1
|
Papaefthymiou A, Doulberis M, Karafyllidou K, Chatzimichael E, Deretzi G, Exadaktylos AK, Sampsonas F, Gelasakis A, Papamichos SI, Kotronis G, Gialamprinou D, Vardaka E, Polyzos SA, Kountouras J. Effect of spironolactone on pharmacological treatment of nonalcoholic fatty liver disease. Minerva Endocrinol (Torino) 2023; 48:346-359. [PMID: 34669319 DOI: 10.23736/s2724-6507.21.03564-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) was recently renamed to metabolic (dysfunction)-associated fatty liver disease (MAFLD) to better characterize its pathogenic origin. NAFLD represents, at least in western societies, a potential epidemic with raising prevalence. Its multifactorial pathogenesis is partially unraveled and till now there is no approved pharmacotherapy for NAFLD. A plethora of various choices are investigated in clinical trials, targeting an arsenal of different pathways and molecules. Since the mineralocorticoid receptor (MR) and renin-angiotensin-aldosterone system (RAAS) appear to be implicated in NAFLD, within this concise review, we focus on a rather classical and inexpensive pharmacological agent, spironolactone. We present the current lines of evidence of MR and RAAS-related preclinical models and human trials reporting an association with NAFLD. In conclusion, evidence about spironolactone of RAAS is commented, as potential future pharmacological management of NAFLD.
Collapse
Affiliation(s)
- Apostolis Papaefthymiou
- Department of Gastroenterology, University Hospital of Larisa, Larisa, Greece -
- School of Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece -
- School of Medicine, First Laboratory of Pharmacology, Aristotle University of Thessaloniki, Thessaloniki, Greece -
| | - Michael Doulberis
- School of Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- School of Medicine, First Laboratory of Pharmacology, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Department of Emergency Medicine, University Hospital Inselspital of Bern, Bern, Switzerland
- Division of Gastroenterology and Hepatology, Department of Medicine, Medical University, Kantonsspital Aarau, Aarau, Switzerland
| | - Kyriaki Karafyllidou
- Department of Pediatrics, University Children's Hospital of Zurich, Zurich, Switzerland
| | - Eleftherios Chatzimichael
- Department of Psychiatry, Psychotherapy and Psychosomatics, Center for Integrative Psychiatry, Psychiatric University Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Georgia Deretzi
- Department of Neurology, Papageorgiou General Hospital, Thessaloniki, Greece
| | | | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, Patras, Greece
| | - Athanasios Gelasakis
- Department of Animal Science, Laboratory of Anatomy and Physiology of Farm Animals, Agricultural University of Athens, Athens, Greece
| | - Spyros I Papamichos
- Blood Transfusion Service Eastern Switzerland, Swiss Red Cross, St. Gallen, Switzerland
| | - Georgios Kotronis
- Department of Internal Medicine, General Hospital Aghios Pavlos of Thessaloniki, Thessaloniki, Greece
| | - Dimitra Gialamprinou
- Second Neonatal Department and NICU, Aristotle University of Thessaloniki, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Elisabeth Vardaka
- School of Health Sciences, Department of Nutritional Sciences and Dietetics, International Hellenic University, Thessaloniki, Greece
| | - Stergios A Polyzos
- School of Medicine, First Laboratory of Pharmacology, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jannis Kountouras
- School of Medicine, Second Medical Clinic, Ippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
2
|
Schreier B, Zipprich A, Uhlenhaut H, Gekle M. Mineralocorticoid receptor in non-alcoholic fatty liver disease. Br J Pharmacol 2021; 179:3165-3177. [PMID: 34935140 DOI: 10.1111/bph.15784] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/13/2021] [Revised: 11/12/2021] [Accepted: 11/30/2021] [Indexed: 11/30/2022] Open
Abstract
Liver diseases are the fourth common death in Europe responsible for about 2 million death per year worldwide. Among the known detrimental causes for liver dysfunction are virus infections, intoxications and obesity. The mineralocorticoid receptor (MR) is a ligand-dependent transcription factor activated by aldosterone or glucocorticoids but also by pathological milieu factors. Canonical actions of the MR take place in epithelial cells of kidney, colon and sweat glands and contribute to sodium reabsorption, potassium secretion and extracellular volume homeostasis. The non-canonical functions can be initiated by inflammation or an altered micro milieu leading to fibrosis, hypertrophy and remodeling in various tissues. This narrative review summarizes the evidence regarding the role of MR in portal hypertension, non-alcoholic fatty liver disease, liver fibrosis and cirrhosis, demonstrating that inhibition of the MR in vivo seems to be beneficial for liver function and not just for volume regulation. Unfortunately, the underlying molecular mechanisms are still not completely understood.
Collapse
Affiliation(s)
- Barbara Schreier
- Julius-Bernstein-Institute of Physiology, Medical Faculty of the Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| | - Alexander Zipprich
- Department of Internal Medicine IV, Friedrich-Schiller-University Jena, Jena, Germany
| | - Henriette Uhlenhaut
- TUM School of Life Sciences, Technical University of Munich, Freising-Weihenstephan, Germany
| | - Michael Gekle
- Julius-Bernstein-Institute of Physiology, Medical Faculty of the Martin-Luther-University Halle-Wittenberg, Halle/Saale, Germany
| |
Collapse
|
3
|
Abstract
The liver, the largest solid visceral organ of the body, has numerous endocrine functions, such as direct hormone and hepatokine production, hormone metabolism, synthesis of binding proteins, and processing and redistribution of metabolic fuels. In the last 10 years, many new endocrine functions of the liver have been discovered. Advances in the classical endocrine functions include delineation of mechanisms of liver production of endocrine hormones [including 25-hydroxyvitamin D, insulin-like growth factor 1 (IGF-1), and angiotensinogen], hepatic metabolism of hormones (including thyroid hormones, glucagon-like peptide-1, and steroid hormones), and actions of specific binding proteins to glucocorticoids, sex steroids, and thyroid hormones. These studies have furthered insight into cirrhosis-associated endocrinopathies, such as hypogonadism, osteoporosis, IGF-1 deficiency, vitamin D deficiency, alterations in glucose and lipid homeostasis, and controversially relative adrenal insufficiency. Several novel endocrine functions of the liver have also been unraveled, elucidating the liver’s key negative feedback regulatory role in the pancreatic α cell-liver axis, which regulates pancreatic α cell mass, glucagon secretion, and circulating amino acid levels. Betatrophin and other hepatokines, such as fetuin-A and fibroblast growth factor 21, have also been discovered to play important endocrine roles in modulating insulin sensitivity, lipid metabolism, and body weight. It is expected that more endocrine functions of the liver will be revealed in the near future.
Collapse
Affiliation(s)
- Jane Rhyu
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Run Yu
- Division of Endocrinology, Diabetes, and Metabolism, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| |
Collapse
|
4
|
Tang M, Jia H, Chen S, Yang B, Patpur BK, Song W, Chang Y, Li J, Yang C. Significance of MR/OPN/HMGB1 axis in NAFLD-associated hepatic fibrogenesis. Life Sci 2020; 264:118619. [PMID: 33091447 DOI: 10.1016/j.lfs.2020.118619] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 07/10/2020] [Revised: 10/05/2020] [Accepted: 10/13/2020] [Indexed: 12/12/2022]
Abstract
AIMS The activation of hepatic stellate cells (HSCs) plays a central role in liver fibrosis, however non-alcoholic fatty liver disease (NAFLD) associated liver fibrogenesis have been poorly understood. We aimed to determine the significance of mineralocorticoid receptor (MR)/osteopontin (OPN)/high-mobility group box-1 (HMGB1) axis in this setting. MAIN METHODS Liver specimens were collected from NAFLD patients and murine NAFLD models established with 12-week high fat diet (HFD) for analysis of both upstream signals of MR and intrahepatic MR/OPN/HMGB1 axis. The in vitro cell model of NAFLD-associated liver fibrogenesis was established by treating LX-2 (a cell line of human HSCs) with free fatty acids (FFA). The effects of MR signaling were evaluated using with ALD (MR activator) or eplerenone (Ep, MR antagonist). Moreover, the in vitro loss- and gain- of function approaches were applied to confirm the upstream and downstream relationships of mediators contained in the intracellular MR/OPN/HMGB1 axis of LX-2. KEY FINDINGS In NAFLD condition, both human and mouse liver tissue samples demonstrated a significant up-regulation of MR/OPN/HMGB1 axis simultaneously with enhanced expression of pro-fibrogenic markers, including ACTA2, TIMP1, TGFB1 and COL1A1. Besides, enhanced production of serum aldosterone (ALD) was also observed in mouse NAFLD models. Moreover, the in vitro data demonstrated MR play an essential role in FFA-induced HSCs fibrogenesis. Meanwhile, MR acts as the upstream effector mediator of OPN and shares downstream HMGB1 with OPN. SIGNIFICANCE The MR/OPN/HMGB1 axis could be therapeutically targeted to treat NAFLD associated hepatic fibrogenesis.
Collapse
Affiliation(s)
- Min Tang
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Haoyu Jia
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Shuai Chen
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Bo Yang
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Bhuvanesh Kinish Patpur
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Weiping Song
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Yizhong Chang
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China
| | - Jing Li
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China.
| | - Changqing Yang
- Department of Gastroenterology and Hepatology, Institution of Digestive Diseases, Tongji Hospital, Tongji University School of Medicine, Shanghai 200065, China.
| |
Collapse
|
5
|
Abstract
Nonalcoholic steatohepatitis (NASH) is a severe form of nonalcoholic fatty liver disease (NAFLD) characterized by liver steatosis, inflammation, and hepatocellular damage. NASH is a serious condition that can progress to cirrhosis, liver failure, and hepatocellular carcinoma. The association of NASH with obesity, type 2 diabetes mellitus, and dyslipidemia has led to an emerging picture of NASH as the liver manifestation of metabolic syndrome. Although diet and exercise can dramatically improve NASH outcomes, significant lifestyle changes can be challenging to sustain. Pharmaceutical therapies could be an important addition to care, but currently none are approved for NASH. Here, we review the most promising targets for NASH treatment, along with the most advanced therapeutics in development. These include targets involved in metabolism (e.g., sugar, lipid, and cholesterol metabolism), inflammation, and fibrosis. Ultimately, combination therapies addressing multiple aspects of NASH pathogenesis are expected to provide benefit for patients.
Collapse
Affiliation(s)
- F Anthony Romero
- Terns Pharmaceuticals, 1065 E. Hillsdale Blvd., Suite 100, Foster City, California 94404, United States
| | - Christopher T Jones
- Terns Pharmaceuticals, 1065 E. Hillsdale Blvd., Suite 100, Foster City, California 94404, United States
| | - Yingzi Xu
- Terns Pharmaceuticals, 1065 E. Hillsdale Blvd., Suite 100, Foster City, California 94404, United States
| | - Martijn Fenaux
- Terns Pharmaceuticals, 1065 E. Hillsdale Blvd., Suite 100, Foster City, California 94404, United States
| | - Randall L Halcomb
- Terns Pharmaceuticals, 1065 E. Hillsdale Blvd., Suite 100, Foster City, California 94404, United States
| |
Collapse
|
6
|
Abstract
Na+/H+ exchangers play pivotal roles in the control of cell and tissue pH by mediating the electroneutral exchange of Na+ and H+ across cellular membranes. They belong to an ancient family of highly evolutionarily conserved proteins, and they play essential physiological roles in all phyla. In this review, we focus on the mammalian Na+/H+ exchangers (NHEs), the solute carrier (SLC) 9 family. This family of electroneutral transporters constitutes three branches: SLC9A, -B, and -C. Within these, each isoform exhibits distinct tissue expression profiles, regulation, and physiological roles. Some of these transporters are highly studied, with hundreds of original articles, and some are still only rudimentarily understood. In this review, we present and discuss the pioneering original work as well as the current state-of-the-art research on mammalian NHEs. We aim to provide the reader with a comprehensive view of core knowledge and recent insights into each family member, from gene organization over protein structure and regulation to physiological and pathophysiological roles. Particular attention is given to the integrated physiology of NHEs in the main organ systems. We provide several novel analyses and useful overviews, and we pinpoint main remaining enigmas, which we hope will inspire novel research on these highly versatile proteins.
Collapse
Affiliation(s)
- S F Pedersen
- Section for Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark; and Université Côte d'Azur, CNRS, Laboratoire de Physiomédecine Moléculaire, LP2M, France, and Laboratories of Excellence Ion Channel Science and Therapeutics, Nice, France
| | - L Counillon
- Section for Cell Biology and Physiology, Department of Biology, University of Copenhagen, Copenhagen, Denmark; and Université Côte d'Azur, CNRS, Laboratoire de Physiomédecine Moléculaire, LP2M, France, and Laboratories of Excellence Ion Channel Science and Therapeutics, Nice, France
| |
Collapse
|
7
|
Murayama H, Eguchi A, Nakamura M, Kawashima M, Nagahara R, Mizukami S, Kimura M, Makino E, Takahashi N, Ohtsuka R, Koyanagi M, Hayashi SM, Maronpot RR, Shibutani M, Yoshida T. Spironolactone in Combination with α-glycosyl Isoquercitrin Prevents Steatosis-related Early Hepatocarcinogenesis in Rats through the Observed NADPH Oxidase Modulation. Toxicol Pathol 2018; 46:530-539. [PMID: 29843569 DOI: 10.1177/0192623318778508] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Administration of the diuretic, spironolactone (SR), can inhibit chronic liver diseases. We determined the effects of SR alone or in combination with the antioxidant α-glycosyl isoquercitrin (AGIQ) on hyperlipidemia- and steatosis-related precancerous lesions in high-fat diet (HFD)-fed rats subjected to a two-stage hepatocarcinogenesis model. Rats were fed with control basal diet or HFD, which was administered with SR alone or in combination with an antioxidant AGIQ in drinking water. An HFD increased body weight, intra-abdominal fat (adipose) tissue weight, and plasma lipids, which were reduced by coadministration of SR and AGIQ. SR and AGIQ coadministration also reduced hepatic steatosis and preneoplastic glutathione S-transferase placental form-positive foci, in association with decrease in NADPH oxidase (NOX) subunit p22phox-positive cells and an increase in active-caspase-3-positive cells in the foci. Hepatic gene expression analysis revealed that the coadministration of SR and AGIQ altered mRNA levels of lipogenic enzymes ( Scd1 and Fasn), antioxidant-related enzymes ( Catalase), NOX component ( P67phox), and anti-inflammatory transcriptional factor ( Pparg). Our results indicated that SR in combination with AGIQ had the potential of suppressing hyperlipidemia- and steatosis-related early hepatocarcinogenesis through the reduced expression of NOX subunits.
Collapse
Affiliation(s)
- Hirotada Murayama
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Ayumi Eguchi
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Misato Nakamura
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Masahi Kawashima
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Rei Nagahara
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Sayaka Mizukami
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan.,2 Pathogenetic Veterinary Science, United Graduate School of Veterinary Sciences, Gifu University, Gifu-shi, Gifu, Japan
| | - Masayuki Kimura
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan.,2 Pathogenetic Veterinary Science, United Graduate School of Veterinary Sciences, Gifu University, Gifu-shi, Gifu, Japan
| | - Emi Makino
- 3 Institute of Environmental Toxicology, Joso-shi, Ibaraki, Japan
| | | | - Ryoichi Ohtsuka
- 3 Institute of Environmental Toxicology, Joso-shi, Ibaraki, Japan
| | - Mihoko Koyanagi
- 4 Global Scientific and Regulatory Affairs, San-Ei Gen F. F. I., Inc., Toyonaka, Osaka, Japan
| | - Shim-Mo Hayashi
- 4 Global Scientific and Regulatory Affairs, San-Ei Gen F. F. I., Inc., Toyonaka, Osaka, Japan
| | | | - Makoto Shibutani
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| | - Toshinori Yoshida
- 1 Laboratory of Veterinary Pathology, Tokyo University of Agriculture and Technology, Fuchu-shi, Tokyo, Japan
| |
Collapse
|
8
|
Polyzos SA, Kountouras J, Mantzoros CS, Polymerou V, Katsinelos P. Effects of combined low-dose spironolactone plus vitamin E vs vitamin E monotherapy on insulin resistance, non-invasive indices of steatosis and fibrosis, and adipokine levels in non-alcoholic fatty liver disease: a randomized controlled trial. Diabetes Obes Metab 2017; 19:1805-1809. [PMID: 28452101 DOI: 10.1111/dom.12989] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 04/19/2017] [Accepted: 04/25/2017] [Indexed: 12/13/2022]
Abstract
The beneficial effects of mineralocorticoid receptor blockade by spironolactone have been shown in animal models of non-alcoholic fatty liver disease (NAFLD). The aim of the present 52-week randomized controlled trial was to compare the effects of low-dose spironolactone and vitamin E combination with those of vitamin E monotherapy on insulin resistance, non-invasive indices of hepatic steatosis and fibrosis, liver function tests, circulating adipokines and hormones in patients with histologically confirmed NAFLD. Homeostasis model of assessment of insulin resistance (HOMA-IR) and non-invasive indices of steatosis and fibrosis were calculated. Analysis was intention-to-treat. NAFLD liver fat score, an index of steatosis, decreased significantly in the combination treatment group (P = .028), but not in the vitamin E group, and the difference for group*time interaction was significant (P = .047). Alanine aminotransferase-to-platelet ratio index, an index of fibrosis, did not change. Insulin levels and HOMA-IR decreased significantly only within the combination group (P = .011 and P = .011, respectively). In conclusion, the combined low-dose spironolactone plus vitamin E regimen significantly decreased NAFLD liver fat score. Larger-scale trials are needed to clarify the effect of low-dose spironolactone on hepatic histology.
Collapse
Affiliation(s)
- Stergios A Polyzos
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Jannis Kountouras
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos S Mantzoros
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vaia Polymerou
- Department of Biopathology, Biomedicine Laboratories, Athens, Greece
| | - Panagiotis Katsinelos
- Second Medical Clinic, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| |
Collapse
|
9
|
Kumar A, Blackshear C, Subauste JS, Esfandiari NH, Oral EA, Subauste AR. Fatty Liver Disease, Women, and Aldosterone: Finding a Link in the Jackson Heart Study. J Endocr Soc 2017; 1:460-469. [PMID: 29264501 PMCID: PMC5686785 DOI: 10.1210/js.2017-00055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 03/17/2017] [Indexed: 02/07/2023] Open
Abstract
Context: Fatty liver disease is one of the most common forms of chronic liver disease. The renin-angiotensin-aldosterone system has been implicated in the pathogenesis of fatty liver. Objective: Determine the relationship between fatty liver and aldosterone in a large cohort study. Design: Community-based, observational cohort study of African Americans. Setting: The original Jackson Heart Study cohort enrolled African American participants from the Jackson, Mississippi, metropolitan area in Hinds, Madison, and Rankin Counties. Participants: Our study population consisted of 2507 Jackson Heart Study participants (1625 women and 882 men) who had liver attenuation measured per computed tomography scans, had aldosterone measurements, and were not taking angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or mineralocorticoid receptor antagonists. Intervention: There was no intervention. Main outcome measure: Liver attenuation on computed tomography scans. Results: Univariate regression analysis demonstrated a statistically significant correlation between aldosterone levels and liver attenuation. Each doubling of aldosterone was associated with 1.08 Hounsfield unit decrease (95% confidence interval, 1.47 to −0.69, P < 0.001). A multivariable model adjusted for body mass index, age, alcohol intake, and homeostatic model assessment of insulin resistance determined that the association was statistically significant only for women. Conclusion: Our data demonstrate a positive association between aldosterone levels and fatty liver in African American women.
Collapse
Affiliation(s)
- Aditi Kumar
- Department of Medicine, Division of Endocrinology, University of Mississippi Medical Center, Jackson, Mississippi, 39216
| | - Chad Blackshear
- Center of Biostatistics and Bioinformatics, University of Mississippi Medical Center, Jackson, Mississippi, 39216
| | - Jose S Subauste
- Department of Medicine, Division of Endocrinology, University of Mississippi Medical Center, Jackson, Mississippi, 39216
| | - Nazanene H Esfandiari
- Department of Internal Medicine, Division of Endocrinology, Metabolism & Diabetes, University of Michigan, Ann Arbor, Michigan, 48105
| | - Elif Arioglu Oral
- Department of Internal Medicine, Division of Endocrinology, Metabolism & Diabetes, University of Michigan, Ann Arbor, Michigan, 48105
| | - Angela R Subauste
- Department of Medicine, Division of Endocrinology, University of Mississippi Medical Center, Jackson, Mississippi, 39216
| |
Collapse
|
10
|
Senoo H, Mezaki Y, Fujiwara M. The stellate cell system (vitamin A-storing cell system). Anat Sci Int. 2017;92:387-455. [PMID: 28299597 DOI: 10.1007/s12565-017-0395-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 02/15/2017] [Indexed: 01/18/2023]
Abstract
Past, present, and future research into hepatic stellate cells (HSCs, also called vitamin A-storing cells, lipocytes, interstitial cells, fat-storing cells, or Ito cells) are summarized and discussed in this review. Kupffer discovered black-stained cells in the liver using the gold chloride method and named them stellate cells (Sternzellen in German) in 1876. Wake rediscovered the cells in 1971 using the same gold chloride method and various modern histological techniques including electron microscopy. Between their discovery and rediscovery, HSCs disappeared from the research history. Their identification, the establishment of cell isolation and culture methods, and the development of cellular and molecular biological techniques promoted HSC research after their rediscovery. In mammals, HSCs exist in the space between liver parenchymal cells (PCs) or hepatocytes and liver sinusoidal endothelial cells (LSECs) of the hepatic lobule, and store 50-80% of all vitamin A in the body as retinyl ester in lipid droplets in the cytoplasm. SCs also exist in extrahepatic organs such as pancreas, lung, and kidney. Hepatic (HSCs) and extrahepatic stellate cells (EHSCs) form the stellate cell (SC) system or SC family; the main storage site of vitamin A in the body is HSCs in the liver. In pathological conditions such as liver fibrosis, HSCs lose vitamin A, and synthesize a large amount of extracellular matrix (ECM) components including collagen, proteoglycan, glycosaminoglycan, and adhesive glycoproteins. The morphology of these cells also changes from the star-shaped HSCs to that of fibroblasts or myofibroblasts.
Collapse
|
11
|
Pizarro M, Solís N, Quintero P, Barrera F, Cabrera D, Santiago PR, Arab JP, Padilla O, Roa JC, Moshage H, Wree A, Inzaugarat E, Feldstein AE, Fardella CE, Baudrand R, Riquelme A, Arrese M. Beneficial effects of mineralocorticoid receptor blockade in experimental non-alcoholic steatohepatitis. Liver Int 2015; 35:2129-38. [PMID: 25646700 PMCID: PMC4522413 DOI: 10.1111/liv.12794] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/28/2015] [Indexed: 12/14/2022]
Abstract
BACKGROUND Therapeutic options to treat Non-alcoholic steatohepatitis (NASH) are limited. Mineralocorticoid receptor (MR) activation could play a role in hepatic fibrogenesis and its modulation could be beneficial for NASH. AIM To investigate whether eplerenone, a specific MR antagonist, ameliorates liver damage in experimental NASH. METHODS C57bl6 mice were fed a choline-deficient and amino acid-defined (CDAA) diet for 22 weeks with or without eplerenone supplementation. Serum levels of aminotransferases and aldosterone were measured and hepatic steatosis, inflammation and fibrosis scored histologically. Hepatic triglyceride content (HTC) and hepatic mRNA levels of pro-inflammatory pro-fibrotic, oxidative stress-associated genes and of MR were also assessed. RESULTS CDAA diet effectively induced fibrotic NASH, and increased the hepatic expression of pro-inflammatory, pro-fibrotic and oxidative stress-associated genes. Hepatic MR mRNA levels significantly correlated with the expression of pro-inflammatory and pro-fibrotic genes and were significantly increased in hepatic stellate cells obtained from CDAA-fed animals. Eplerenone administration was associated to a reduction in histological steatosis and attenuation of liver fibrosis development, which was associated to a significant decrease in the expression of collagen-α1, collagen type III, alpha 1 and Matrix metalloproteinase-2. CONCLUSION The expression of MR correlates with inflammation and fibrosis development in experimental NASH. Specific MR blockade with eplerenone has hepatic anti-steatotic and anti-fibrotic effects. These data identify eplerenone as a potential novel therapy for NASH. Considering its safety and FDA-approved status, human studies are warranted.
Collapse
Affiliation(s)
- Margarita Pizarro
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Nancy Solís
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Pablo Quintero
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Francisco Barrera
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Daniel Cabrera
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile,Departamento de Ciencias Químico-Biológicas, Universidad Bernardo O'Higgins, Santiago, Chile
| | - Pamela Rojasde Santiago
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Oslando Padilla
- Departamento de Salud Pública, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Carlos Roa
- Departamento de Patología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Han Moshage
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexander Wree
- Department of Pediatrics, University of California, San Diego, CA, USA
| | | | | | - Carlos E. Fardella
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Rene Baudrand
- Departamento de Endocrinología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Arnoldo Riquelme
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile,Corresponding author: Marco Arrese, M.D. Department of Gastroenterology Escuela de Medicina Pontificia Universidad Católica de Chile Marcoleta #367 833-0024 Santiago CHILE Phone/Fax: 56-2-6397780,
| |
Collapse
|
12
|
Queisser N, Happ K, Link S, Jahn D, Zimnol A, Geier A, Schupp N. Aldosterone induces fibrosis, oxidative stress and DNA damage in livers of male rats independent of blood pressure changes. Toxicol Appl Pharmacol 2014; 280:399-407. [PMID: 25204689 DOI: 10.1016/j.taap.2014.08.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 02/05/2014] [Revised: 08/21/2014] [Accepted: 08/27/2014] [Indexed: 12/30/2022]
Abstract
Mineralocorticoid receptor blockers show antifibrotic potential in hepatic fibrosis. The mechanism of this protective effect is not known yet, although reactive oxygen species seem to play an important role. Here, we investigated the effects of elevated levels of aldosterone (Ald), the primary ligand of the mineralocorticoid receptor, on livers of rats in a hyperaldosteronism model: aldosterone-induced hypertension. Male Sprague-Dawley rats were treated for 4 weeks with aldosterone. To distinguish if damage caused in the liver depended on increased blood pressure or on increased Ald levels, the mineralocorticoid receptor antagonist spironolactone was given in a subtherapeutic dose, not normalizing blood pressure. To investigate the impact of oxidative stress, the antioxidant tempol was administered. Aldosterone induced fibrosis, detected histopathologically, and by expression analysis of the fibrosis marker, α-smooth muscle actin. Further, the mRNA amount of the profibrotic cytokine TGF-β was increased significantly. Fibrosis could be reduced by scavenging reactive oxygen species, and also by blocking the mineralocorticoid receptor. Furthermore, aldosterone treatment caused oxidative stress and DNA double strand breaks in livers, as well as the elevation of DNA repair activity. An increase of the transcription factor Nrf2, the main regulator of the antioxidative response could be observed, and of its target genes heme oxygenase-1 and γ-glutamylcysteine synthetase. All these effects of aldosterone were prevented by spironolactone and tempol. Already after 4 weeks of treatment, aldosteroneinfusion induced fibrosis in the liver. This effect was independent of elevated blood pressure. DNA damage caused by aldosterone might contribute to fibrosis progression when aldosterone is chronically increased.
Collapse
Affiliation(s)
- Nina Queisser
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Kathrin Happ
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Samuel Link
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Daniel Jahn
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Anna Zimnol
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany
| | - Andreas Geier
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Nicole Schupp
- Institute of Pharmacology and Toxicology, University of Würzburg, Würzburg, Germany.
| |
Collapse
|
13
|
Zhao Q, Feng Y, Jia X, Yin L, Zheng Y, Ouyang D, Zhou H, Zhang L. Proteome analysis of hepatic non-parenchymal cells of immune liver fibrosis rats. Sci China Life Sci 2014; 57:303-14. [PMID: 24562544 DOI: 10.1007/s11427-014-4619-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Accepted: 11/20/2013] [Indexed: 12/31/2022]
Abstract
Elucidation of the mechanisms of liver fibrogenesis is important to treat liver fibrosis. In this study, we established rat models of liver fibrosis with stages from 0-1, 2, and 3-4 to 4 at 2, 4, 6, and 8 weeks, respectively, by injection of pig serum. Liver fibrogenesis was detected by Masson's trichrome staining. Rat non-parenchymal cells (NPCs) were enriched 4-fold by Percoll density gradient centrifugation. Protein extracts from NPCs were prepared at 4 and 8 weeks, separated by two-dimensional electrophoresis, and then stained with Coomassie Blue G-250. At 4 weeks, we identified 18 non-redundant differentially expressed proteins of which protein disulfide-isomerase associated protein 3 (PDIA3) and NDUV showed consistent expression at protein and mRNA levels from 4 to 8 weeks. PDIA3 was found to be down-regulated by Western blotting in the rat model and immunohistochemically in human liver. Our results revealed important aspects of the pathogenesis/progression of liver fibrosis and demonstrated important changes in protein expression levels of NPCs at various stages of liver fibrosis.
Collapse
|
14
|
Luo W, Meng Y, Ji HL, Pan CQ, Huang S, Yu CH, Xiao LM, Cui K, Ni SY, Zhang ZS, Li X. Spironolactone lowers portal hypertension by inhibiting liver fibrosis, ROCK-2 activity and activating NO/PKG pathway in the bile-duct-ligated rat. PLoS One 2012; 7:e34230. [PMID: 22479572 PMCID: PMC3316615 DOI: 10.1371/journal.pone.0034230] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Accepted: 02/24/2012] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Aldosterone, one of the main peptides in renin angiotensin aldosterone system (RAAS), has been suggested to mediate liver fibrosis and portal hypertension. Spironolactone, an aldosterone antagonist, has beneficial effect on hyperdynamic circulation in clinical practice. However, the mechanisms remain unclear. The present study aimed to investigate the role of spionolactone on liver cirrhosis and portal hypertension. METHODS Liver cirrhosis was induced by bile duct ligation (BDL). Spironolactone was administered orally (20 mg/kg/d) after bile duct ligation was performed. Liver fibrosis was assessed by histology, Masson's trichrome staining, and the measurement of hydroxyproline and type I collagen content. The activation of HSC was determined by analysis of alpha smooth muscle actin (α-SMA) expression. Protein expressions and protein phosphorylation were determined by immunohistochemical staining and Western blot analysis, Messenger RNA levels by quantitative real time polymerase chain reaction (Q-PCR). Portal pressure and intrahepatic resistance were examined in vivo. RESULTS Treatment with spironolactone significantly lowered portal pressure. This was associated with attenuation of liver fibrosis, intrahepatic resistance and inhibition of HSC activation. In BDL rat liver, spironolactone suppressed up-regulation of proinflammatory cytokines (TNFα and IL-6). Additionally, spironolactone significantly decreased ROCK-2 activity without affecting expression of RhoA and Ras. Moreover, spironolactone markedly increased the levels of endothelial nitric oxide synthase (eNOS), phosphorylated eNOS and the activity of NO effector-protein kinase G (PKG) in the liver. CONCLUSION Spironolactone lowers portal hypertension by improvement of liver fibrosis and inhibition of intrahepatic vasoconstriction via down-regulating ROCK-2 activity and activating NO/PKG pathway. Thus, early spironolactone therapy might be the optional therapy in cirrhosis and portal hypertension.
Collapse
Affiliation(s)
- Wei Luo
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Ying Meng
- Department of Respiratory Diseases, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Hong-Li Ji
- Department of Oncology, 153rd Hospital of People's Liberation Army, Zhengzhou, China
| | - Chun-Qiu Pan
- Department of Emergency, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Shan Huang
- Department of Emergency, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Chang-Hui Yu
- Department of Respiratory Diseases, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Li-Ming Xiao
- Department of Emergency, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Kai Cui
- Department of Cardiovascular, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Shu-Yuan Ni
- Department of Emergency, Southern Medical University, Nanfang Hospital, Guangzhou, China
| | - Zhen-Shu Zhang
- Guangdong Provincial Key Laboratory of Gastroenterology, Department of Gastroenterology, Southern Medical University, Nanfang Hospital, Guangzhou, China
- * E-mail: (ZSZ); (XL)
| | - Xu Li
- Department of Emergency, Southern Medical University, Nanfang Hospital, Guangzhou, China
- * E-mail: (ZSZ); (XL)
| |
Collapse
|
15
|
Polyzos SA, Kountouras J, Zafeiriadou E, Patsiaoura K, Katsiki E, Deretzi G, Zavos C, Tsarouchas G, Rakitzi P, Slavakis A. Effect of spironolactone and vitamin E on serum metabolic parameters and insulin resistance in patients with nonalcoholic fatty liver disease. J Renin Angiotensin Aldosterone Syst 2011; 12:498-503. [DOI: 10.1177/1470320311402110] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim: The renin–angiotensin–aldosterone system has been implicated in the pathogenesis of insulin resistance and nonalcoholic fatty liver disease (NAFLD). The beneficial effect of spironolactone in a mouse model with diabetes and NAFLD has recently been reported. The main aim was assessment of the effect of spironolactone on serum metabolic parameters and insulin resistance in patients with NAFLD. Methods: This study includes preliminary results of a single-centre randomised controlled trial of treatment with vitamin E (group 1, 10 patients) versus spironolactone plus vitamin E (group 2, 10 patients) in biopsy-proven NAFLD. Serum transaminases, lipids, potassium, sodium, glucose and insulin were measured, and homeostatic model assessment-insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (QUICKI) were calculated before and 8 weeks after baseline assessment. Results: Insulin was decreased within group 2 (15.3 ± 2.7 at baseline vs. 10.3 ± 5.0 at week 8, p = 0.013). Although no difference in glucose was observed, HOMA-IR significantly decreased (4.4 ± 0.9 vs. 2.8 ± 0.5, respectively, p = 0.047). QUICKI was increased, but not statistically significantly. Conclusions: Spironolactone and vitamin E combined therapy seems to exhibit a favourable effect on serum insulin and HOMA-IR in patients with NAFLD. If validated in a large-scale clinical trial, it may prove an inexpensive therapeutic approach for the management of NAFLD patients.
Collapse
Affiliation(s)
- Stergios A Polyzos
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | - Jannis Kountouras
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | | | | | | | - Georgia Deretzi
- Department of Neurology, Papageorgiou General Hospital, Thessaloniki, Greece
| | - Christos Zavos
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | - Georgios Tsarouchas
- Second Medical Clinic, Medical School, Aristotle University of Thessaloniki, Ippokration Hospital, Thessaloniki, Greece
| | | | | |
Collapse
|
16
|
Zhang L, Peng X, Zhang Z, Feng Y, Jia X, Shi Y, Yang H, Zhang Z, Zhang X, Liu L, Yin L, Yuan Z. Subcellular proteome analysis unraveled annexin A2 related to immune liver fibrosis. J Cell Biochem 2010; 110:219-28. [PMID: 20225235 DOI: 10.1002/jcb.22529] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
It is important to study the mechanism of liver fibrogenesis, and find new non-invasive biomarkers. In this study, we used subcellular proteomic technology to study the plasma membrane (PM) proteins related to immune liver fibrosis and search for new non-invasive biomarkers. A rat liver fibrosis model was induced by pig serum injection. The liver fibrogenesis from stage (S) S0-1, S2, S3-4, and S4 was detected by Masson staining and HE staining in this rat model after 2, 4, 6, and 8 weeks of treatment. The liver PM was enriched and analyzed using subcellular proteomic technology. The differentially expressed proteins were verified by Western blotting, immunohistochemistry, and ELISA. PM with 149-fold purification was obtained and 22 differentially expressed proteins were identified. Of which, annexin A2 (ANXA2) was detected to be increased obviously in S4 compared with S0-1, and verified by Western blotting of rat liver tissue and immunohistochemistry of rat and human liver tissue. The expression of ANXA2 in human plasma with S1-2 was also found to be up-regulated for 1.4-fold than that in S0. Furthermore, ANXA2 was detected to translocate from nuclear membrane and cytosol to PM as HBV stimulation through immunocytochemical analysis in vitro. This study identified 22 differentially expressed proteins related to liver fibrosis, and verified a potential biomarker (ANXA2) for non-invasive diagnosis of immune liver fibrosis. To our knowledge, it was the first time to dynamically study the proteins related to liver fibrosis and select biomarkers for liver fibrosis diagnosis through PM proteome research.
Collapse
Affiliation(s)
- Lijun Zhang
- Shanghai Public Health Clinical Center, Shanghai 201508, China.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
17
|
De BK, Dutta D, Som R, Biswas PK, Pal SK, Biswas A. Hemodynamic effects of propranolol with spironolactone in patients with variceal bleeds: A randomized controlled trial. World J Gastroenterol 2008; 14:1908-13. [PMID: 18350631 PMCID: PMC2700421 DOI: 10.3748/wjg.14.1908] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the hemodynamic effects of spironolactone with propranolol vs propranolol alone in the secondary prophylaxis of variceal bleeding.
METHODS: Thirty-five cirrhotics with variceal bleeding randomly received propranolol (n = 17: Group A) or spironolactone plus propranolol (n = 18: Group B). Hemodynamic assessment was performed at baseline and on the eighth day.
RESULTS: Spironolactone with propranolol caused a greater reduction in the hepatic venous pressure gradient than propranolol alone (26.94% vs 10.2%; P < 0.01). Fourteen out of eighteen patients on the combination treatment had a reduction in hepatic venous pressure gradient to ≤ 12 mmHg or a 20% reduction from baseline in contrast to only six out of seventeen (6/17) on propranolol alone (P < 0.05).
CONCLUSION: Spironolactone with propranolol results in a better response with a greater reduction in hepatic venous pressure gradient in the secondary prophylaxis of variceal bleeding. A greater number of patients may be protected by this combination therapy than by propranolol alone. Hence, this combination may be recommended for secondary prophylaxis in patients with variceal bleeding.
Collapse
|