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Drug-induced liver injury (DILI) is an adverse reaction to medications and other xenobiotics that leads to liver dysfunction. Based on differential clinical patterns of injury, DILI is classified into hepatocellular, cholestatic, and mixed types; although hepatocellular DILI is associated with inflammation, necrosis, and apoptosis, cholestatic DILI is associated with bile plugs and bile duct paucity. Ursodeoxycholic acid (UDCA) has been empirically used as a supportive drug mainly in cholestatic DILI, but both curative and prophylactic beneficial effects have been observed for hepatocellular DILI as well, according to preliminary clinical studies. This could reflect the fact that UDCA has a plethora of beneficial effects potentially useful to treat the wide range of injuries with different etiologies and pathomechanisms occurring in both types of DILI, including anticholestatic, antioxidant, anti-inflammatory, antiapoptotic, antinecrotic, mitoprotective, endoplasmic reticulum stress alleviating, and immunomodulatory properties. In this review, a revision of the literature has been performed to evaluate the efficacy of UDCA across the whole DILI spectrum, and these findings were associated with the multiple mechanisms of UDCA hepatoprotection. This should help better rationalize and systematize the use of this versatile and safe hepatoprotector in each type of DILI scenarios.

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Ursodeoxycholic acid (UDCA) is a natural substance physiologically produced in the liver. Initially used to dissolve gallstones, it is now successfully used in treating primary biliary cirrhosis and as adjuvant therapy for various hepatobiliary cholestatic diseases. However, the mechanisms underlying its beneficial effects still need to be clarified. Evidence suggests three mechanisms of action for UDCA that could benefit humans with cholestatic liver disease (CLD): protection of cholangiocytes against hydrophobic bile acid (BA) cytotoxicity, stimulation of hepatobiliary excretion, and protection of hepatocytes against BA-induced apoptosis. These mechanisms may act individually or together to potentiate them. At the molecular level, it has been observed that UDCA can generate modifications in the transcription and translation of proteins essential in the transport of BA, correcting the deficit in BA secretion in CLD, in addition to activating signaling pathways to translocate these transporters to the sites where they should fulfill their function. Inhibition of BA-induced hepatocyte apoptosis may play a role in CLD, characterized by BA retention in the hepatocyte. Thus, different mechanisms of action contribute to the improvement after UDCA administration in CLD. On the other hand, the effects of UDCA on tissues that possess receptors that may interact with BAs in pathological contexts, such as skeletal muscle, are still unclear. This work aims to describe the main molecular mechanisms by which UDCA acts in the human body, emphasizing the interaction in tissues other than the liver.

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OBJECTIVE: The objective of this article is to evaluate the response to 6000 IU oral cholecalciferol (OC) treatment in children with chronic liver disease (CLD) and 25(OH)D deficiency. METHODS: This historical cohort included non-transplanted CLD patients younger than 18 years old, which were analyzed for serum 25(OH)D, liver function, bone metabolism, Child-Pugh classification, and anthropometry. Patients with 25(OH)D deficiency (defined as 25(OH)D < 20 ng/mL) who received 6000 IU/day of OC were analyzed pre- and post-intervention, and considered responders if 25(OH)D > 20 ng/mL after at least 60 days. We compared clinical and laboratory data from patients with and without 25(OH)D deficiency, responders and nonresponders. RESULTS: We studied 96 patients, of which 57.2% had biliary atresia. The prevalence of 25(OH)D deficiency was 67.7% (65/96). These patients were younger ( P < 0.001), had higher Child-Pugh scores ( P < 0.001), higher levels of total bilirubin (TB) ( P < 0.001), gamma-glutamyl transferase ( P < 0.001), and alkaline phosphatase ( P = 0.002), as well as lower levels of phosphorus ( P = 0.009) compared with patients without 25(OH)D deficiency. The median treatment length was 126 days (70-307 days). At the end of treatment, we observed a higher median of 25(OH)D ( P < 0.001), and lower median of parathyroid hormone (PTH) ( P = 0.023). Nine patients (29%) restored 25(OH)D to normal range; they had lower Child-Pugh score ( P = 0.001), lower TB levels ( P = 0.001), and higher level of phosphorus ( P = 0.003) after treatment. CONCLUSION: Despite an increase in 25(OH)D and decrease in PTH levels, 6000 IU/day of OC was not sufficient to restore 25(OH)D deficiency in most of the patients in this study.

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BACKGROUND: Liver disease rates are gradually increasing over the years, becoming a severe public health problem. The indiscriminate use of drugs associated with a rich fat diet, high consumption of alcoholic beverages, and exposure to viral infections and lipid peroxidative products are considered the chief factors for developing hepatic disorders. Owing to the absence of reliable hepatoprotective drugs in the therapeutic arsenal, since they present a high incidence of adverse reactions and/or lack of efficacy in some cases, liver diseases are widely treated with medicinal plants. Among them are the plants producing iridoids, which are believed to be good remedies for liver disease due to their bitter taste. The hepatoprotective effect of iridoids and extracts, rich in these compounds, has been demonstrated, both in vitro and in vivo. OBJECTIVE: This review aims to scrutinize the available literature related to the hepatoprotective activity of iridoids. METHODS: The information was obtained from scientific databases (Science Direct, PubMed, Web of Science, Scopus, ACS Publications, Wiley Online Library) until December, 2021. RESULTS AND CONCLUSION: A total of 63 hepatoprotective iridoids were found, including aucubin, catalpol and picroliv, a mixture of two iridoids. They are the target of a high number of studies, which revealed their protective action against different hepatotoxic agents and detailed action mechanisms.

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During liver fibrogenesis, there is an imbalance between regeneration and wound healing. The current treatment is the withdrawal of the causing agent; thus, investigation of new and effective treatments is important. Studies have highlighted the action of chondroitin sulfate (CS) in different cells; thus, our aim was to analyze its effect on an experimental model of bile duct ligation (BDL). Adult Wistar rats were subjected to BDL and treated with CS for 7, 14, 21, or 28 days intraperitoneally. We performed histomorphometric analyses on Picrosirius-stained liver sections. Cell death was analyzed according to caspase-3 and cathepsin B activity and using a TUNEL assay. Regeneration was evaluated using PCNA immunohistochemistry. BDL led to increased collagen content with corresponding decreased liver parenchyma. CS treatment reduced total collagen and increased parenchyma content after 21 and 28 days. The treatment also promoted changes in the hepatic collagen type III/I ratio. Furthermore, it was observed that CS treatment reduced caspase-3 activity and the percentage of TUNEL-positive cells after 14 days and cathepsin B activity only after 28 days. The regeneration increased after 14, 21, and 28 days of CS treatment. In conclusion, our study showed a promising hepatoprotective action of CS in fibrogenesis induced by BDL.

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Carbohydrates and lipids are two components of the diet that provide the necessary energy to carry out various physiological processes to help maintain homeostasis in the body. However, when the metabolism of both biomolecules is altered, development of various liver diseases takes place; such as metabolic-associated fatty liver diseases (MAFLD), hepatitis B and C virus infections, alcoholic liver disease (ALD), and in more severe cases, hepatocelular carcinoma (HCC). On the other hand, PPARs are a family of ligand-dependent transcription factors with an important role in the regulation of metabolic processes to hepatic level as well as in other organs. After interaction with specific ligands, PPARs are translocated to the nucleus, undergoing structural changes to regulate gene transcription involved in lipid metabolism, adipogenesis, inflammation and metabolic homeostasis. This review aims to provide updated data about PPARs' critical role in liver metabolic regulation, and their involvement triggering the genesis of several liver diseases. Information is provided about their molecular characteristics, cell signal pathways, and the main pharmacological therapies that modulate their function, currently engaged in the clinic scenario, or in pharmacological development.

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SUMMARY: The present study was aimed to investigate the hepatoprotective effects of date palm hydroalcoholic extract (DP)in diabetic rats using biochemical and histopathological approaches. Diabetes was induced by administration of 60 mg/kg of streptozotocin intraperitoneally. In this analysis 32 adult rats were randomly divided into four groups; group 1: non-diabetic control whic received 0.1 mL normal saline, group 2:served as non-diabetic control which treated with 270 mg/kg of DP, group 3: served as untreated diabetic, and group 4: diabetic rats treated with 270 mg/kg of DP. Diabetic rats treated with the DP extracts exhibited lower hepatic oxidative stress and lower hepatic enzymes level. Extract treatment decreased the level of malondealdehyde (MDA) as a marker of lipid peroxidation. Stereological estimations revealed a significant increase in the liver volume in diabetic rats which was reduced in DP-treated rats. Immunofluorescence staining showed high synthesis of acrolein as a byproduct of lipid proxidation. While, optical density measurement revealed significant decrease in acrolein after DP administration. Histopathological examination showed severe changes in untreated diabetic liver tissue manifested by dilated portal vein, leukocytic infiltration, fatty degeneration and necrotic nuclei, whereas, DP treatment attenuated the adverse effects of diabetes on the liver represented by relatively healthy hepatocytes and sinusoids. The obtained results indicated that date pam extract was beneficial in the prevention of diabetes-induced hepatotoxicity due to its natural antioxidant constituents. Further preclinical and clinical studies are needed for considering this plant in management of prediabetes and diabetes hepatic complications.

RESUMEN: El presente estudio tuvo como objetivo investigar los efectos hepatoprotectores del extracto hidroalcohólico (DP) de la palmera datilera en ratas diabéticas utilizando enfoques bioquímicos e histopatológicos. La diabetes fue inducida mediante la administración de 60 mg / kg de estreptozotocina por vía intraperitoneal. Se dividieron al azar 32 ratas adultas en cuatro grupos; grupo 1: control no diabético que recibió 0,1 mL de solución salina normal, grupo 2: control no diabético tratado con 270 mg / kg de DP, grupo 3: fue separado como diabético no tratado, y grupo 4: ratas diabéticas tratadas con 270 mg / kg de DP mg / kg de DP. Las ratas diabéticas tratadas con los extractos de DP mostraron menor estrés oxidativo hepático y menor nivel de enzimas hepáticas. El tratamiento con extracto disminuyó el nivel de malondealdehído (MDA) como marcador de la proxidación de lípidos. Las estimaciones estereológicas revelaron un aumento significativo en el volumen del hígado en ratas diabéticas que se redujo en las ratas tratadas con DP. La tinción por inmunofluorescencia mostró una alta síntesis de acroleína como subproducto de la proxidación de lípidos. Mientras que, la medición de la densidad óptica reveló una disminución significativa de la acroleína después de la administración de DP. El examen histopatológico mostró cambios significativos en el tejido hepático diabético no tratado manifestados por vena porta dilatada, infiltración leucocítica, degeneración grasa y núcleos necróticos, mientras que el tratamiento con DP atenuó los efectos adversos de la diabetes en el hígado representados por hepatocitos y sinusoides relativamente sanos. Los resultados obtenidos indicaron que el extracto de palmera datilera fue beneficioso en la prevención de la hepatotoxicidad inducida por diabetes debido a sus constituyentes antioxidantes naturales. Se necesitan más estudios clínicos para considerar esta planta en el manejo de la prediabetes y las complicaciones hepáticas de la diabetes.

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The lack of prevention of noncommunicable diseases (NCDs) has caused an increase in the mortality rate including conditions such as chronic kidney disease (CKD) and liver disease (LD). The high complexity of CKD and LD results in alterations in the metabolism of carbohydrates, proteins, and lipids. One of the changes observed in CKD and LD is the decrease in albumin, elevation of PO4-3, K+, creatinine, urea, and transaminase enzymes. The pharmacological treatment is expensive. Nowadays, phytotherapy is an option to treat NCDs. Aqueous, ethanolic, methanolic, and ethyl acetate extracts of Cnidoscolus aconitifolius have shown nephroprotective and hepatoprotective potential and can be an alternative to prevent and treat CKD and LD. C. aconitifolius, known as Chaya by Mayas in Yucatán, is a shrub that is consumed in Mexico and in the world, has a low cost, it is very accessible, and can growth in extreme weather. The aim of this review is to show the potential biological effects of C. aconitifolius extracts, and the association of the phytochemicals in the extract. It is known that different solvents result in the uptake of different phytochemicals. These have shown various effects such as hypoglycemic, hypotensive, hypolipidemic, and antioxidant, being a natural alternative to the treatment of NCDs.Key teaching pointsPhytotherapy is a proposal to treat NCDs.Cnidoscolus aconitifolius extracts have a hypotensive effect.Cnidoscolus aconitifolius extracts reduce blood sugar in diabetic rats.Chaya extracts are no toxic for renal and hepatic cells.

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INTRODUCTION: Metabolic and hormonal disorders resulting from chronic liver diseases culminate in increased proteolysis and decreased protein synthesis, which contributes to the development and progression of malnutrition and, consequently, sarcopenia. Nutritional management of sarcopenia in liver cirrhosis is a continuously evolving field and data on essential amino acid supplementation in chronic liver diseases is scarce. AREAS COVERED: This review encompasses the current literature on oral amino acids supplementation in patients with chronic liver disease or patients with liver cirrhosis to try to elucidate the possible effects of L-branched-chain amino acids and isolated L-leucine as a therapeutic approach to malnutrition and sarcopenia. EXPERT COMMENTARY: To ensure an optimal nutritional status and to reduce sarcopenia, it is necessary to assess nutritional status in all patients with liver cirrhosis and to apply nutritional interventions accordingly. The supply of calories, proteins, and essential amino acids is necessary for the maintenance of muscle mass and function. Although supplementation of L-branched-chain amino acids plays an important role in liver disease, L-leucine has been described as the main amino acid involved in protein turnover, reducing proteolysis, and stimulating protein synthesis.

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The coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) virus. COVID-19 affected more than 6million persons worldwide in fewer than 4 months, after the report of the first cases in China in December 2019. The relation of the disease caused by SARS-Cov-2 to immunosuppressive treatment used in different gastrointestinal disorders is uncertain, resulting in debate with regard to suspending immunosuppressive therapy to improve infection outcome. Said suspension implies the inherent risk for graft rejection or autoimmune disease exacerbation that can potentially worsen the course of the infection. Based on the presently available evidence, a treatment stance has been established for patients with gastrointestinal diseases that require immunosuppressive therapy.

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Silymarin (Silybum marianum; SM), popularly known as milk thistle, is an extract that has been used for many centuries to treat liver diseases. In recent years, several studies have shown that SM is not only just another antioxidant but also a multifunctional compound that exhibits several beneficial properties for use in the treatment and prevention of different types of pathologies and disorders. This review aims at demonstrating the main protective activities of SM in diseases, such as cancer, diabetes, hepatitis, non-alcoholic fatty liver disease, alcoholic liver disease, hepatitis C virus, hepatitis B virus, metabolic syndrome, depression, cardiovascular diseases and thalassemia, in addition to its photoprotective activity in in vitro tests and preclinical studies. Its main functions include antioxidant and anti-inflammatory effects, and it acts as modulator of signaling pathways. It has been suggested that SM presents great multifunctional potential and is capable of achieving promising results in different types of research. However, caution is still needed regarding its indiscriminate use in humans as there are only a few clinical studies relating to the adequate dose and the actual efficacy of this extract in different types of diseases.

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OBJECTIVE: To report our clinical experience with bevacizumab in a cohort of Hereditary Hemorrhagic Telangiectasia (HHT) patients with severe hepatic involvement and/or refractory anemia. METHODS: Observational, ambispective study of the Institutional Registry of HHT at Hospital Italiano de Buenos Aires. Patients were treated with bevacizumab due to iron deficiency refractory anemia secondary to nasal/gastrointestinal bleeding and/or high output cardiac failure. We describe basal clinical data, bevacizumab schedules, efficacy outcomes and adverse events. Wilcoxon signed ranks test and longitudinal analysis were conducted. RESULTS: Twenty adult patients were included from July 2013 to June 2019. Clinical indications were: 13 for anemia, 4 for heart failure and 3 for both. In the anemia group, median pretreatment hemoglobin was 8.1 g/dl [IQR: 7.2-8.4] and median transfusion requirement was 4 units [2-6]. In heart failure group, pretreatment median cardiac index was 4.5 L/min/m2 [4.1-5.6] and cardiac output was 8.3 L/min [7.5-9.2]. Bevacizumab 5 mg/kg/dose every 2 weeks for 6 applications was scheduled. By the end of induction, median hemoglobin at 3 months was 10.9 g/dl [9.5-12.8] (p = 0.01) and median transfusion requirement 0 units [0-1] (p<0.01), and this effect was more or less sustained during a year. Regarding heart failure group, two patients had complete hemodynamic response and achieved liver transplantation and two had partial response. No serious adverse events were registered. CONCLUSION: Bevacizumab is a promising line of treatment for HHT patients with refractory anemia. For patients with high output cardiac failure, bevacizumab may be useful as bridge therapy awaiting for liver transplantation.

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The liver is one of the most complex organs of the human body and is involved in various metabolic processes. Due to its anatomical proximity to the digestive tract, its blood flow, and its contribution to the detoxification process, the liver is susceptible to a wide variety of disorders. Hepatic diseases can be caused by alcoholism, viral infections, malnutrition and xenobiotics, which result in a high frequency of patients with liver disease and subsequent increase in the number of deaths from these diseases, for which adequate treatments are not yet available. Therefore, the search for new alternatives to treat these liver conditions is mandatory. In recent decades, there has been an increase in interest in medicinal herbs due to their safety and hepatoprotective properties that arise from their anti-inflammatory, antioxidant, antifibrotic, antiviral, immunomodulatory and anticancer properties. Epidemiological and clinical studies have shown that the consumption of these compounds is associated with a decrease in the risk of developing liver diseases; thus, medicinal herbs have emerged as a viable option for the treatment of these hepatic pathologies. However, more basic and clinical studies are needed before reaching a final recommendation to treat human liver diseases. This review provides molecular and clinical information on some natural compounds and medicinal herbs that have hepatoprotective effects and could be useful for the treatment of hepatic disorders.

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INTRODUCTION AND OBJECTIVES: Zinc deficiency has been associated with poor prognosis in chronic liver disease. This systematic review and meta-analysis aimed to evaluate the role of zinc supplementation in the management of chronic liver diseases. MATERIALS AND METHODS: We searched MEDLINE, LILACS, EMBASE, and Cochrane CENTRAL databases from inception to August 2018. We included randomized controlled trials evaluating adult patients with chronic liver disease of any etiology receiving zinc supplementation. Studies with other designs or evaluating chronic conditions other than liver disease were excluded. Two reviewers independently screened and extracted data from eligible studies. Study quality was assessed using the Cochrane Collaboration's tool for assessing risk of bias in randomized studies. RESULTS: Of 1315 studies screened, 13 were included. Six assessed chronic hepatitis C treatment, with a relative risk of 0.83 indicating no protective effect of zinc supplementation on the improvement of sustained virological response. Three evaluated response to hepatic encephalopathy treatment, with a relative risk of 0.66 indicating a favorable effect of zinc supplementation on clinical improvement of this condition. Of four studies evaluating the management of cirrhosis, two analyzed the effect of zinc supplementation on serum albumin levels, with no statistical difference between zinc and placebo groups. CONCLUSIONS: Clinical trials assessing zinc supplementation in liver diseases do not show benefits in terms of clinical improvement or disease halting. There are possible benefits of zinc supplementation on hepatic encephalopathy, however, this is based on limited evidence. This research question is still open for evaluation in larger, well-designed, clinical trials.

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Purpose: Coleus forskohlii Briq., a medicinal plant originally from India, has been indicated against heart disease, expiratory disorders, convulsions, and hepatic changes, among others. In view of the broad pharmacological potential of the plant and the scarce information about its effects, the objective of the present study was to investigate the effect of its use for pretreatment of partially hepatectomized rats. Methods: The animals were divided into two experimental groups: Control (CG) receiving physiological saline for 10 days before partial hepatetctomy, and Treated (TG) receiving 40 mg Coleus forskohlii/kg/day for 10 days before partial hepatectomy. The treatments were performed by gastric gavage. After the surgical procedure, treatment was continued according to the following groups: CG 24 h, CG 48 h, TG 24 h, and TG 48 hs, and liver tissue and intracardiac blood samples were obtained for histological and biochemical analysis, respectively. Results: No significant differences were observed in mitotic or apoptotic index or in the concentrations of the enzymes AST, ALT and alkaline phosphatase, and no areas of fibrosis were detected. Conclusion: Treatment with Coleus forskohlii did not interfere with the course of hepatic hyperplasia.(AU)

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This study investigates the acute anti-inflammatory activity of Mangifera indica L. leaf extract and mangiferin in the liver of rats fed a cafeteria diet. This study was a randomized longitudinal experimental study. The animals were divided into three groups - Control: cafeteria diet (CD); Extract: CD + leaf extract (250 mg kg-1); and Mangiferin: CD + mangiferin (40 mg kg-1). Body weight and food intake were measured every week. On day eight, mRNA and protein expression of inflammatory markers were evaluated in the liver. Also, liver weight, SOD activity and malondialdehyde concentration were measured. Treatment for only eight days with mango leaf extract and mangiferin increased SOD activity. Mangiferin intake increased the mRNA expression of PPAR-α and HSP72. The leaf extract treatment enhanced PPAR-α mRNA expression. Mangiferin and leaf extract consumption caused a lower concentration of NFκB (p65) in nuclear extracts, and greater IL-10 mRNA and protein levels. This study highlights the potential of acute treatment with mango leaf extract and mangiferin to prevent liver inflammation caused by fat-rich diets. These results indicate a new use for a product that has low cost, is found in great amounts, and is not routinely used.

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Bile acids (BAs) are key molecules in generating bile flow, which is an essential function of the liver. In the last decades, there have been great advances in the understanding of BA physiology, and new insights have emerged regarding the role of BAs in determining cell damage and death in several liver diseases. This new knowledge has helped to better delineate the pathophysiology of cholestasis and the adaptive responses of hepatocytes to cholestatic liver injury as well as of the mechanisms of injury of biliary epithelia. In this context, therapeutic approaches for liver diseases using hydrophilic BA (i.e., ursodeoxycholic acid, tauroursodeoxycholic, and, more recently, norursodeoxycholic acid), have been revamped. In the present review, we summarize current experimental and clinical data regarding these BAs and its role in the treatment of certain liver diseases.

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ETHNOPHARMACOLOGICAL RELEVANCE: Verbena montevidensis and Verbena litoralis are plants that present morphological similarities. They are both known as "gervão" and "fel-da-terra", among other popular names, and are used in folk medicine to treat diseases related to the liver and stomach. AIMS OF THE STUDY: The aim of the current investigation was to determine the chemical composition and evaluate the hepatoprotective properties and cytotoxicity of the methanolic and aqueous extracts of V. montevidensis, V. litoralis and their main iridoid in HepG2 cells. MATERIALS AND METHODS: Aqueous and methanolic extracts from the dried aerial parts of V. montevidensis and V. litoralis were obtained. The methanolic extract of V. montevidensis afforded an iridoid as the main compound. The extracts and isolated compound were examined for the hepatoprotective effect and cytotoxicity in human hepatoblastoma HepG2 cells by MTT reduction and neutral red uptake methods. RESULTS: The methanolic and aqueous extracts of both species showed the presence of iridoid and phenylethanoids as the main compounds. The iridoid brasoside was isolated and identified by spectroscopic methods. The phenylethanoid was characterized by HPLC, comparing the UV profile and retention time with an authentic sample. The results of the biological assays indicate that both aqueous and methanolic extracts of V. montevidensis and V. litoralis as well as brasoside were hepatoprotective against ethanol-induced damage in HepG2 cells. The effect can be attributed to the main compounds present since both classes are recognized for this activity. CONCLUSIONS: Our results contribute towards validation of the traditional use of V. montevidensis and V. litoralis in the treatment of liver disorders.

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