Nonalcoholic fatty liver disease(NAFLD) is the commonest chronic liver disease and its prevalence is increasing driven by the pandemic of obesity and type 2 diabetes mellitus. NAFLD can progress to cirrhosis and is as...Nonalcoholic fatty liver disease(NAFLD) is the commonest chronic liver disease and its prevalence is increasing driven by the pandemic of obesity and type 2 diabetes mellitus. NAFLD can progress to cirrhosis and is associated with increased risk for cardiovascular disease and hepatocellular cancer. Diet and exercise are limited by suboptimal long-term adherence in patients with NAFLD. On the other hand, current pharmacological treatment of NAFLD has limited efficacy and unfavorable safety profile. In this context, obeticholic acid(OCA), a selective agonist of the farnesoid X receptors, might represent a useful option in these patients. Preclinical studies suggest that OCA improves hepatic steatosis, inflammation and fibrosis. A proof-of-concept study and the randomized, placebo-controlled Farnesoid X Receptor Ligand Obeticholic Acid in non-alcoholic steatohepatitis Treatment(FLINT) trial also showed improvements in liver histology in patients with NAFLD who received OCA. Weight loss and reduction in blood pressure were also observed. However, the effects of OCA on insulin resistance are conflicting and the lipid profile is adversely affected by this agent. In addition, pruritus is frequently observed during treatment with OCA and might lead to treatment discontinuation. However, given the limitations of existing treatments for NAFLD, OCA might represent a useful therapeutic option in selected patients with NAFLD.展开更多
BACKGROUND The morbidity and mortality of human immunodeficiency virus(HIV)-infection is often associated with liver disease,which progresses slowly into severe liver dysfunction.There are multiple insults which exace...BACKGROUND The morbidity and mortality of human immunodeficiency virus(HIV)-infection is often associated with liver disease,which progresses slowly into severe liver dysfunction.There are multiple insults which exacerbate HIV-related liver injury,including HIV-associated dysregulation of lipid metabolism and fat turnover,coinfections with hepatotropic viruses and alcohol abuse.As we reported before,exposure of hepatocytes to HIV and alcohol metabolites causes high oxidative stress,impairs proteasomal and lysosomal functions leading to accumulation of HIV in these cells,which end-ups with apoptotic cell death and finally promotes development of liver fibrosis.AIM To study whether obeticholic acid(OCA)prevents HIV/ethanol metabolisminduced hepatotoxicity and subsequent activation of hepatic stellate cells(HSC)by HIV+apoptotic hepatocyte engulfment.METHODS Huh7.5-CYP(RLW)cells were exposed to HIV and acetaldehyde-generating system(AGS)in the presence or absence of OCA.In the cells,we measured the expression of HIV-related markers:HIVgagRNA-by real-time polymerase chain reaction(PCR),p24-by western blot,HIV DNA-by semi-nested PCR,integrated HIV DNA-by ddPCR.Lysosomal and proteasomal activities were measured using fluorometrically-labeled substrates.For hepatocyte apoptosis,cleaved caspase 3 and cleaved PARP were visualized by western blot and cytokeratin 18-by M30 ELISA-in supernatants.Apoptotic bodies were generated from untreated and HIV-treated RLW cells exposed to UV light.Pro-fibrotic activation of HSC was characterized by Col1A1 and transforming growth factor-βmRNAs,while inflammasome activation-by NLRP3,caspase 1,interleukin(IL)-6,IL-1βmRNA levels.RESULTS In RLW cells,OCA treatment attenuated HIV-AGS-induced accumulation of HIVgagRNA,HIV DNA and p24.OCA suppressed reactive oxygen species production and restored chymotrypsin-like proteasome activity as well as cathepsin B lysosome activity.OCA also decreased HIV-AGS-triggered apoptosis in RLW cells.Exposure of HIV-containing apoptotic hepatocytes to HSC prevented activation of inflammasome and induced pro-fibrotic activation in these cells.CONCLUSION We conclude that by suppressing oxidative stress and restoring proteasomal and lysosomal functions impaired by HIV and ethanol metabolism,OCA decreases accumulation of HIV in hepatocytes,leading to down-regulation of apoptosis in these cells.In addition,OCA reverses pro-fibrotic and inflammasome-related activation of HSC triggered by engulfment of HIV-containing apoptotic hepatocytes,potentially contributing to suppression of liver fibrosis development.展开更多
Obeticholic acid(OCA), the first FXR-targeting drug, has been claimed effective in the therapy of liver fibrosis. However, recent clinical trials indicated that OCA might not be effective against liver fibrosis, possi...Obeticholic acid(OCA), the first FXR-targeting drug, has been claimed effective in the therapy of liver fibrosis. However, recent clinical trials indicated that OCA might not be effective against liver fibrosis, possibly due to the lower dosage to reduce the incidence of the side-effect of pruritus. Here we propose a combinatory therapeutic strategy of OCA and apoptosis inhibitor for combating against liver fibrosis. CCl4-injured mice, D-galactosamine/LPS(GalN/LPS)-treated mice and cycloheximide/TNFα(CHX/TNFα)-treated HepG2 cells were employed to assess the effects of OCA, or together with IDN-6556, an apoptosis inhibitor. OCA treatment significantly inhibited hepatic stellate cell(HSC)activation/proliferation and prevented fibrosis. Elevated bile acid(BA) levels and hepatocyte apoptosis triggered the activation and proliferation of HSCs. OCA treatment reduced BA levels but could not inhibit hepatocellular apoptosis. An enhanced anti-fibrotic effect was observed when OCA was co-administrated with IDN-6556. Our study demonstrated that OCA inhibits HSCs activation/proliferation partially by regulating BA homeostasis and thereby inhibiting activation of HSCs. The findings in this study suggest that combined use of apoptosis inhibitor and OCA at lower dosage represents a novel therapeutic strategy for liver fibrosis.展开更多
Primary bile acids were reported to augment secretion of chemokine(C-X-C motif)ligand16(CXCL16)from liver sinusoidal endothelial cells(LSECs)and trigger natural killer T(NKT)cellbased immunotherapy for liver cancer.Ho...Primary bile acids were reported to augment secretion of chemokine(C-X-C motif)ligand16(CXCL16)from liver sinusoidal endothelial cells(LSECs)and trigger natural killer T(NKT)cellbased immunotherapy for liver cancer.However,abundant expression of receptors for primary bile acids across the gastrointestinal tract overwhelms the possibility of using agonists against these receptors for liver cancer control.Taking advantage of the intrinsic property of LSECs in capturing circulating nanoparticles in the circulation,we proposed a strategy using nanoemulsion-loaded obeticholic acid(OCA),a clinically approved selective farnesoid X receptor(FXR)agonist,for precisely manipulating LSECs for triggering NKT cell-mediated liver cancer immunotherapy.The OCA-nanoemulsion(OCA-NE)was prepared via ultrasonic emulsification method,with a diameter of 184 nm and good stability.In vivo biodistribution studies confirmed that the injected OCA-NE mainly accumulated in the liver and especially in LSECs and Kupffer cells.As a result,OCA-NE treatment significantly suppressed hepatic tumor growth in a murine orthotopic H22 tumor model,which performed much better than oral medication of free OCA.Immunologic analysis revealed that the OCA-NE resulted in augmented secretion of CXCL16 and IFN-g,as well as increased NKT cell populations inside the tumor.Overall,our research provides a new evidence for the antitumor effect of receptors for primary bile acids,and should inspire using nanotechnology for precisely manipulating LSECs for liver cancer therapy.展开更多
Knowledge of the etiological and pathogenetic mechanisms of the development of any disease is essential for its treatment.Because the cause of primary biliary cholangitis(PBC),a chronic,slowly progressive cholestatic ...Knowledge of the etiological and pathogenetic mechanisms of the development of any disease is essential for its treatment.Because the cause of primary biliary cholangitis(PBC),a chronic,slowly progressive cholestatic liver disease,is still unknown,treatment remains symptomatic.Knowledge of the physicochemical properties of various bile acids and the adaptive responses of cholangiocytes and hepatocytes to them has provided an important basis for the development of relatively effective drugs based on hydrophilic bile acids that can potentially slow the progression of the disease.Advances in the use of hydrophilic bile acids for the treatment of PBC are also associated with the discovery of pathogenetic mechanisms of the development of cholangiocyte damage and the appearance of the first signs of this disease.For 35 years,ursodeoxycholic acid(UDCA)has been the unique drug of choice for the treatment of patients with PBC.In recent years,the list of hydrophilic bile acids used to treat cholestatic liver diseases,including PBC,has expanded.In addition to UDCA,the use of obeticholic acid,tauroursodeoxycholic acid and norursodeoxycholic acid as drugs is discussed.The pathogenetic rationale for treatment of PBC with various bile acid drugs is discussed in this review.Emphasis is made on the mechanisms explaining the beneficial therapeutic effects and potential of each of the bile acid as a drug,based on the understanding of the pathogenesis of the initial stages of PBC.展开更多
Primary biliary cholangitis is a chronic cholestatic autoimmune liver disease that progressively damages the bile ducts,leading to cholestasis and,in advanced stages,cirrhosis.While it primarily affects middle-aged wo...Primary biliary cholangitis is a chronic cholestatic autoimmune liver disease that progressively damages the bile ducts,leading to cholestasis and,in advanced stages,cirrhosis.While it primarily affects middle-aged women,recent data indicate a rising incidence in men.The interplay between genetic susceptibility,environmental exposures,and gut microbiome alterations is thought to drive disease onset.Diagnosis relies on persistent cholestatic enzyme elevation,diseasespecific autoantibodies,and,in select cases,liver biopsy.Ursodeoxycholic acid remains the cornerstone of treatment,but many patients show an incomplete response.The recent withdrawal of obeticholic acid from the market,due to insufficient evidence of long-term benefit,has highlighted the urgent need for effective second-line therapies.Agonists of peroxisome proliferator-activated receptors,such as elafibranor and seladelpar,have demonstrated promising biochemical improvements and may reshape the therapeutic landscape.Future research is focused on refining risk assessment,optimizing treatment combinations,and addressing symptoms such as fatigue and pruritus to enhance patient well-being.A shift toward early intervention and personalized treatment strategies may further improve long-term outcomes in primary biliary cholangitis.展开更多
Metabolic dysfunction-associated steatotic liver disease(MASLD),recognized as the most prevalent liver disease worldwide and a leading cause of liver transplantation,is closely associated with type 2 diabetes,cardiova...Metabolic dysfunction-associated steatotic liver disease(MASLD),recognized as the most prevalent liver disease worldwide and a leading cause of liver transplantation,is closely associated with type 2 diabetes,cardiovascular disease,and metabolic dysfunction.Its multifactorial pathogenesis involves insulin resistance,lipotoxicity,gut dysbiosis,and dysregulated signaling involving multiple receptors and pathways,culminating in hepatic steatosis,inflammation,fibrosis,and,ultimately,cirrhosis.Emerging insights into bile acid metabolism,shortchain fatty acids,and fibrogenic mediators underscore the complexity of disease progression.Despite increasing global prevalence,effective pharmacological treatments remain limited.Resmetirom,a thyroid hormone receptorβ(THR-β)agonist,is currently the lone agent approved for treating metabolic dysfunctionassociated steatohepatitis(MASH).Off-label use of vitamin E and obeticholic acid has met with some treatment success.Peroxisome proliferator-activated receptor(PPAR)agonists,novel antidiabetic agents,glucagon-like peptide 1 agonists,and sodium-glucose cotransporter 2 inhibitors have shown promising results in MASLD/MASH;however,further data are needed to prove their efficacy and safety.While metformin has largely failed to demonstrate efficacy,hepatotoxicity remains an area of concern with statin therapy.Novel agents,such as fibroblast growth factor analogs,fatty acid synthase inhibitors,galectin-3 inhibitors,and stearoyl-CoA desaturase inhibitors,are in the early stages of development and trials,warranting further research in steatotic liver diseases.Despite encouraging advances,long-term safety,durability of response,and regulatory approvals remain key hurdles before these agents can be broadly implemented in clinical practice.This review summarizes current knowledge on the pathogenesis of MASLD/MASH and the molecular pathways that may offer therapeutic potential in managing this widespread metabolic liver disease.展开更多
Primary biliary cholangitis(PBC)is a chronic autoimmune cholestatic liver disease characterized by progressive bile duct destruction,leading to fibrosis,cirrhosis,and eventual liver failure.Over the past two decades,s...Primary biliary cholangitis(PBC)is a chronic autoimmune cholestatic liver disease characterized by progressive bile duct destruction,leading to fibrosis,cirrhosis,and eventual liver failure.Over the past two decades,significant advancements have paved the way for novel therapeutic strategies.Ursodeoxycholic acid(UDCA)has been the cornerstone of PBC management,improving survival and delaying disease progression in most patients.However,up to 40%of patients demonstrate an inadequate response to UDCA,necessitating additional treatment options.Obeticholic acid(OCA),a farnesoid X receptor agonist,has emerged as a second-line therapy,showing efficacy in reducing alkaline phosphatase levels and improving liver biochemistry.Beyond UDCA and OCA,a new wave of therapeutic agents are reshaping the PBC landscape.These include fibrates,peroxisome proliferator-activated receptor agonists and novel immunomodulatory drugs aimed at reducing autoimmune-mediated liver injury.Bile acid transport inhibitors,anti-fibrotic agents,and gut microbiome-targeted therapies are also under investigation,offering hope for personalized treatment approaches.This review highlights the evolution of PBC therapy,emphasizing the unmet needs of patients with refractory disease and the potential of emerging therapies to improve outcomes.As the therapeutic landscape continues to expand,optimizing treatment strategies through precision medicine holds the promise of transforming the management of PBC.展开更多
AIM To characterize the efficacy of the dual FXR/TGR5 receptor agonist INT-767 upon histological endpoints in a rodent model of diet-induced and biopsy-confirmed non-alcoholic steatohepatitis(NASH).METHODS The effects...AIM To characterize the efficacy of the dual FXR/TGR5 receptor agonist INT-767 upon histological endpoints in a rodent model of diet-induced and biopsy-confirmed non-alcoholic steatohepatitis(NASH).METHODS The effects of INT-767 on histological features of NASH were assessed in two studies using Lep^(ob/ob)(ob/ob) NASH mice fed the AMLN diet(high fat with transfat, cholesterol and fructose). In a proof-of-conceptstudy, Lep^(ob/ob)(ob/ob) NASH mice were first dosed with INT-767(3 or 10 mg/kg for 8 wk). A second ob/ob NASH study compared INT-767(3 and 10 mg/kg) to obeticholic acid(OCA)(10 or 30 mg/kg; 16 wk). Primary histological endpoints included qualitative and quantitative assessments of NASH. Other metabolic and plasma endpoints were also assessed. A comparative assessment of INT-767 and OCA effects on drug distribution and hepatic gene expression was performed in C57 Bl/6 mice on standard chow. C57 Bl/6 mice were orally dosed with INT-767 or OCA(1-30 mg/kg) for 2 wk, and expression levels of candidate genes were assessed by RNA sequencing and tissue drug levels were measured by liquid chromatography tandem-mass spectrometry.RESULTS INT-767 dose-dependently(3 and 10 mg/kg, PO, QD, 8 wk) improved qualitative morphometric scores on steatohepatitis severity, inflammatory infiltrates and fibrosis stage. Quantitative morphometric analyses revealed that INT-767 reduced parenchymal collagen area, collagen fiber density, inflammation(assessed by Galectin-3 immunohistochemistry) and hepatocyte lipid droplet area following INT-767 treatment. In a comparative study(16 wk), the FXR agonists OCA(10 and 30 mg/kg) and INT-767(3 and 10 mg/kg) both improved NASH histopathology, with INT-767 exerting greater therapeutic potency and efficacy than OCA. Mechanistic studies suggest that both drugs accumulate similarly within the liver and ileum, however, the effects of INT-767 may be driven by enhanced hepatic, but not ileal, FXR function. CONCLUSION These findings confirm the potential utility of FXR and dual FXR/TGR5 activation as disease intervention strategies in NASH.展开更多
The main treatment of patients with non-alcoholic fatty liver disease(NAFLD) is life style modification including weight reduction and dietary regimen.Majority of patients are safely treated with this management and p...The main treatment of patients with non-alcoholic fatty liver disease(NAFLD) is life style modification including weight reduction and dietary regimen.Majority of patients are safely treated with this management and pharmacologic interventions are not recommended. However, a subgroup of NAFLD patients with non-alcoholic steatohepatitis(NASH) who cannot achieve goals of life style modification may need pharmacological therapy. One major obstacle is measurement of histological outcome by liver biopsy which is an invasive method and is not recommended routinely in these patients. Several medications, mainly targeting baseline mechanism of NAFLD, have been investigated in clinical trials for treatment of NASH with promising results. At present, only pioglitazone acting as insulin sensitizing agent and vitamin E as an antioxidant have been recommended for treatment of NASH by international guidelines. Lipid lowering agents including statins and fibrates, pentoxifylline, angiotensin receptor blockers, ursodeoxycholic acid, probiotics and synbiotics are current agents with beneficial effects for treatment of NASH but have not been approved yet. Several emerging medications are in development for treatment of NASH. Obeticholic acid, liraglutide, elafibranor, cenicriviroc and aramchol have been tested in clinical trials or are completing trials. Here in, current and upcoming medications with promising results in clinical trial for treatment of NAFLD were reviewed.展开更多
Environmental toxicants have been linked to aging and age-related diseases.The emerging evidence has shown that the enhancement of detoxification gene expression is a common transcriptome marker of long-lived mice,Dro...Environmental toxicants have been linked to aging and age-related diseases.The emerging evidence has shown that the enhancement of detoxification gene expression is a common transcriptome marker of long-lived mice,Drosophila melanogaster,and Caenorhabditis elegans.Meanwhile,the resistance to toxicants was increased in long-lived animals.Here,we show that farnesoid X receptor(FXR)agonist obeticholic acid(OCA),a marketed drug for the treatment of cholestasis,may extend the lifespan and healthspan both in C.elegans and chemical-induced early senescent mice.Furthermore,OCA increased the resistance of worms to toxicants and activated the expression of detoxification genes in both mice and C.elegans.The longevity effects of OCA were attenuated in Fxr^(−/−)mice and Fxr homologous nhr-8 and daf-12 mutant C.elegans.In addition,metabolome analysis revealed that OCA increased the endogenous agonist levels of the pregnane X receptor(PXR),a major nuclear receptor for detoxification regulation,in the liver of mice.Together,our findings suggest that OCA has the potential to lengthen lifespan and healthspan by activating nuclear receptor-mediated detoxification functions,thus,targeting FXR may offer to promote longevity.展开更多
Ursodeoxycholic acid(UDCA)remains the cornerstone of treatment for primary biliary cholangitis(PBC).However,approximately 30-40% of patients fail to achieve a complete biochemical response,a factor associated with inc...Ursodeoxycholic acid(UDCA)remains the cornerstone of treatment for primary biliary cholangitis(PBC).However,approximately 30-40% of patients fail to achieve a complete biochemical response,a factor associated with increased risk of disease progression and liver-related complications(1).This emphasizes the importance of early assessment of therapeutic response and the implementation of individualized treatment strategies based on risk stratification and disease stage.展开更多
Primary biliary cholangitis,formerly known as primary biliary cirrhosis,is a chronic,autoimmune,and cholestatic disease ameliorating the biliary epithelial system causing fibrosis and end-stage liver disease,over time...Primary biliary cholangitis,formerly known as primary biliary cirrhosis,is a chronic,autoimmune,and cholestatic disease ameliorating the biliary epithelial system causing fibrosis and end-stage liver disease,over time.Patients range from an asymptomatic phase early in the disease course,to symp-toms of decompensated cirrhosis later in its course.This review focuses on the current consensus on the epidemiology,diagnosis,and management of patients with primary biliary cholangitis.We also discuss established medical manage-ment as well as novel and investigational therapeutics in the pipeline for management of PBC.展开更多
Non-alcoholic steatohepatitis(NASH)results from inflammation and hepatocyte injury in the setting of hepatic steatosis.Non-alcoholic steatohepatitis increases the risk of progression to liver fibrosis and cirrhosis,an...Non-alcoholic steatohepatitis(NASH)results from inflammation and hepatocyte injury in the setting of hepatic steatosis.Non-alcoholic steatohepatitis increases the risk of progression to liver fibrosis and cirrhosis,and is the most rapidly growing etiology for liver failure and indication for liver transplantation in the USA.Weight loss and lifestyle modification remain the standard first-line treatment,as no USA Food and Drug Administration-approved pharmacotherapy currently exists.The past decade has seen an explosion of interest in drug development targeting pathologic pathways in non-alcoholic steatohepatitis,with numerous phase 2 and 3 trials currently in progress.Here,we concisely review the major targets and mechanisms of action by class,summarize results from com-pleted pivotal phase 2 studies,and provide a detailed outline of key active studies with trial data for drugs in development,including obeticholic acid,elafibranor,cenicriviroc and selonsertib.展开更多
Nonalcoholic fatty liver disease (NAFLD) is a global epidemic that is likely to become the most common cause of chronic liver disease in the next decade, worldwide. Though numerous drugs have been evaluated in clinica...Nonalcoholic fatty liver disease (NAFLD) is a global epidemic that is likely to become the most common cause of chronic liver disease in the next decade, worldwide. Though numerous drugs have been evaluated in clinical trials, most of them have returned inconclusive results and shown poorly-tolerated adverse effects. None of the drugs have been approved by the Food and Drug Administration for treating biopsy-proven non-alcoholic steatohepatitis (NASH). Vitamin E and pioglitazone have been extensively used in treatment of biopsy-proven nondiabetic NASH patients. Although some amelioration of inflammation has been seen, these drugs did not improve the fibrosis component of NASH. Therefore, dietary modification and weight reduction have remained the cornerstone of treatment of NASH;moreover, they have shown to improve histological activity as well as fibrosis. The search for an ideal drug or ‘Holy Grail’ within this landscape of possible agents continues, as weight reduction is achieved only in less than 10% of patients. In this current review, we summarize the drugs for NASH which are under investigation, and we provide a critical analysis of their up-to-date results and outcomes.展开更多
Cholestatic liver disease is a group of diseases in which bile acid accumulates in the liver for various reasons,resulting in abnormal liver biochemical indicators and histological damage.Cholestasis can be divided in...Cholestatic liver disease is a group of diseases in which bile acid accumulates in the liver for various reasons,resulting in abnormal liver biochemical indicators and histological damage.Cholestasis can be divided into intrahepatic cholestasis and extrahepatic cholestasis,which will contribute to liver damage and progress to liver fibrosis and cirrhosis.Primary biliary cholangitis(PBC)and primary sclerosing cholangitis are the two most typical cholestatic liver diseases.Ursodeoxycholic acid is currently the first-line treatment for PBC,while obeticholic acid,budesonide and fibrates have also shown good potential in the treatment of PBC.There are currently no official drugs approved to treat primary sclerosing cholangitis,and the use of ursodeoxycholic acid may have certain clinical benefits.At present,progress has been made in new treatment directions for cholestatic liver disease,including fibroblast growth factor 19,cholestyramine,S-adenosyl-L-methionine,steroid drugs,farnesoid X receptor agonists,and more.Considerable progress has been made in the management of cholestatic liver disease but there are still many opportunities and challenges.In this review,we summarized the recommended guidelines for the management of cholestatic disease and the progress of new drug research and development,in order to provide an important reference for the clinical practice of cholestatic liver disease.展开更多
Obeticholic acid(OCA),a farnesoid X receptor(FXR)agonist with favorable effects on fatty and glucose metabolism,has been considered the leading candidate drug for nonalcoholic steatohepatitis(NASH)treatment.However,it...Obeticholic acid(OCA),a farnesoid X receptor(FXR)agonist with favorable effects on fatty and glucose metabolism,has been considered the leading candidate drug for nonalcoholic steatohepatitis(NASH)treatment.However,its limited effectiveness in resolving liver fibrosis and lipotoxicity-induced cell death remains a major drawback.Ferroptosis,a newly recognized form of cell death characterized by uncontrolled lipid peroxidation,is involved in the progression of NASH.Nitric oxide(NO)is a versatile biological molecule that can degrade extracellular matrix.In this study,we developed a PEGylated thiolated hollow mesoporous silica nanoparticles(MSN)loaded with OCA,as well as a ferroptosis inhibitor liproxsatin-1 and a NO donor S-nitrosothiol(ONL@MSN).Biochemical analyses,histology,multiplexed flow cytometry,bulk-tissue RNA sequencing,and fecal 16S ribosomal RNA sequencing were utilized to evaluate the effects of the combined nanoparticle(ONL@MSN)in a mouse NASH model.Compared with the OCA-loaded nanoparticles(O@MSN),ONL@MSN not only protected against hepatic steatosis but also greatly ameliorated fibrosis and ferroptosis.ONL@MSN also displayed enhanced therapeutic actions on the maintenance of intrahepatic macrophages/monocytes homeostasis,inhibition of immune response/lipid peroxidation,and correction of microbiota dysbiosis.These findings present a promising synergistic nanotherapeutic strategy for the treatment of NASH by simultaneously targeting FXR,ferroptosis,and fibrosis.展开更多
Current phase 3 trials for the treatment of non-alcoholic steatohepatitis(NASH)are discussed in this review.Modalities that are based on weight loss include therapeutic lifestyle changes,pharmacological weight loss dr...Current phase 3 trials for the treatment of non-alcoholic steatohepatitis(NASH)are discussed in this review.Modalities that are based on weight loss include therapeutic lifestyle changes,pharmacological weight loss drugs(e.g.,orlistat),and bariatric surgery.Traditionally,insulin resistance has been targeted using pioglitazone,but liraglutide and elafibranor are emerging as potential treatments.With regard to the farnesoid X receptor(FXR)pathway,obeticholic acid has been approved for primary biliary cholangitis and is being studied as a treatment for NASH.Antioxidants include vitamin E and statins.Medications that target fibrogenesis directly instead of NASH include selonsertib.展开更多
文摘Nonalcoholic fatty liver disease(NAFLD) is the commonest chronic liver disease and its prevalence is increasing driven by the pandemic of obesity and type 2 diabetes mellitus. NAFLD can progress to cirrhosis and is associated with increased risk for cardiovascular disease and hepatocellular cancer. Diet and exercise are limited by suboptimal long-term adherence in patients with NAFLD. On the other hand, current pharmacological treatment of NAFLD has limited efficacy and unfavorable safety profile. In this context, obeticholic acid(OCA), a selective agonist of the farnesoid X receptors, might represent a useful option in these patients. Preclinical studies suggest that OCA improves hepatic steatosis, inflammation and fibrosis. A proof-of-concept study and the randomized, placebo-controlled Farnesoid X Receptor Ligand Obeticholic Acid in non-alcoholic steatohepatitis Treatment(FLINT) trial also showed improvements in liver histology in patients with NAFLD who received OCA. Weight loss and reduction in blood pressure were also observed. However, the effects of OCA on insulin resistance are conflicting and the lipid profile is adversely affected by this agent. In addition, pruritus is frequently observed during treatment with OCA and might lead to treatment discontinuation. However, given the limitations of existing treatments for NAFLD, OCA might represent a useful therapeutic option in selected patients with NAFLD.
文摘BACKGROUND The morbidity and mortality of human immunodeficiency virus(HIV)-infection is often associated with liver disease,which progresses slowly into severe liver dysfunction.There are multiple insults which exacerbate HIV-related liver injury,including HIV-associated dysregulation of lipid metabolism and fat turnover,coinfections with hepatotropic viruses and alcohol abuse.As we reported before,exposure of hepatocytes to HIV and alcohol metabolites causes high oxidative stress,impairs proteasomal and lysosomal functions leading to accumulation of HIV in these cells,which end-ups with apoptotic cell death and finally promotes development of liver fibrosis.AIM To study whether obeticholic acid(OCA)prevents HIV/ethanol metabolisminduced hepatotoxicity and subsequent activation of hepatic stellate cells(HSC)by HIV+apoptotic hepatocyte engulfment.METHODS Huh7.5-CYP(RLW)cells were exposed to HIV and acetaldehyde-generating system(AGS)in the presence or absence of OCA.In the cells,we measured the expression of HIV-related markers:HIVgagRNA-by real-time polymerase chain reaction(PCR),p24-by western blot,HIV DNA-by semi-nested PCR,integrated HIV DNA-by ddPCR.Lysosomal and proteasomal activities were measured using fluorometrically-labeled substrates.For hepatocyte apoptosis,cleaved caspase 3 and cleaved PARP were visualized by western blot and cytokeratin 18-by M30 ELISA-in supernatants.Apoptotic bodies were generated from untreated and HIV-treated RLW cells exposed to UV light.Pro-fibrotic activation of HSC was characterized by Col1A1 and transforming growth factor-βmRNAs,while inflammasome activation-by NLRP3,caspase 1,interleukin(IL)-6,IL-1βmRNA levels.RESULTS In RLW cells,OCA treatment attenuated HIV-AGS-induced accumulation of HIVgagRNA,HIV DNA and p24.OCA suppressed reactive oxygen species production and restored chymotrypsin-like proteasome activity as well as cathepsin B lysosome activity.OCA also decreased HIV-AGS-triggered apoptosis in RLW cells.Exposure of HIV-containing apoptotic hepatocytes to HSC prevented activation of inflammasome and induced pro-fibrotic activation in these cells.CONCLUSION We conclude that by suppressing oxidative stress and restoring proteasomal and lysosomal functions impaired by HIV and ethanol metabolism,OCA decreases accumulation of HIV in hepatocytes,leading to down-regulation of apoptosis in these cells.In addition,OCA reverses pro-fibrotic and inflammasome-related activation of HSC triggered by engulfment of HIV-containing apoptotic hepatocytes,potentially contributing to suppression of liver fibrosis development.
基金supported by National Natural Science Foundation of China (grants 81430091, 81720108032, 81421005, 91429308 and 81603194)the Project for Major New Drug Innovation and Development (grant 2015ZX09501010 and 2017ZX09101003-002-003, China)+3 种基金Overseas Expertise Introduction Project for Discipline Innovation (G20582017001, China)"Double First Class" Initiative Project (CPU2018GF01 and CPU2018GF09, China)State Key Laboratory of Natural Medicines at China Pharmaceutical University (SKLNMZZCX201610 and SKLNMZZCX201801, China)China Postdoctoral Science Foundation (grants 2016M600455 and 2017T100423)
文摘Obeticholic acid(OCA), the first FXR-targeting drug, has been claimed effective in the therapy of liver fibrosis. However, recent clinical trials indicated that OCA might not be effective against liver fibrosis, possibly due to the lower dosage to reduce the incidence of the side-effect of pruritus. Here we propose a combinatory therapeutic strategy of OCA and apoptosis inhibitor for combating against liver fibrosis. CCl4-injured mice, D-galactosamine/LPS(GalN/LPS)-treated mice and cycloheximide/TNFα(CHX/TNFα)-treated HepG2 cells were employed to assess the effects of OCA, or together with IDN-6556, an apoptosis inhibitor. OCA treatment significantly inhibited hepatic stellate cell(HSC)activation/proliferation and prevented fibrosis. Elevated bile acid(BA) levels and hepatocyte apoptosis triggered the activation and proliferation of HSCs. OCA treatment reduced BA levels but could not inhibit hepatocellular apoptosis. An enhanced anti-fibrotic effect was observed when OCA was co-administrated with IDN-6556. Our study demonstrated that OCA inhibits HSCs activation/proliferation partially by regulating BA homeostasis and thereby inhibiting activation of HSCs. The findings in this study suggest that combined use of apoptosis inhibitor and OCA at lower dosage represents a novel therapeutic strategy for liver fibrosis.
基金financially supported by the National Natural Science Foundation of China(51673189,51973215,51833010and 51520105004)Ministry of Science and Technology of China(Project 2018ZX09711003-012)+1 种基金the Program of Scientific Development of Jilin Province(20170101100JC,20180520207JH,20190103112JH,China)supported by NIH grant CA198999(USA)
文摘Primary bile acids were reported to augment secretion of chemokine(C-X-C motif)ligand16(CXCL16)from liver sinusoidal endothelial cells(LSECs)and trigger natural killer T(NKT)cellbased immunotherapy for liver cancer.However,abundant expression of receptors for primary bile acids across the gastrointestinal tract overwhelms the possibility of using agonists against these receptors for liver cancer control.Taking advantage of the intrinsic property of LSECs in capturing circulating nanoparticles in the circulation,we proposed a strategy using nanoemulsion-loaded obeticholic acid(OCA),a clinically approved selective farnesoid X receptor(FXR)agonist,for precisely manipulating LSECs for triggering NKT cell-mediated liver cancer immunotherapy.The OCA-nanoemulsion(OCA-NE)was prepared via ultrasonic emulsification method,with a diameter of 184 nm and good stability.In vivo biodistribution studies confirmed that the injected OCA-NE mainly accumulated in the liver and especially in LSECs and Kupffer cells.As a result,OCA-NE treatment significantly suppressed hepatic tumor growth in a murine orthotopic H22 tumor model,which performed much better than oral medication of free OCA.Immunologic analysis revealed that the OCA-NE resulted in augmented secretion of CXCL16 and IFN-g,as well as increased NKT cell populations inside the tumor.Overall,our research provides a new evidence for the antitumor effect of receptors for primary bile acids,and should inspire using nanotechnology for precisely manipulating LSECs for liver cancer therapy.
文摘Knowledge of the etiological and pathogenetic mechanisms of the development of any disease is essential for its treatment.Because the cause of primary biliary cholangitis(PBC),a chronic,slowly progressive cholestatic liver disease,is still unknown,treatment remains symptomatic.Knowledge of the physicochemical properties of various bile acids and the adaptive responses of cholangiocytes and hepatocytes to them has provided an important basis for the development of relatively effective drugs based on hydrophilic bile acids that can potentially slow the progression of the disease.Advances in the use of hydrophilic bile acids for the treatment of PBC are also associated with the discovery of pathogenetic mechanisms of the development of cholangiocyte damage and the appearance of the first signs of this disease.For 35 years,ursodeoxycholic acid(UDCA)has been the unique drug of choice for the treatment of patients with PBC.In recent years,the list of hydrophilic bile acids used to treat cholestatic liver diseases,including PBC,has expanded.In addition to UDCA,the use of obeticholic acid,tauroursodeoxycholic acid and norursodeoxycholic acid as drugs is discussed.The pathogenetic rationale for treatment of PBC with various bile acid drugs is discussed in this review.Emphasis is made on the mechanisms explaining the beneficial therapeutic effects and potential of each of the bile acid as a drug,based on the understanding of the pathogenesis of the initial stages of PBC.
文摘Primary biliary cholangitis is a chronic cholestatic autoimmune liver disease that progressively damages the bile ducts,leading to cholestasis and,in advanced stages,cirrhosis.While it primarily affects middle-aged women,recent data indicate a rising incidence in men.The interplay between genetic susceptibility,environmental exposures,and gut microbiome alterations is thought to drive disease onset.Diagnosis relies on persistent cholestatic enzyme elevation,diseasespecific autoantibodies,and,in select cases,liver biopsy.Ursodeoxycholic acid remains the cornerstone of treatment,but many patients show an incomplete response.The recent withdrawal of obeticholic acid from the market,due to insufficient evidence of long-term benefit,has highlighted the urgent need for effective second-line therapies.Agonists of peroxisome proliferator-activated receptors,such as elafibranor and seladelpar,have demonstrated promising biochemical improvements and may reshape the therapeutic landscape.Future research is focused on refining risk assessment,optimizing treatment combinations,and addressing symptoms such as fatigue and pruritus to enhance patient well-being.A shift toward early intervention and personalized treatment strategies may further improve long-term outcomes in primary biliary cholangitis.
文摘Metabolic dysfunction-associated steatotic liver disease(MASLD),recognized as the most prevalent liver disease worldwide and a leading cause of liver transplantation,is closely associated with type 2 diabetes,cardiovascular disease,and metabolic dysfunction.Its multifactorial pathogenesis involves insulin resistance,lipotoxicity,gut dysbiosis,and dysregulated signaling involving multiple receptors and pathways,culminating in hepatic steatosis,inflammation,fibrosis,and,ultimately,cirrhosis.Emerging insights into bile acid metabolism,shortchain fatty acids,and fibrogenic mediators underscore the complexity of disease progression.Despite increasing global prevalence,effective pharmacological treatments remain limited.Resmetirom,a thyroid hormone receptorβ(THR-β)agonist,is currently the lone agent approved for treating metabolic dysfunctionassociated steatohepatitis(MASH).Off-label use of vitamin E and obeticholic acid has met with some treatment success.Peroxisome proliferator-activated receptor(PPAR)agonists,novel antidiabetic agents,glucagon-like peptide 1 agonists,and sodium-glucose cotransporter 2 inhibitors have shown promising results in MASLD/MASH;however,further data are needed to prove their efficacy and safety.While metformin has largely failed to demonstrate efficacy,hepatotoxicity remains an area of concern with statin therapy.Novel agents,such as fibroblast growth factor analogs,fatty acid synthase inhibitors,galectin-3 inhibitors,and stearoyl-CoA desaturase inhibitors,are in the early stages of development and trials,warranting further research in steatotic liver diseases.Despite encouraging advances,long-term safety,durability of response,and regulatory approvals remain key hurdles before these agents can be broadly implemented in clinical practice.This review summarizes current knowledge on the pathogenesis of MASLD/MASH and the molecular pathways that may offer therapeutic potential in managing this widespread metabolic liver disease.
文摘Primary biliary cholangitis(PBC)is a chronic autoimmune cholestatic liver disease characterized by progressive bile duct destruction,leading to fibrosis,cirrhosis,and eventual liver failure.Over the past two decades,significant advancements have paved the way for novel therapeutic strategies.Ursodeoxycholic acid(UDCA)has been the cornerstone of PBC management,improving survival and delaying disease progression in most patients.However,up to 40%of patients demonstrate an inadequate response to UDCA,necessitating additional treatment options.Obeticholic acid(OCA),a farnesoid X receptor agonist,has emerged as a second-line therapy,showing efficacy in reducing alkaline phosphatase levels and improving liver biochemistry.Beyond UDCA and OCA,a new wave of therapeutic agents are reshaping the PBC landscape.These include fibrates,peroxisome proliferator-activated receptor agonists and novel immunomodulatory drugs aimed at reducing autoimmune-mediated liver injury.Bile acid transport inhibitors,anti-fibrotic agents,and gut microbiome-targeted therapies are also under investigation,offering hope for personalized treatment approaches.This review highlights the evolution of PBC therapy,emphasizing the unmet needs of patients with refractory disease and the potential of emerging therapies to improve outcomes.As the therapeutic landscape continues to expand,optimizing treatment strategies through precision medicine holds the promise of transforming the management of PBC.
文摘AIM To characterize the efficacy of the dual FXR/TGR5 receptor agonist INT-767 upon histological endpoints in a rodent model of diet-induced and biopsy-confirmed non-alcoholic steatohepatitis(NASH).METHODS The effects of INT-767 on histological features of NASH were assessed in two studies using Lep^(ob/ob)(ob/ob) NASH mice fed the AMLN diet(high fat with transfat, cholesterol and fructose). In a proof-of-conceptstudy, Lep^(ob/ob)(ob/ob) NASH mice were first dosed with INT-767(3 or 10 mg/kg for 8 wk). A second ob/ob NASH study compared INT-767(3 and 10 mg/kg) to obeticholic acid(OCA)(10 or 30 mg/kg; 16 wk). Primary histological endpoints included qualitative and quantitative assessments of NASH. Other metabolic and plasma endpoints were also assessed. A comparative assessment of INT-767 and OCA effects on drug distribution and hepatic gene expression was performed in C57 Bl/6 mice on standard chow. C57 Bl/6 mice were orally dosed with INT-767 or OCA(1-30 mg/kg) for 2 wk, and expression levels of candidate genes were assessed by RNA sequencing and tissue drug levels were measured by liquid chromatography tandem-mass spectrometry.RESULTS INT-767 dose-dependently(3 and 10 mg/kg, PO, QD, 8 wk) improved qualitative morphometric scores on steatohepatitis severity, inflammatory infiltrates and fibrosis stage. Quantitative morphometric analyses revealed that INT-767 reduced parenchymal collagen area, collagen fiber density, inflammation(assessed by Galectin-3 immunohistochemistry) and hepatocyte lipid droplet area following INT-767 treatment. In a comparative study(16 wk), the FXR agonists OCA(10 and 30 mg/kg) and INT-767(3 and 10 mg/kg) both improved NASH histopathology, with INT-767 exerting greater therapeutic potency and efficacy than OCA. Mechanistic studies suggest that both drugs accumulate similarly within the liver and ileum, however, the effects of INT-767 may be driven by enhanced hepatic, but not ileal, FXR function. CONCLUSION These findings confirm the potential utility of FXR and dual FXR/TGR5 activation as disease intervention strategies in NASH.
文摘The main treatment of patients with non-alcoholic fatty liver disease(NAFLD) is life style modification including weight reduction and dietary regimen.Majority of patients are safely treated with this management and pharmacologic interventions are not recommended. However, a subgroup of NAFLD patients with non-alcoholic steatohepatitis(NASH) who cannot achieve goals of life style modification may need pharmacological therapy. One major obstacle is measurement of histological outcome by liver biopsy which is an invasive method and is not recommended routinely in these patients. Several medications, mainly targeting baseline mechanism of NAFLD, have been investigated in clinical trials for treatment of NASH with promising results. At present, only pioglitazone acting as insulin sensitizing agent and vitamin E as an antioxidant have been recommended for treatment of NASH by international guidelines. Lipid lowering agents including statins and fibrates, pentoxifylline, angiotensin receptor blockers, ursodeoxycholic acid, probiotics and synbiotics are current agents with beneficial effects for treatment of NASH but have not been approved yet. Several emerging medications are in development for treatment of NASH. Obeticholic acid, liraglutide, elafibranor, cenicriviroc and aramchol have been tested in clinical trials or are completing trials. Here in, current and upcoming medications with promising results in clinical trial for treatment of NAFLD were reviewed.
基金supported by the National Natural Science Foundation of China(82073951)Cheng Huang and the Fok Ying Tung Education Foundation(171036)to Shengjie Fan.
文摘Environmental toxicants have been linked to aging and age-related diseases.The emerging evidence has shown that the enhancement of detoxification gene expression is a common transcriptome marker of long-lived mice,Drosophila melanogaster,and Caenorhabditis elegans.Meanwhile,the resistance to toxicants was increased in long-lived animals.Here,we show that farnesoid X receptor(FXR)agonist obeticholic acid(OCA),a marketed drug for the treatment of cholestasis,may extend the lifespan and healthspan both in C.elegans and chemical-induced early senescent mice.Furthermore,OCA increased the resistance of worms to toxicants and activated the expression of detoxification genes in both mice and C.elegans.The longevity effects of OCA were attenuated in Fxr^(−/−)mice and Fxr homologous nhr-8 and daf-12 mutant C.elegans.In addition,metabolome analysis revealed that OCA increased the endogenous agonist levels of the pregnane X receptor(PXR),a major nuclear receptor for detoxification regulation,in the liver of mice.Together,our findings suggest that OCA has the potential to lengthen lifespan and healthspan by activating nuclear receptor-mediated detoxification functions,thus,targeting FXR may offer to promote longevity.
文摘Ursodeoxycholic acid(UDCA)remains the cornerstone of treatment for primary biliary cholangitis(PBC).However,approximately 30-40% of patients fail to achieve a complete biochemical response,a factor associated with increased risk of disease progression and liver-related complications(1).This emphasizes the importance of early assessment of therapeutic response and the implementation of individualized treatment strategies based on risk stratification and disease stage.
文摘Primary biliary cholangitis,formerly known as primary biliary cirrhosis,is a chronic,autoimmune,and cholestatic disease ameliorating the biliary epithelial system causing fibrosis and end-stage liver disease,over time.Patients range from an asymptomatic phase early in the disease course,to symp-toms of decompensated cirrhosis later in its course.This review focuses on the current consensus on the epidemiology,diagnosis,and management of patients with primary biliary cholangitis.We also discuss established medical manage-ment as well as novel and investigational therapeutics in the pipeline for management of PBC.
文摘Non-alcoholic steatohepatitis(NASH)results from inflammation and hepatocyte injury in the setting of hepatic steatosis.Non-alcoholic steatohepatitis increases the risk of progression to liver fibrosis and cirrhosis,and is the most rapidly growing etiology for liver failure and indication for liver transplantation in the USA.Weight loss and lifestyle modification remain the standard first-line treatment,as no USA Food and Drug Administration-approved pharmacotherapy currently exists.The past decade has seen an explosion of interest in drug development targeting pathologic pathways in non-alcoholic steatohepatitis,with numerous phase 2 and 3 trials currently in progress.Here,we concisely review the major targets and mechanisms of action by class,summarize results from com-pleted pivotal phase 2 studies,and provide a detailed outline of key active studies with trial data for drugs in development,including obeticholic acid,elafibranor,cenicriviroc and selonsertib.
文摘Nonalcoholic fatty liver disease (NAFLD) is a global epidemic that is likely to become the most common cause of chronic liver disease in the next decade, worldwide. Though numerous drugs have been evaluated in clinical trials, most of them have returned inconclusive results and shown poorly-tolerated adverse effects. None of the drugs have been approved by the Food and Drug Administration for treating biopsy-proven non-alcoholic steatohepatitis (NASH). Vitamin E and pioglitazone have been extensively used in treatment of biopsy-proven nondiabetic NASH patients. Although some amelioration of inflammation has been seen, these drugs did not improve the fibrosis component of NASH. Therefore, dietary modification and weight reduction have remained the cornerstone of treatment of NASH;moreover, they have shown to improve histological activity as well as fibrosis. The search for an ideal drug or ‘Holy Grail’ within this landscape of possible agents continues, as weight reduction is achieved only in less than 10% of patients. In this current review, we summarize the drugs for NASH which are under investigation, and we provide a critical analysis of their up-to-date results and outcomes.
文摘Cholestatic liver disease is a group of diseases in which bile acid accumulates in the liver for various reasons,resulting in abnormal liver biochemical indicators and histological damage.Cholestasis can be divided into intrahepatic cholestasis and extrahepatic cholestasis,which will contribute to liver damage and progress to liver fibrosis and cirrhosis.Primary biliary cholangitis(PBC)and primary sclerosing cholangitis are the two most typical cholestatic liver diseases.Ursodeoxycholic acid is currently the first-line treatment for PBC,while obeticholic acid,budesonide and fibrates have also shown good potential in the treatment of PBC.There are currently no official drugs approved to treat primary sclerosing cholangitis,and the use of ursodeoxycholic acid may have certain clinical benefits.At present,progress has been made in new treatment directions for cholestatic liver disease,including fibroblast growth factor 19,cholestyramine,S-adenosyl-L-methionine,steroid drugs,farnesoid X receptor agonists,and more.Considerable progress has been made in the management of cholestatic liver disease but there are still many opportunities and challenges.In this review,we summarized the recommended guidelines for the management of cholestatic disease and the progress of new drug research and development,in order to provide an important reference for the clinical practice of cholestatic liver disease.
基金This work was supported by the grants from National Natural Science Foundation of China(82073915 and 82104530)Shanghai Natural Science Foundation(23ZR1477500,China)+1 种基金Shanghai Science and Technology Commission(21XD1424900,China)Shanghai Shuguang Program(19SG32,China).
文摘Obeticholic acid(OCA),a farnesoid X receptor(FXR)agonist with favorable effects on fatty and glucose metabolism,has been considered the leading candidate drug for nonalcoholic steatohepatitis(NASH)treatment.However,its limited effectiveness in resolving liver fibrosis and lipotoxicity-induced cell death remains a major drawback.Ferroptosis,a newly recognized form of cell death characterized by uncontrolled lipid peroxidation,is involved in the progression of NASH.Nitric oxide(NO)is a versatile biological molecule that can degrade extracellular matrix.In this study,we developed a PEGylated thiolated hollow mesoporous silica nanoparticles(MSN)loaded with OCA,as well as a ferroptosis inhibitor liproxsatin-1 and a NO donor S-nitrosothiol(ONL@MSN).Biochemical analyses,histology,multiplexed flow cytometry,bulk-tissue RNA sequencing,and fecal 16S ribosomal RNA sequencing were utilized to evaluate the effects of the combined nanoparticle(ONL@MSN)in a mouse NASH model.Compared with the OCA-loaded nanoparticles(O@MSN),ONL@MSN not only protected against hepatic steatosis but also greatly ameliorated fibrosis and ferroptosis.ONL@MSN also displayed enhanced therapeutic actions on the maintenance of intrahepatic macrophages/monocytes homeostasis,inhibition of immune response/lipid peroxidation,and correction of microbiota dysbiosis.These findings present a promising synergistic nanotherapeutic strategy for the treatment of NASH by simultaneously targeting FXR,ferroptosis,and fibrosis.
基金W.Dunn is the principal investigator of the STELLAR-3,STELLAR-4 and REGENERATE Trial at the University of Kansas Medical Center.
文摘Current phase 3 trials for the treatment of non-alcoholic steatohepatitis(NASH)are discussed in this review.Modalities that are based on weight loss include therapeutic lifestyle changes,pharmacological weight loss drugs(e.g.,orlistat),and bariatric surgery.Traditionally,insulin resistance has been targeted using pioglitazone,but liraglutide and elafibranor are emerging as potential treatments.With regard to the farnesoid X receptor(FXR)pathway,obeticholic acid has been approved for primary biliary cholangitis and is being studied as a treatment for NASH.Antioxidants include vitamin E and statins.Medications that target fibrogenesis directly instead of NASH include selonsertib.
