ± 2.47 U/mL vs 138.27 ± 2.87 U/mL, P < 0.01), and in severe and critical patients than in moderate and mild patients (89.63 ± 2.38 U/mL vs 122.53 ± 3.18 U/mL, P < 0.01). A serum level of SOD < 88.6 U/mL at admission was associated with a significant increase in mortality risk in HFRS patients. Conclusion: Our results indicate that serum levels of SOD measured at admission can be used to assess disease severity and assign patients into high- and low-risk groups. SOD can be considered a novel biomarker of severity and outcomes in patients with HFRS.