High serum fibroblast growth factor 21 is associated with inferior hepatocellular carcinoma survival: A prospective cohort study

Serum FGF21 as a predictor of response to atezolizumab and bevacizumab in HCC

Background & Aims

Fibroblast growth factor 21 (FGF21) is a crucial regulator of cell metabolism. Tumour-secreted FGF21 has shown immune-checkpoint factor functions, and high FGF21 levels are associated with a poor prognosis for patients. However, its prognostic value and impact on treatment response in patients with hepatocellular carcinoma (HCC) treated with immune-checkpoint inhibitors (ICIs) remain unclear. Thus, this study investigated the potential of high FGF21 levels as a prognostic marker and whether traditional ICI-based therapy can improve the prognosis of patients with high FGF21 levels.

Methods

In this retrospective multicentre study, patients with unresectable HCC who received atezolizumab/bevacizumab in the NORTE study group (n = 117) were classified into high (≥915 pg/ml; n = 29) and non-high (n = 88) FGF21 groups. For validation, we investigated patients treated with atezolizumab/bevacizumab in an independent cohort (n = 285). Overall survival, progression-free survival, and treatment response were compared between patients with and without high baseline FGF21 levels.

Results

The median overall survival (p <0.001) and progression-free survival (p = 0.045) were significantly shorter in the high FGF21 group than in the non-high FGF21 group. Independent cohort analysis validated these results. In the overall cohort, the median progression-free survival (5.75 vs. 8.84 months; p = 0.027) and median overall survival (14.13 vs. 22.08 months; p <0.001) were significantly shorter in the high FGF21 group than in the non-high FGF21 group. The durable response (≥6 months) + complete response rate was significantly decreased in the high FGF21 group (p = 0.045). No patient with a high FGF21 level achieved a complete response, whereas this was achieved in 4.1% (13/319) of patients with non-high FGF21 levels. Multivariate Cox regression analysis identified high baseline serum FGF21 as an independent poor prognostic factor for overall survival (hazard ratio 2.20, p <0.001).

Conclusions

Serum FGF21 may be a robust, non-invasive prognostic and treatment response marker for unresectable HCC treated with atezolizumab/bevacizumab.

Impact and implications

FGF21 has been reported to act as a secreted immune-checkpoint factor, and elevated levels of FGF21 are associated with a poor prognosis in patients with HCC. It is not fully understood whether ICIs can overcome the impact of high FGF21 levels on the shortened prognosis of patients with HCC. In this multicentre retrospective study, patients with HCC and high baseline levels of serum FGF21 who received atezolizumab/bevacizumab treatment exhibited a significantly shorter overall survival and shorter progression-free survival. These findings suggest serum FGF21 as a robust prognostic marker and an indicator of treatment response in unresectable HCC treated with ICI-based therapy. These findings could be crucial for the implementation of personalised treatment strategies for unresectable HCC. However, identifying optimal therapeutic options for patients with unresectable HCC and high serum FGF21 levels remains an urgent and critical clinical issue.

FGF21 affects the glycolysis process via mTOR-HIF1α axis in hepatocellular carcinoma

BACKGROUND

Metabolic reprogramming, particularly glycolysis, is essential in processes like cancer and immune response. While FGF21's role in hepatocyte glucose metabolism has been linked to glucose transporters and its impact on aerobic glycolysis and cellular growth in HCC remain unclear. In this study, we investigated FGF21-mediated modulation of glucose metabolism in HCC through mTOR and HIF1α axis in HCC.

METHODS

The study evaluated the dysregulation of FGF21 and its prognostic impact in HCC using various datasets. The literature review was done to identify glycolysis related genes to find significant interaction with FGF21 using stringdb and their correlation in datasets. The regulation of FGF21 was validated in HepG2 cell lines by transfecting FGF21 and measuring its effects on glycolysis, including glucose uptake, lactate levels, and key glycolytic enzymes using rt-PCR. Additionally, the effect of FGF21 transfection on mTOR and HIF1α was also evaluated using rt-PCR.

RESULTS

The insilico analysis indicates that the FGF21-mTOR-HIF1α signaling axis regulates glucose metabolism, with mTOR as a central integrator of signals from FGF21 and HIF1α. Invitro experiments showed that silencing FGF21 expression via siRNA reduced glycolytic enzyme expression, glucose uptake, lactate levels, and cell proliferation in HepG2 cells. Conversely, recombinant FGF21 treatment has a reverse effect in HepG2 cells. Additionally, FGF21 treatment also affected mTOR and HIF1α expression, highlighting its role in metabolic regulation and disease through the mTOR-HIF1α axis.

CONCLUSION

The regulation of FGF21 influences glycolysis via the mTOR-HIF1α axis, highlighting its critical role in glucose metabolism and metabolic adaptation in response to energy availability.

Role of the serum levels of the inter-organs messenger fibroblast growth factor 21 (FGF21) in the diagnosis and prognosis of breast cancer patients

FGF21 regulates local and systemic metabolic homeostasis. High serum FGF21 was found in obesity, metabolic syndrome, type 2 diabetes mellitus, and coronary heart disease. The pathways linking obesity and breast cancer remain elusive. We aimed to analyze the serum FGF21 in breast cancer patients at diagnosis. Circulating FGF21 levels in 45 breast cancer women (median age 59, range 32-88 years) and 51 age-matched healthy controls were evaluated using a quantitative ELISA assay. Patients' samples were obtained before surgery ahead of any previous therapy. Breast cancer patients showed significantly elevated serum FGF21 (median 267.13, range 28.41-780.45) respect to healthy controls (76.86, 0.00-425.60) (p < 0.0001). A ROC curve determined a cut-off value of 130.64 pg/ml to define positive or high FGF21 levels. Based on this cut-off point, 30/45 (66.7%) breast cancer patients showed positive serum FGF21 levels as compared to 18/51 (35.3%) healthy controls. Circulating FGF21 levels could be useful as a highly sensitive diagnosis biomarker for early breast cancer detection. We did not find any significant association between the serum FGF21 levels, and many clinical-pathological or metabolic parameters determined at the diagnosis of the primary disease. Interestingly, a statistically significant correlation was determined between serum FGF21 and the body mass index (BMI). Furthermore, patients with positive FGF21 serum levels had a worst overall survival (Log Rank Test [Mantle Cox] p = 0.017). We propose serum FGF21 levels determined at the diagnosis of primary breast cancer as a promising diagnostic and prognosis biomarker in this oncological disease.

The value of promoter methylation of fibroblast factor 21 (FGF21) in predicting the course of chronic hepatitis B and the occurrence of oxidative stress

BACKGROUND

Oxidative stress plays a crucial role in the pathogenesis of HBV. This study aimed to investigate the value of fibroblast growth factor 21 (FGF21) promoter methylation in the occurrence and development of chronic hepatitis B (CHB) oxidative stress.

METHODS

A total of 241 participants including 221 patients with CHB and 20 healthy controls (HCs) were recruited. Methylation level of FGF21 promoter in peripheral blood mononuclear cells was quantitatively determined. Enzyme-linked immunosorbent assay was used to assess oxidative stress in CHB patients.

RESULTS

Our study shows that the FGF21 methylation level was significantly lower in HBeAg-positive CHB patients compared to HBeAg-negative CHB patients and HCs (P < 0.0001). The oxidative stress of HBeAg-positive CHB patients was more severe. Further correlation analysis showed that there was a significant correlation between the methylation level of FGF21 promoter and the occurrence of oxidative stress in CHB patients. In addition, assessment based on FGF21 promoter methylation level proved effective for predicting oxidative stress occurrence and disease progression among CHB patients.

CONCLUSION

FGF21 promoter methylation level is an important marker for predicting oxidative stress and disease progression in patients with CHB.

Pregnane X receptor (PXR) deficiency promotes hepatocarcinogenesis via induction of Akr1c18 expression and prostaglandin F2α (PGF2α) levels

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Pregnane X receptor (PXR), a xenobiotic-sensing nuclear receptor, plays a critical role in the metabolism of endogenous and exogenous substances in the liver. Here, we investigate whether PXR plays a role in pathogenesis of HCC. We show that liver tumors were developed in diethylnitrosamine (DEN)-treated in PXR knockout (KO) mice. Hepatic levels of prostaglandin F2α (PGF2α) and aldo-keto reductase family 1 member C18 (Akr1c18), a prostaglandin synthase of catalyzing reduction of PGH2 to PGF2α, were significantly elevated in DEN-treated PXR KO mice. Hepatic mRNA levels of alpha fetoprotein (AFP), cyclin D1 (Ccnd1), fibroblast growth factor 21 (FGF21), and inflammatory cytokine interleukin 6 (IL-6) were significantly increased in DEN-treated PXR KO mice. Other members of Akr1c family, liver metabolizing enzymes including Cyp1a2, Cyp2b10 and Cyp3a11, and bile acid synthesis enzyme Cyp7a1 mRNA levels were significantly decreased in DEN-treated PXR KO mice. Our findings revealed that PXR deficiency promoted DEN-induced HCC in mice via induction of Akr1c18 expression and PGF2α levels and the increased PGF2α levels synthetized by Akr1c18 enhanced hepatocytes proliferation and induced inflammatory cytokine production, which accelerated liver tumor development after DEN treatment, suggesting that PXR deficiency may create a microenvironment that is more prone to DEN-induced liver tumors and targeting PXR and Akr1c18 to reduce PGF2α biosynthesis may be a potential and novel therapeutic strategy for HCC.

Recent progress in understanding mitokines as diagnostic and therapeutic targets in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most prevalent tumors worldwide and the leading contributor to cancer-related deaths. The progression and metastasis of HCC are closely associated with altered mitochondrial metabolism, including mitochondrial stress response. Mitokines, soluble proteins produced and secreted in response to mitochondrial stress, play an essential immunomodulatory role. Immunotherapy has emerged as a crucial treatment option for HCC. However, a positive response to therapy is typically dependent on the interaction of tumor cells with immune regulation within the tumor microenvironment. Therefore, exploring the specific immunomodulatory mechanisms of mitokines in HCC is essential for improving the efficacy of immunotherapy. This study provides a comprehensive overview of the association between HCC and the immune microenvironment and highlights recent progress in understanding the involvement of mitochondrial function in preserving liver function. In addition, a systematic review of mitokines-mediated immunomodulation in HCC is presented. Finally, the potential diagnostic and therapeutic roles of mitokines in HCC are prospected and summarized. Recent progress in mitokine research represents a new prospect for mitochondrial therapy. Considering the potential of mitokines to regulate immune function, investigating them as a relevant molecular target holds great promise for the diagnosis and treatment of HCC.

Aberrant acetylated modification of FGF21‑KLB signaling contributes to hepatocellular carcinoma metastasis through the β‑catenin pathway

β‑Klotho (KLB) is a vital element of the fibroblast growth factor (FGF) receptor complex and acts as a co‑receptor to facilitate the binding of FGF19 and FGF21 to the FGFRs on the target cells. The present study aimed to determine the contribution of FGF21‑KLB signaling to hepatocellular carcinoma (HCC) metastasis. KLB expression was measured in HCC tissues and cell lines using western blot and reverse transcription‑quantitative PCR. Furthermore, the proliferation, apoptosis and metastasis capacity of KLB‑knockdown Huh7 cells (human HCC cell line) were assessed by Cell Counting Kit‑8 assay, 5‑ethynyl‑2'‑deoxyuridine assay, flow cytometry, wound‑healing assay and Transwell assay. Enrichment analysis was used to explore the underlying regulatory mechanisms of KLB. The metastasis potential of human HCC cells in the context of FGF21 with or without KLB inhibition was determined in vitro and in vivo. Acetylated modification of KLB was determined using a co‑immunoprecipitation assay. The results indicated a significant upregulation of KLB in HCC tissues compared with the corresponding normal tissues. In addition, KLB expression was closely associated with HCC metastasis. Migration and invasion assays revealed that KLB knockdown promoted the metastatic capability of HCC cells. Gene set variation analysis and subsequent mechanistic investigations revealed that KLB is the upstream regulatory factor of β‑catenin signaling. Furthermore, FGF21 was indicated to suppress HCC metastasis by inhibiting β‑catenin signaling‑driven epithelial‑mesenchymal transition (EMT), while KLB knockdown and simultaneous FGF21 overexpression promoted HCC cell motility. Histone deacetylase 3 (HDAC3) was further characterized as the potential deacetylase for KLB. Furthermore, the results revealed that HDAC3 inhibitor‑mediated acetylated modification led to KLB inactivation, resulting in the blockade of FGF21‑KLB signaling, which further triggered the expression of EMT induction‑related genes in Huh7 cells. In conclusion, the present study demonstrated that aberrant acetylated modification of KLB inhibited FGF21‑KLB signaling, thereby promoting β‑catenin signaling‑driven EMT and HCC metastasis.

A wide scan of plasma proteins demonstrates thioredoxin reductase 1 as a potential new diagnostic biomarker for hepatocellular carcinoma

BACKGROUND

Patients with liver cirrhosis are recommended ultrasonography screening for early detection of hepatocellular carcinoma to increase the chances of curative treatment. However, ultrasonography alone lacks in sensitivity. Adding plasma biomarkers may increase the detection rate. We performed a broad exploratory analysis to find new plasma proteins with potential applicability for HCC screening in patients with cirrhosis.

METHODS

In a protein discovery cohort of 172 patients with cirrhosis or HCC, we screened for 481 proteins with suspension bead array or proximity extension assay. From these, 24 proteins were selected for further analysis in a protein verification cohort (n = 160), using ELISA, Luminex or an electrochemiluminescence platform. A cut-off model and a stepwise logistic regression model were used to find combinations of proteins with the best discriminatory performance between HCC and cirrhosis.

RESULTS

Stepwise logistic regression revealed alpha-fetoprotein (AFP), decarboxy-prothrombin (DCP), thioredoxin reductase 1 (TXNRD1), and fibroblast growth factor 21 (FGF21) as the proteins with the best discriminatory performance between HCC and cirrhosis. Adding TXNRD1 to DCP and AFP increased the AUC from 0.844 to 0.878, and combining AFP, DCP and TXNRD1 with age and sex resulted in an AUC of 0.920. FGF21, however, did not further increase the performance when including age and sex.

CONCLUSION

In the present study, TXNRD1 improves the sensitivity and specificity of AFP and DCP as HCC screening tools in patients with cirrhosis. We suggest that TXNRD1 should be validated in prospective settings as a new complementary HCC biomarker together with AFP and DCP.

Increased serum fibroblast growth factor 21 levels are associated with adverse clinical outcomes after intracerebral hemorrhage

Introduction

Intracerebral hemorrhage (ICH) is the most prevalent cause of death. We sought to explore whether serum Fibroblast growth factor 21 (FGF21) is of substantial benefit in predicting poor prognosis in ICH patient.

Methods

A prospective, multicenter cohort analysis of serum FGF21 levels in 418 ICH patients was carried out. At three months following ICH start, the primary endpoint was death or major disability, whereas the secondary endpoint was death. We investigated the association between serum FGF21 and clinical outcomes. We added FGF21 to the existing rating scale to assess whether it enhanced the prediction ability of the original model. Effectiveness was determined by calculating the C-statistic, net reclassification index (NRI), absolute integrated discrimination improvement (IDI) index.

Results

Among 418 enrolled patients, 217 (51.9%) of the all subjects had death or significant disability. Compared with patients in the lowest quartile group, those in the first quartile group had higher risk of the primary outcome (Odds ratio, 2.73 [95%CI,1.42-5.26, p < 0.05]) and second outcome (Hazard ratio, 4.28 [95%CI,1.61-11.42, p < 0.001]). The integration of FGF21 into many current ICH scales improved the discrimination and calibration quality for the integrated discrimination index's prediction of main and secondary findings (all p < 0.05).

Conclusion

Elevated serum FGF21 is associated with increased risks of adverse clinical outcomes at 3 months in ICH patients, suggesting FGF21 may be a valuable prognostic factor.

The role of FGF21 and its analogs on liver associated diseases

Fibroblast growth factor 21 (FGF21), a member of fibroblast growth factor family, is a hormone-like growth factor that is synthesized mainly in the liver and adipose tissue. FGF21 regulates lipid and glucose metabolism and has substantial roles in decreasing lipogenesis and increasing hepatic insulin sensitivity which causing lipid profile improvement. FGF21 genetic variations also affect nutritional and addictive behaviors such as smoking and alcohol consumption and eating sweets. The role of FGF21 in metabolic associated diseases like diabetes mellitus had been confirmed previously. Recently, several studies have demonstrated a correlation between FGF21 and liver diseases. Non-alcoholic fatty liver disease (NAFLD) is the most prevalent type of chronic liver disease worldwide. NAFLD has a wide range from simple steatosis to steatohepatitis with or without fibrosis and cirrhosis. Elevated serum levels of FGF21 associated with NAFLD and its pathogenesis. Alcoholic fatty liver disease (AFLD), another condition that cause liver injury, significantly increased FGF21 levels as a protective factor; FGF21 can reverse the progression of AFLD and can be a potential therapeutic agent for it. Also, NAFLD and AFLD are the most important risk factors for hepatocellular carcinoma (HCC) which is the fourth deadliest cancer in the world. Several studies showed that lack of FGF21 induced oncogenic condition and worsened HCC. In this review article, we intend to discuss different aspects of FGF21 in NAFLD, AFLD and HCC; including the role of FGF21 in pathophysiology of these conditions, the effects of FGF21 mutations, the possible use of the FGF21 as a biomarker in different stages of these diseases, as well as the usage of FGF21 and its analog molecules in the treatment of these diseases.

Beneficial Effects of Table Grape Use on Serum Levels of Omega-3 Index and Liver Function: A Randomized Controlled Clinical Trial

This clinical trial was aimed to investigate the effects of fresh table grape intake on the serum levels of the Omega-3 index, defined as the sum of eicosapentaenoic acid (EPA) + docosahexaenoic acid (DHA) levels. Forty consecutive healthy subjects were randomly assigned to the control group, receiving only dietary recommendations, and the grape group receiving a daily dose of 5 g of fresh table grape per kg of body weight, for 21 days. Compared with baseline, the grape treatment produced no significant difference in the serum levels of glucose, liver transaminase, and triglycerides, with the exception of cholesterol value, which was significantly reduced in both control and grape group (180.5 ± 20.32 vs. 196.1 ± 30.0 and 181.4 ± 21.9 vs. 194.3 ± 37.5, respectively). After 4 weeks from the end of grape treatment, the analysis of single fatty acids showed a significant increase in oleic acid content (14.15 ± 1.8 vs. 12.85 ± 1.6, p < 0.05) and a significant induction of the Omega-3 index (8.23 ± 1.9 vs. 6.09 ± 1.2, p < 0.05), associated with increased serum levels of adiponectin (24.09 ± 1.08 vs. 8.8 ± 0.7, p < 0.001). In contrast, the expression of fibroblast growth factor 21 (FGF21), a molecule associated with metabolic syndrome and liver disease, was significantly reduced (37.9 ± 6.8 vs. 107.8 ± 10.1, p < 0.001). The data suggest that the intake of fresh grape improves the Omega-3 index in the serum and exerts beneficial effects on liver function through the overexpression of adiponectin and the reduction in FGF21 levels.

Investigation of the Characteristics of Crimean Congo Hemorrhagic Fever Cases Reported in Afyonkarahisar Province

OBJECTIVE

Crimean Congo Hemorrhagic Fever (CCHF); fever, widespread pain in the body, deterioration in liver function tests; it is a tick-borne viral infectious disease that can cause bleeding and death in the skin, mucous membranes, and sometimes internal organs. In this study, we retrospectively evaluated the clinical, laboratory, and epidemiological characteristics of CCHF cases diagnosed in Afyonkarahisar.

METHODS

Demographic and clinical characteristics, laboratory findings, treatments, and prognoses of patients diagnosed with CCHF in Afyonkarahisar were retrospectively analyzed.

RESULTS

In Afyonkarahisar, it was determined that 35 case reports were made between 2002 and November 2019, the date when the CCHF was first seen in Turkey. A history of tick attachment was detected in 31 subjects. Tick arrest cases were most common in June (12 cases; 34.3%) and July (9 cases; 2.9%). There was a history of living in rural areas in twenty-seven (77.1%) patients, close contact with animals in 12 patients, and a history of contact with animal blood in 4 patients. All the 35 cases that followed resulted in healing and no mortality was observed.

CONCLUSION

CCHF is an endemic disease that still maintains its importance in our country. The most important factor in the control with the disease is to prevent virus contact to prevent transmission. People living in endemic areas should be informed about the precautions to be taken against tick bites, and awareness should be raised by providing education about the disease.