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Fu Y, Wang Z, Qin H. Examining the Pathogenesis of MAFLD and the Medicinal Properties of Natural Products from a Metabolic Perspective. Metabolites 2024; 14:218. [PMID: 38668346 PMCID: PMC11052500 DOI: 10.3390/metabo14040218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Metabolic-associated fatty liver disease (MAFLD), characterized primarily by hepatic steatosis, has become the most prevalent liver disease worldwide, affecting approximately two-fifths of the global population. The pathogenesis of MAFLD is extremely complex, and to date, there are no approved therapeutic drugs for clinical use. Considerable evidence indicates that various metabolic disorders play a pivotal role in the progression of MAFLD, including lipids, carbohydrates, amino acids, and micronutrients. In recent years, the medicinal properties of natural products have attracted widespread attention, and numerous studies have reported their efficacy in ameliorating metabolic disorders and subsequently alleviating MAFLD. This review aims to summarize the metabolic-associated pathological mechanisms of MAFLD, as well as the natural products that regulate metabolic pathways to alleviate MAFLD.
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Affiliation(s)
| | | | - Hong Qin
- Department of Nutrition and Food Hygiene, Xiangya School of Public Health, Central South University, Changsha 410006, China; (Y.F.); (Z.W.)
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2
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Mahmoudi SK, Tarzemani S, Aghajanzadeh T, Kasravi M, Hatami B, Zali MR, Baghaei K. Exploring the role of genetic variations in NAFLD: implications for disease pathogenesis and precision medicine approaches. Eur J Med Res 2024; 29:190. [PMID: 38504356 PMCID: PMC10953212 DOI: 10.1186/s40001-024-01708-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 02/01/2024] [Indexed: 03/21/2024] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is one of the leading causes of chronic liver diseases, affecting more than one-quarter of people worldwide. Hepatic steatosis can progress to more severe forms of NAFLD, including NASH and cirrhosis. It also may develop secondary diseases such as diabetes and cardiovascular disease. Genetic and environmental factors regulate NAFLD incidence and progression, making it a complex disease. The contribution of various environmental risk factors, such as type 2 diabetes, obesity, hyperlipidemia, diet, and sedentary lifestyle, to the exacerbation of liver injury is highly understood. Nevertheless, the underlying mechanisms of genetic variations in the NAFLD occurrence or its deterioration still need to be clarified. Hence, understanding the genetic susceptibility to NAFLD is essential for controlling the course of the disease. The current review discusses genetics' role in the pathological pathways of NAFLD, including lipid and glucose metabolism, insulin resistance, cellular stresses, and immune responses. Additionally, it explains the role of the genetic components in the induction and progression of NAFLD in lean individuals. Finally, it highlights the utility of genetic knowledge in precision medicine for the early diagnosis and treatment of NAFLD patients.
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Affiliation(s)
- Seyedeh Kosar Mahmoudi
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran
| | - Shadi Tarzemani
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran
| | - Taha Aghajanzadeh
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran.
| | - Mohammadreza Kasravi
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran
| | - Behzad Hatami
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran
| | - Mohammad Reza Zali
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran
| | - Kaveh Baghaei
- Basic and Molecular Epidemiology of Gastrointestinal Disorders Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran.
- Gastroenterology and Liver Diseases Research Center, Research Institute for Gastroenterology and Liver Diseases, Shahid Beheshti University of Medical Sciences, Tehran, 1985714711, Iran.
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Uehara K, Lee WD, Stefkovich M, Biswas D, Santoleri D, Garcia Whitlock A, Quinn W, Coopersmith T, Creasy KT, Rader DJ, Sakamoto K, Rabinowitz JD, Titchenell PM. mTORC1 controls murine postprandial hepatic glycogen synthesis via Ppp1r3b. J Clin Invest 2024; 134:e173782. [PMID: 38290087 PMCID: PMC10977990 DOI: 10.1172/jci173782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 01/26/2024] [Indexed: 02/01/2024] Open
Abstract
In response to a meal, insulin drives hepatic glycogen synthesis to help regulate systemic glucose homeostasis. The mechanistic target of rapamycin complex 1 (mTORC1) is a well-established insulin target and contributes to the postprandial control of liver lipid metabolism, autophagy, and protein synthesis. However, its role in hepatic glucose metabolism is less understood. Here, we used metabolomics, isotope tracing, and mouse genetics to define a role for liver mTORC1 signaling in the control of postprandial glycolytic intermediates and glycogen deposition. We show that mTORC1 is required for glycogen synthase activity and glycogenesis. Mechanistically, hepatic mTORC1 activity promotes the feeding-dependent induction of Ppp1r3b, a gene encoding a phosphatase important for glycogen synthase activity whose polymorphisms are linked to human diabetes. Reexpression of Ppp1r3b in livers lacking mTORC1 signaling enhances glycogen synthase activity and restores postprandial glycogen content. mTORC1-dependent transcriptional control of Ppp1r3b is facilitated by FOXO1, a well characterized transcriptional regulator involved in the hepatic response to nutrient intake. Collectively, we identify a role for mTORC1 signaling in the transcriptional regulation of Ppp1r3b and the subsequent induction of postprandial hepatic glycogen synthesis.
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Affiliation(s)
- Kahealani Uehara
- Institute for Diabetes, Obesity, and Metabolism
- Biochemistry and Molecular Biophysics Graduate Group, and
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Won Dong Lee
- Lewis Sigler Institute for Integrative Genomics
- Department of Chemistry, and
- Ludwig Institute for Cancer Research, Princeton Branch, Princeton, New Jersey, USA
| | | | - Dipsikha Biswas
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Dominic Santoleri
- Institute for Diabetes, Obesity, and Metabolism
- Biochemistry and Molecular Biophysics Graduate Group, and
| | | | | | | | - Kate Townsend Creasy
- Institute for Diabetes, Obesity, and Metabolism
- Department of Medicine, Division of Translational Medicine and Human Genetics, and
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel J. Rader
- Institute for Diabetes, Obesity, and Metabolism
- Department of Medicine, Division of Translational Medicine and Human Genetics, and
| | - Kei Sakamoto
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Joshua D. Rabinowitz
- Lewis Sigler Institute for Integrative Genomics
- Department of Chemistry, and
- Ludwig Institute for Cancer Research, Princeton Branch, Princeton, New Jersey, USA
- Department of Molecular Biology, Princeton University, Princeton, New Jersey, USA
| | - Paul M. Titchenell
- Institute for Diabetes, Obesity, and Metabolism
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Iakovleva V, Wuestefeld A, Ong ABL, Gao R, Kaya NA, Lee MY, Zhai W, Tam WL, Dan YY, Wuestefeld T. Mfap4: a promising target for enhanced liver regeneration and chronic liver disease treatment. NPJ Regen Med 2023; 8:63. [PMID: 37935709 PMCID: PMC10630300 DOI: 10.1038/s41536-023-00337-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 10/11/2023] [Indexed: 11/09/2023] Open
Abstract
The liver has a remarkable regenerative capacity. Nevertheless, under chronic liver-damaging conditions, this capacity becomes exhausted, allowing the accumulation of fibrotic tissue and leading to end-stage liver disease. Enhancing the endogenous regenerative capacity by targeting regeneration breaks is an innovative therapeutic approach. We set up an in vivo functional genetic screen to identify such regeneration breaks. As the top hit, we identified Microfibril associated protein 4 (Mfap4). Knockdown of Mfap4 in hepatocytes enhances cell proliferation, accelerates liver regeneration, and attenuates chronic liver disease by reducing liver fibrosis. Targeting Mfap4 modulates several liver regeneration-related pathways including mTOR. Our research opens the way to siRNA-based therapeutics to enhance hepatocyte-based liver regeneration.
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Affiliation(s)
- Viktoriia Iakovleva
- Laboratory of In Vivo Genetics and Gene Therapy, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Republic of Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, 117599, Republic of Singapore
| | - Anna Wuestefeld
- Laboratory of In Vivo Genetics and Gene Therapy, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
| | - Agnes Bee Leng Ong
- Laboratory of In Vivo Genetics and Gene Therapy, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
| | - Rong Gao
- Laboratory of In Vivo Genetics and Gene Therapy, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
| | - Neslihan Arife Kaya
- Laboratory of Translational Cancer Biology, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
| | - May Yin Lee
- Laboratory of Translational Cancer Biology, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
| | - Weiwei Zhai
- Key Laboratory of Zoological Systematics and Evolution, Institute of Zoology, Chinese Academy of Sciences, 100101, Beijing, China
- Center for Excellence in Animal Evolution and Genetics, Chinese Academy of Sciences, Kunming, 650223, China
| | - Wai Leong Tam
- Laboratory of Translational Cancer Biology, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, 117599, Republic of Singapore
| | - Yock Young Dan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 119228, Republic of Singapore
- Division of Gastroenterology and Hepatology, National University Health System, Singapore, 119074, Republic of Singapore
| | - Torsten Wuestefeld
- Laboratory of In Vivo Genetics and Gene Therapy, Genome Institute of Singapore, Agency for Science, Technology and Research (A*STAR), 60 Biopolis Street, Singapore, 138672, Republic of Singapore.
- School of Biological Science, Nanyang University of Singapore, Singapore, 637551, Republic of Singapore.
- National Cancer Centre, Singapore, 169610, Republic of Singapore.
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Arora M, Pavlíková Z, Kučera T, Kozlík P, Šopin T, Vacík T, Ľupták M, Duda M, Slanař O, Kutinová Canová N. Pharmacological effects of mTORC1/C2 inhibitor in a preclinical model of NASH progression. Biomed Pharmacother 2023; 167:115447. [PMID: 37683589 DOI: 10.1016/j.biopha.2023.115447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/29/2023] [Accepted: 09/04/2023] [Indexed: 09/10/2023] Open
Abstract
Knowledge of the benefits of mTOR inhibition concerning adipogenesis and inflammation has recently encouraged the investigation of a new generation of mTOR inhibitors for non-alcoholic steatohepatitis (NASH). We investigated whether treatment with a specific mTORC1/C2 inhibitor (Ku-0063794; KU) exerted any beneficial impacts on experimentally-induced NASH in vitro and in vivo. The results indicated that KU decreases palmitic acid-induced lipotoxicity in cultivated primary hepatocytes, thus emerging as a successful candidate for testing in an in vivo NASH dietary model, which adopted the intraperitoneal KU dosing route rather than oral application due to its significantly greater bioavailability in mice. The pharmacodynamics experiments commenced with the feeding of male C57BL/6 mice with a high-fat atherogenic western-type diet (WD) for differing intervals over several weeks aimed at inducing various phases of NASH. In addition to the WD, the mice were treated with KU for 3 weeks or 4 months. Acute and chronic KU treatments were observed to be safe at the given concentrations with no toxicity indications in the mice. KU was found to alleviate NASH-related hepatotoxicity, mitochondrial and oxidative stress, and decrease the liver triglyceride content and TNF-α mRNA in at least one set of in vivo experiments. The KU modulated liver expression of selected metabolic and oxidative stress-related genes depended upon the length and severity of the disease. Although KU failed to completely reverse the histological progression of NASH in the mice, we demonstrated the complexity of mTORC1/C2 signaling regulation and suggest a stratified therapeutic management approach throughout the disease course.
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Affiliation(s)
- Mahak Arora
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Zuzana Pavlíková
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Prague, Czech Republic; Department of Anthropology and Human Genetics, Faculty of Science, Charles University, Prague, Czech Republic
| | - Tomáš Kučera
- Institute of Histology and Embryology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Petr Kozlík
- Department of Analytical Chemistry, Faculty of Science, Charles University, Prague, Czech Republic
| | - Tijana Šopin
- Institute of Biology and Medical Genetics of the First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Tomáš Vacík
- Institute of Biology and Medical Genetics of the First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Matej Ľupták
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Matthias Duda
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Nikolina Kutinová Canová
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Agarwal H, Wang Y, Ozcan L. Rap1 Activation Protects Against Fatty Liver and Non-Alcoholic Steatohepatitis Development. bioRxiv 2023:2023.10.24.563728. [PMID: 37961406 PMCID: PMC10634782 DOI: 10.1101/2023.10.24.563728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
We previously demonstrated that hepatic activation of a small G protein of the Ras family, Rap1a, is suppressed in obesity, which results in increased hepatic glucose production and glucose intolerance in obese mice. Here, we show that Rap1a inhibition in obese mice liver also results in fatty liver formation, which is characteristic of the diabetic liver. Specifically, we report that Rap1a activity is decreased in the livers of patients with non-alcoholic steatohepatitis (NASH) and mouse models of non-alcoholic fatty liver disease (NAFLD) and NASH. Restoring hepatic Rap1a activity by overexpressing a constitutively active mutant form of Rap1a lowered the mature, processed form of lipogenic transcription factor, Srebp1, without an effect on the unprocessed Srebp1 and suppressed hepatic TG accumulation, whereas liver Rap1a deficiency increased Srebp1 processing and exacerbated steatosis. Mechanistically, we show that mTORC1, which promotes Srebp1 cleavage, is hyperactivated upon Rap1a deficiency despite disturbed insulin signaling. In proof-of-principle studies, we found that treatment of obese mice with a small molecule activator of Rap1a (8-pCPT) or inhibiting Rap1a's endogenous inhibitor, Rap1Gap, recapitulated our hepatic gain-of-function model and resulted in improved hepatic steatosis and lowered lipogenic genes. Thus, hepatic Rap1a serves as a signaling molecule that suppresses both hepatic gluconeogenesis and steatosis, and inhibition of its activity in the liver contributes to the pathogenesis of glucose intolerance and NAFLD/NASH development.
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Rayego-Mateos S, Morgado-Pascual JL, García-Caballero C, Lazaro I, Sala-Vila A, Opazo-Rios L, Mas-Fontao S, Egido J, Ruiz-Ortega M, Moreno JA. Intravascular hemolysis triggers NAFLD characterized by a deregulation of lipid metabolism and lipophagy blockade. J Pathol 2023; 261:169-183. [PMID: 37555366 DOI: 10.1002/path.6161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 05/30/2023] [Accepted: 06/14/2023] [Indexed: 08/10/2023]
Abstract
Intravascular hemolysis is a common feature of different clinical entities, including sickle cell disease and malaria. Chronic hemolytic disorders are associated with hepatic damage; however, it is unknown whether heme disturbs lipid metabolism and promotes liver steatosis, thereby favoring the progression to nonalcoholic fatty liver disease (NAFLD). Using an experimental model of acute intravascular hemolysis, we report here the presence of liver injury in association with microvesicular lipid droplet deposition. Hemolysis promoted serum hyperlipidemia and altered intrahepatic triglyceride fatty acid composition, with increments in oleic, palmitoleic, and palmitic acids. These findings were related to augmented expression of transporters involved in fatty acid uptake (CD36 and MSR1) and deregulation of LDL transport, as demonstrated by decreased levels of LDL receptor and increased PCSK9 expression. Hemolysis also upregulated hepatic enzymes associated with cholesterol biosynthesis (SREBP2, HMGC1, LCAT, SOAT1) and transcription factors regulating lipid metabolism (SREBP1). Increased LC3II/LC3I ratio and p62/SQSTM1 protein levels were reported in mice with intravascular hemolysis and hepatocytes stimulated with heme, indicating a blockade of lipophagy. In cultured hepatocytes, cell pretreatment with the autophagy inductor rapamycin diminished heme-mediated toxicity and accumulation of lipid droplets. In conclusion, intravascular hemolysis enhances liver damage by exacerbating lipid accumulation and blocking the lipophagy pathway, thereby promoting NAFLD. These new findings have a high translational potential as a novel NAFLD-promoting mechanism in individuals suffering from severe hemolysis episodes. © 2023 The Authors. The Journal of Pathology published by John Wiley & Sons Ltd on behalf of The Pathological Society of Great Britain and Ireland.
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Affiliation(s)
- Sandra Rayego-Mateos
- Molecular and Cellular Biology in Renal and Vascular Pathology. IIS-Fundación Jiménez Díaz, Universidad Autónoma Madrid, Madrid, Spain
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, Cordoba, Spain
| | - José Luis Morgado-Pascual
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, Cordoba, Spain
| | - Cristina García-Caballero
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, Cordoba, Spain
| | - Iolanda Lazaro
- Cardiovascular Risk and Nutrition, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Aleix Sala-Vila
- Cardiovascular Risk and Nutrition, Hospital del Mar Medical Research Institute (IMIM), Barcelona, Spain
| | - Lucas Opazo-Rios
- Health Science Faculty, Universidad de Las Américas, Concepción-Talcahuano, Chile
| | - Sebastian Mas-Fontao
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV), Madrid, Spain
- Instituto de Investigación Sanitaria (IIS)-Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
| | - Jesús Egido
- Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
- Instituto de Investigación Sanitaria (IIS)-Fundación Jiménez Díaz, Universidad Autónoma, Madrid, Spain
| | - Marta Ruiz-Ortega
- Molecular and Cellular Biology in Renal and Vascular Pathology. IIS-Fundación Jiménez Díaz, Universidad Autónoma Madrid, Madrid, Spain
| | - Juan Antonio Moreno
- Maimonides Biomedical Research Institute of Cordoba (IMIBIC), Hospital Universitario Reina Sofía, Cordoba, Spain
- Department of Cell Biology, Physiology and Immunology, University of Cordoba, Cordoba, Spain
- Biomedical Research Networking Center on Cardiovascular Diseases (CIBERCV), Madrid, Spain
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Chao X, Wang S, Ma X, Zhang C, Qian H, Williams SN, Sun Z, Peng Z, Liu W, Li F, Sheshadri N, Zong WX, Ni HM, Ding WX. Persistent mTORC1 activation due to loss of liver tuberous sclerosis complex 1 promotes liver injury in alcoholic hepatitis. Hepatology 2023; 78:503-517. [PMID: 36999531 PMCID: PMC10363242 DOI: 10.1097/hep.0000000000000373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/01/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND AND AIMS The aim of the study was to investigate the role and mechanisms of tuberous sclerosis complex 1 (TSC1) and mechanistic target of rapamycin complex 1 (mTORC1) in alcohol-associated liver disease. APPROACH AND RESULTS Liver-specific Tsc1 knockout (L- Tsc1 KO) mice and their matched wild-type mice were subjected to Gao-binge alcohol. Human alcoholic hepatitis (AH) samples were also used for immunohistochemistry staining, western blot, and quantitative real-time PCR (q-PCR) analysis. Human AH and Gao-binge alcohol-fed mice had decreased hepatic TSC1 and increased mTORC1 activation. Gao-binge alcohol markedly increased liver/body weight ratio and serum alanine aminotransferase levels in L- Tsc1 KO mice compared with Gao-binge alcohol-fed wild-type mice. Results from immunohistochemistry staining, western blot, and q-PCR analysis revealed that human AH and Gao-binge alcohol-fed L- Tsc1 KO mouse livers had significantly increased hepatic progenitor cells, macrophages, and neutrophils but decreased HNF4α-positive cells. Gao-binge alcohol-fed L- Tsc1 KO mice also developed severe inflammation and liver fibrosis. Deleting Tsc1 in cholangiocytes but not in hepatocytes promoted cholangiocyte proliferation and aggravated alcohol-induced ductular reactions, fibrosis, inflammation, and liver injury. Pharmacological inhibition of mTORC1 partially reversed hepatomegaly, ductular reaction, fibrosis, inflammatory cell infiltration, and liver injury in alcohol-fed L- Tsc1 KO mice. CONCLUSIONS Our findings indicate that persistent activation of mTORC1 due to the loss of cholangiocyte TSC1 promotes liver cell repopulation, ductular reaction, inflammation, fibrosis, and liver injury in Gao-binge alcohol-fed L- Tsc1 KO mice, which phenocopy the pathogenesis of human AH.
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Affiliation(s)
- Xiaojuan Chao
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Shaogui Wang
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Xiaowen Ma
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Chen Zhang
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Hui Qian
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Sha Neisha Williams
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Zhaoli Sun
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA
| | - Zheyun Peng
- Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences; and Department of Pharmacology, School of Medicine, Wayne State University, Detroit, Michigan 48201, USA
| | - Wanqing Liu
- Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences; and Department of Pharmacology, School of Medicine, Wayne State University, Detroit, Michigan 48201, USA
| | - Feng Li
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, Texas 77030, USA
| | - Namratha Sheshadri
- Department of Chemical Biology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey 08854, USA
| | - Wei-Xing Zong
- Department of Chemical Biology, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey 08854, USA
| | - Hong-Min Ni
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
| | - Wen-Xing Ding
- Department of Pharmacology, Toxicology and Therapeutics, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas 66160, USA
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9
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Shi F, Collins S. Regulation of mTOR Signaling: Emerging Role of Cyclic Nucleotide-Dependent Protein Kinases and Implications for Cardiometabolic Disease. Int J Mol Sci 2023; 24:11497. [PMID: 37511253 PMCID: PMC10380887 DOI: 10.3390/ijms241411497] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/07/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
The mechanistic target of rapamycin (mTOR) kinase is a central regulator of cell growth and metabolism. It is the catalytic subunit of two distinct large protein complexes, mTOR complex 1 (mTORC1) and mTORC2. mTOR activity is subjected to tight regulation in response to external nutrition and growth factor stimulation. As an important mechanism of signaling transduction, the 'second messenger' cyclic nucleotides including cAMP and cGMP and their associated cyclic nucleotide-dependent kinases, including protein kinase A (PKA) and protein kinase G (PKG), play essential roles in mediating the intracellular action of a variety of hormones and neurotransmitters. They have also emerged as important regulators of mTOR signaling in various physiological and disease conditions. However, the mechanism by which cAMP and cGMP regulate mTOR activity is not completely understood. In this review, we will summarize the earlier work establishing the ability of cAMP to dampen mTORC1 activation in response to insulin and growth factors and then discuss our recent findings demonstrating the regulation of mTOR signaling by the PKA- and PKG-dependent signaling pathways. This signaling framework represents a new non-canonical regulation of mTOR activity that is independent of AKT and could be a novel mechanism underpinning the action of a variety of G protein-coupled receptors that are linked to the mTOR signaling network. We will further review the implications of these signaling events in the context of cardiometabolic disease, such as obesity, non-alcoholic fatty liver disease, and cardiac remodeling. The metabolic and cardiac phenotypes of mouse models with targeted deletion of Raptor and Rictor, the two essential components for mTORC1 and mTORC2, will be summarized and discussed.
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Affiliation(s)
- Fubiao Shi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
| | - Sheila Collins
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN 37232, USA
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10
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Uehara K, Santoleri D, Whitlock AEG, Titchenell PM. Insulin Regulation of Hepatic Lipid Homeostasis. Compr Physiol 2023; 13:4785-4809. [PMID: 37358513 PMCID: PMC10760932 DOI: 10.1002/cphy.c220015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/27/2023]
Abstract
The incidence of obesity, insulin resistance, and type II diabetes (T2DM) continues to rise worldwide. The liver is a central insulin-responsive metabolic organ that governs whole-body metabolic homeostasis. Therefore, defining the mechanisms underlying insulin action in the liver is essential to our understanding of the pathogenesis of insulin resistance. During periods of fasting, the liver catabolizes fatty acids and stored glycogen to meet the metabolic demands of the body. In postprandial conditions, insulin signals to the liver to store excess nutrients into triglycerides, cholesterol, and glycogen. In insulin-resistant states, such as T2DM, hepatic insulin signaling continues to promote lipid synthesis but fails to suppress glucose production, leading to hypertriglyceridemia and hyperglycemia. Insulin resistance is associated with the development of metabolic disorders such as cardiovascular and kidney disease, atherosclerosis, stroke, and cancer. Of note, nonalcoholic fatty liver disease (NAFLD), a spectrum of diseases encompassing fatty liver, inflammation, fibrosis, and cirrhosis, is linked to abnormalities in insulin-mediated lipid metabolism. Therefore, understanding the role of insulin signaling under normal and pathologic states may provide insights into preventative and therapeutic opportunities for the treatment of metabolic diseases. Here, we provide a review of the field of hepatic insulin signaling and lipid regulation, including providing historical context, detailed molecular mechanisms, and address gaps in our understanding of hepatic lipid regulation and the derangements under insulin-resistant conditions. © 2023 American Physiological Society. Compr Physiol 13:4785-4809, 2023.
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Affiliation(s)
- Kahealani Uehara
- Institute of Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Biochemistry and Molecular Biophysics Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Dominic Santoleri
- Institute of Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Biochemistry and Molecular Biophysics Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anna E. Garcia Whitlock
- Institute of Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Paul M. Titchenell
- Institute of Diabetes, Obesity, and Metabolism, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Physiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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11
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Niranjan S, Phillips BE, Giannoukakis N. Uncoupling hepatic insulin resistance - hepatic inflammation to improve insulin sensitivity and to prevent impaired metabolism-associated fatty liver disease in type 2 diabetes. Front Endocrinol (Lausanne) 2023; 14:1193373. [PMID: 37396181 PMCID: PMC10313404 DOI: 10.3389/fendo.2023.1193373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/01/2023] [Indexed: 07/04/2023] Open
Abstract
Diabetes mellitus is a metabolic disease clinically-characterized as acute and chronic hyperglycemia. It is emerging as one of the common conditions associated with incident liver disease in the US. The mechanism by which diabetes drives liver disease has become an intense topic of discussion and a highly sought-after therapeutic target. Insulin resistance (IR) appears early in the progression of type 2 diabetes (T2D), particularly in obese individuals. One of the co-morbid conditions of obesity-associated diabetes that is on the rise globally is referred to as non-alcoholic fatty liver disease (NAFLD). IR is one of a number of known and suspected mechanism that underlie the progression of NAFLD which concurrently exhibits hepatic inflammation, particularly enriched in cells of the innate arm of the immune system. In this review we focus on the known mechanisms that are suspected to play a role in the cause-effect relationship between hepatic IR and hepatic inflammation and its role in the progression of T2D-associated NAFLD. Uncoupling hepatic IR/hepatic inflammation may break an intra-hepatic vicious cycle, facilitating the attenuation or prevention of NAFLD with a concurrent restoration of physiologic glycemic control. As part of this review, we therefore also assess the potential of a number of existing and emerging therapeutic interventions that can target both conditions simultaneously as treatment options to break this cycle.
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Affiliation(s)
- Sitara Niranjan
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - Brett E. Phillips
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, PA, United States
| | - Nick Giannoukakis
- Department of Biological Sciences, Carnegie Mellon University, Pittsburgh, PA, United States
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12
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Bhat N, Mani A. Dysregulation of Lipid and Glucose Metabolism in Nonalcoholic Fatty Liver Disease. Nutrients 2023; 15:2323. [PMID: 37242206 PMCID: PMC10222271 DOI: 10.3390/nu15102323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/08/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Non-Alcoholic Fatty Liver Disease (NAFLD) is a highly prevalent condition affecting approximately a quarter of the global population. It is associated with increased morbidity, mortality, economic burden, and healthcare costs. The disease is characterized by the accumulation of lipids in the liver, known as steatosis, which can progress to more severe stages such as steatohepatitis, fibrosis, cirrhosis, and even hepatocellular carcinoma (HCC). This review focuses on the mechanisms that contribute to the development of diet-induced steatosis in an insulin-resistant liver. Specifically, it discusses the existing literature on carbon flux through glycolysis, ketogenesis, TCA (Tricarboxylic Acid Cycle), and fatty acid synthesis pathways in NAFLD, as well as the altered canonical insulin signaling and genetic predispositions that lead to the accumulation of diet-induced hepatic fat. Finally, the review discusses the current therapeutic efforts that aim to ameliorate various pathologies associated with NAFLD.
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Affiliation(s)
| | - Arya Mani
- Cardiovascular Research Center, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06511, USA
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Gutiérrez-Cuevas J, Lucano-Landeros S, López-Cifuentes D, Santos A, Armendariz-Borunda J. Epidemiologic, Genetic, Pathogenic, Metabolic, Epigenetic Aspects Involved in NASH-HCC: Current Therapeutic Strategies. Cancers (Basel) 2022; 15. [PMID: 36612019 DOI: 10.3390/cancers15010023] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and is the sixth most frequent cancer in the world, being the third cause of cancer-related deaths. Nonalcoholic steatohepatitis (NASH) is characterized by fatty infiltration, oxidative stress and necroinflammation of the liver, with or without fibrosis, which can progress to advanced liver fibrosis, cirrhosis and HCC. Obesity, metabolic syndrome, insulin resistance, and diabetes exacerbates the course of NASH, which elevate the risk of HCC. The growing prevalence of obesity are related with increasing incidence of NASH, which may play a growing role in HCC epidemiology worldwide. In addition, HCC initiation and progression is driven by reprogramming of metabolism, which indicates growing appreciation of metabolism in the pathogenesis of this disease. Although no specific preventive pharmacological treatments have recommended for NASH, dietary restriction and exercise are recommended. This review focuses on the molecular connections between HCC and NASH, including genetic and risk factors, highlighting the metabolic reprogramming and aberrant epigenetic alterations in the development of HCC in NASH. Current therapeutic aspects of NASH/HCC are also reviewed.
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Kong D, Mai Z, Chen Y, Luo L, Liu H, Zhao L, Huang R, Wang S, Chen R, Zhou H, Chen H, Zhang J, Yu H, Ding Y. ATL I, Acts as a SIRT6 Activator to Alleviate Hepatic Steatosis in Mice via Suppression of NLRP3 Inflammasome Formation. Pharmaceuticals (Basel) 2022; 15:ph15121526. [PMID: 36558977 PMCID: PMC9781479 DOI: 10.3390/ph15121526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/05/2022] [Accepted: 12/05/2022] [Indexed: 12/13/2022] Open
Abstract
Accumulating evidence has highlighted that sirtuin-6 (SIRT6) plays an important role in hepatic gluconeogenesis and lipogenesis. We aim to investigate the underlying mechanisms and pharmacological interventions of SIRT6 on hepatic steatosis treatment. Herein, our results showed that atractylenolide I (ATL I) activated the deacetylase activity of SIRT6 to promote peroxisome proliferator-activated receptor alpha (PPARα) transcription and translation, while suppressing nuclear factor NF-kappa-B (NFκB)-induced NACHT, LRR, and PYD domains containing protein 3 (NLRP3) inflammasome formation. Together, these decreased the infiltration of F4/80 and CD11B positive macrophages, accompanied by decreased mRNA expression and serum levels of tumor necrosis factor alpha (TNF-α), interleukin-6 (IL6), and interleukin-1 beta (IL1β). Additionally, these changes decreased sterol regulatory element-binding protein-1c (SREBP-1c) expression, while restoring carnitine O-palmitoyltransferase 1a (Cpt1a) expression, to decrease the size of adipocytes and adipose deposition, which, in turn, reversed high-fat diet (HFD)-induced liver weight and body weight accumulation in C57 mice. SIRT6 knockout or hepatic SIRT6 knockout in C57 mice largely abolished the effect of ATL I on ameliorating hepatic steatosis. Taken together, our results suggest that ATL I acts as a promising compound that activates SIRT6/PPARα signaling and attenuates the NLRP3 inflammasome to ameliorate hepatic inflammation and steatosis.
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Affiliation(s)
- Danli Kong
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Zhenhua Mai
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
- Department of Critical Care Medicine, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524002, China
| | - Yongze Chen
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Zhanjiang 524002, China
| | - Ling Luo
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Hao Liu
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Le Zhao
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Ruixian Huang
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Shuang Wang
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Rong Chen
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Hao Zhou
- Department of Hospital Infection Management of Nanfang Hospital, Southern Medical University, Guangzhou 510515, China
| | - Hao Chen
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Jingjing Zhang
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Haibing Yu
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
| | - Yuanlin Ding
- Department of Epidemiology and Medical Statistics, School of Public Health, Guangdong Medical University, Dongguan 523808, China
- Correspondence: ; Tel.: +86-0769-22896575
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Tsuneki H, Maeda T, Takata S, Sugiyama M, Otsuka K, Ishizuka H, Onogi Y, Tokai E, Koshida C, Kon K, Takasaki I, Hamashima T, Sasahara M, Rudich A, Koya D, Sakurai T, Yanagisawa M, Yamanaka A, Wada T, Sasaoka T. Hypothalamic orexin prevents non-alcoholic steatohepatitis and hepatocellular carcinoma in obesity. Cell Rep 2022; 41:111497. [DOI: 10.1016/j.celrep.2022.111497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 06/22/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
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Min RWM, Aung FWM, Liu B, Arya A, Win S. Mechanism and Therapeutic Targets of c-Jun-N-Terminal Kinases Activation in Nonalcoholic Fatty Liver Disease. Biomedicines 2022; 10:biomedicines10082035. [PMID: 36009582 PMCID: PMC9406172 DOI: 10.3390/biomedicines10082035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/15/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Non-alcoholic fatty liver (NAFL) is the most common chronic liver disease. Activation of mitogen-activated kinases (MAPK) cascade, which leads to c-Jun N-terminal kinase (JNK) activation occurs in the liver in response to the nutritional and metabolic stress. The aberrant activation of MAPKs, especially c-Jun-N-terminal kinases (JNKs), leads to unwanted genetic and epi-genetic modifications in addition to the metabolic stress adaptation in hepatocytes. A mechanism of sustained P-JNK activation was identified in acute and chronic liver diseases, suggesting an important role of aberrant JNK activation in NASH. Therefore, modulation of JNK activation, rather than targeting JNK protein levels, is a plausible therapeutic application for the treatment of chronic liver disease.
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Affiliation(s)
| | | | - Bryant Liu
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, 2011 Zonal Ave., HMR 612, Los Angeles, CA 90089, USA
| | - Aliza Arya
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, 2011 Zonal Ave., HMR 612, Los Angeles, CA 90089, USA
| | - Sanda Win
- Division of Gastrointestinal and Liver Disease, Department of Medicine, Keck School of Medicine, University of Southern California, 2011 Zonal Ave., HMR 612, Los Angeles, CA 90089, USA
- Correspondence:
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17
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Finck BN. Something to mTORC About in NASH. Cell Mol Gastroenterol Hepatol 2022; 13:1843-1844. [PMID: 35378066 PMCID: PMC9123568 DOI: 10.1016/j.jcmgh.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 03/09/2022] [Indexed: 12/10/2022]
Affiliation(s)
- Brian N. Finck
- Correspondence Address correspondence to: Brian N. Finck, PhD, 660 South Euclid Avenue, MSC 8031-0014-01, St. Louis, Missouri 63110.
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