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Bile acids (BAs) can regulate their own metabolism and transport as well as other key aspects of metabolic homeostasis via dedicated (nuclear and G protein-coupled) receptors. Disrupted BA transport and homeostasis results in the development of cholestatic disorders and contributes to a wide range of liver diseases, including nonalcoholic fatty liver disease and hepatocellular and cholangiocellular carcinoma. Furthermore, impaired BA homeostasis can also affect the intestine, contributing to the pathogenesis of irritable bowel syndrome, inflammatory bowel disease, and colorectal and oesophageal cancer. Here, we provide a summary of the role of BAs and their disrupted homeostasis in the development of gastrointestinal and hepatic disorders and present novel insights on how targeting BA pathways might contribute to novel treatment strategies for these disorders.Here, the authors describe the role of bile acids and their receptors in health and in gastrointestinal and liver disease. This Review provides insights on therapeutic strategies based on targeting bile acid homeostasis.

Preventing SARS-CoV-2 infection by modulating viral host receptors, such as angiotensin-converting enzyme 2 (ACE2) 1 , could represent a new chemoprophylactic approach for COVID-19 that complements vaccination 2 , 3 . However, the mechanisms that control the expression of ACE2 remain unclear. Here we show that the farnesoid X receptor (FXR) is a direct regulator of ACE2 transcription in several tissues affected by COVID-19, including the gastrointestinal and respiratory systems. We then use the over-the-counter compound z-guggulsterone and the off-patent drug ursodeoxycholic acid (UDCA) to reduce FXR signalling and downregulate ACE2 in human lung, cholangiocyte and intestinal organoids and in the corresponding tissues in mice and hamsters. We show that the UDCA-mediated downregulation of ACE2 reduces susceptibility to SARS-CoV-2 infection in vitro, in vivo and in human lungs and livers perfused ex situ. Furthermore, we reveal that UDCA reduces the expression of ACE2 in the nasal epithelium in humans. Finally, we identify a correlation between UDCA treatment and positive clinical outcomes after SARS-CoV-2 infection using retrospective registry data, and confirm these findings in an independent validation cohort of recipients of liver transplants. In conclusion, we show that FXR has a role in controlling ACE2 expression and provide evidence that modulation of this pathway could be beneficial for reducing SARS-CoV-2 infection, paving the way for future clinical trials. FXR regulates the levels of ACE2 in tissues of the respiratory and gastrointestinal systems that are affected by COVID-19, and inhibiting FXR with ursodeoxycholic acid downregulates ACE2 and reduces susceptibility to SARS-CoV-2 infection.

Bile salt export pump (Bsep) (Abcb11)−/− mice are protected from acquired cholestatic injury due to metabolic preconditioning with a hydrophilic bile acid (BA) pool with formation of tetrahydroxylated bile acids (THBAs). We aimed to explore whether loss of Bsep and subsequent elevation of THBA levels may have immunomodulatory effects, thus improving liver injury in the multidrug resistance protein 2 (Mdr2) (Abcb4)−/− mouse. Cholestatic liver injury in Mdr2−/−Bsep−/− double knockout (DKO), Mdr2−/−, Bsep−/−, and wild‐type mice was studied for comparison. Mdr2−/− mice were treated with a THBA (3α,6α,7α,12α‐Tetrahydroxycholanoic acid). RNA/protein expression of inflammatory/fibrotic markers were investigated. Serum BA‐profiling was assessed by ultra‐performance liquid chromatography tandem mass spectrometry. Hepatic immune cell profile was quantified by flow cytometric analysis (FACS). In vitro, the THBA effect on chenodeoxycholic acid (CDCA)–induced inflammatory signaling in hepatocyte and cholangiocytes as well as lipopolysaccharide (LPS)/interferon‐γ (IFN‐γ)–induced macrophage activation was analyzed. In contrast to Mdr2−/−, DKO mice showed no features of sclerosing cholangitis. Sixty‐seven percent of serum BAs in DKO mice were polyhydroxylated (mostly THBAs), whereas Mdr2−/− mice did not have these BAs. Compared with Mdr2−/−, DKO animals were protected from hepatic inflammation/fibrosis. THBA feeding in Mdr2−/− mice improved liver injury. FACS analysis in DKO and Mdr2−/− THBA‐fed mice showed changes of the hepatic immune cell profile towards an anti‐inflammatory pattern. Early growth response 1 (EGR1) protein expression was reduced in DKO and in Mdr2−/− THBA‐fed mice compared with Mdr2−/− control mice. In vitro, THBA‐reduced CDCA induced EGR1 protein and mRNA expression of inflammatory markers in hepatocytes and cholangiocytes. LPS/IFN‐γ–induced macrophage activation was ameliorated by THBA. THBAs repress EGR1‐related key pro‐inflammatory pathways. Conclusion: THBA and their downstream targets may represent a potential treatment strategy for cholestatic liver diseases. Loss of Bsep (Abcb11) in Mdr2 (Abcb4)−/− mice led to a more hydrophilic, less toxic, bile acid pool mainly consisting of tetrahydroxylated bile acids. Our data demonstrate that tetrahydroxylated bile acids suppress EGR1‐mediated cytokine secretion from hepatocytes, thereby decreasing the recruitment of immune cells such as macrophages and neutrophils to the liver. This immunomodulatory function of tetrahydroxylated bile acids protects Mdr2 (Abcb4)−/− mice from development of hepatic inflammation, fibrosis and bile duct injury.

Altered lipid metabolic pathways including hydrolysis of triglycerides are key players in the pathogenesis of nonalcoholic fatty liver disease (NAFLD). Whether adiponutrin (patatin-like phospholipase domain containing protein-3—PNPLA3) and monoacylglycerol lipase (MGL) synergistically contribute to disease progression remains unclear. We generated double knockout (DKO) mice lacking both Mgl and Pnpla3; DKO mice were compared to Mgl−/− after a challenge by high-fat diet (HFD) for 12 weeks to induce steatosis. Serum biochemistry, liver transaminases as well as histology were analyzed. Fatty acid (FA) profiling was assessed in liver and adipose tissue by gas chromatography. Markers of inflammation and lipid metabolism were analyzed. Bone marrow derived macrophages (BMDMs) were isolated and treated with oleic acid. Combined deficiency of Mgl and Pnpla3 resulted in weight gain on a chow diet; when challenged by HFD, DKO mice showed increased hepatic FA synthesis and diminished beta-oxidation compared to Mgl−/−.DKO mice exhibited more pronounced hepatic steatosis with inflammation and recruitment of immune cells to the liver associated with accumulation of saturated FAs. Primary BMDMs isolated from the DKO mice showed increased inflammatory activities, which could be reversed by oleic acid supplementation. Pnpla3 deficiency aggravates the effects of Mgl deletion on steatosis and inflammation in the liver under HFD challenge.

Abstract Background & Aims 24-NorUrsodeoxycholic acid (NorUDCA) is novel therapy for immune-mediated liver diseases such as primary sclerosing cholangitis (PSC) where dysregulated T cells including CD8+ T cells cause liver immunopathology. We hypothesized that NorUDCA may directly modulate CD8+ T cell effector function thus contributing to its therapeutic efficacy independent of anti-cholestatic effects. Methods NorUDCA effects on CD8+ T cell function in vivo were investigated in a hepatic injury model system induced by excessive CD8+ T cell immune response upon non-cytolytic lymphocytic choriomeningitis virus (LCMV) infection. Mechanistic studies included molecular and biochemical approaches, flow cytometry and metabolic assays in mouse CD8+ T cells in vitro. Mass spectrometry (MS) was used to identify potential targets modulated by NorUDCA in CD8+ T cells. NorUDCA signaling effects observed in murine systems were validated in peripheral T cells from healthy volunteers and PSC patients. Results In vivo NorUDCA ameliorated hepatic injury and systemic inflammation upon LCMV infection. Mechanistically, NorUDCA demonstrated a strong immunomodulatory efficacy in CD8+ T cells affecting lymphoblastogenesis, mTORC1 signaling and glycolysis of CD8+ T cells. With MS, we identified that NorUDCA regulates CD8+ T cells via targeting mTORC1. NorUDCA’s impact on mTORC1 signaling was further confirmed in circulating human CD8+ T cells. Conclusions NorUDCA possesses a yet-unrecognized direct modulatory potency on CD8+ T cells and attenuates excessive CD8+ T cell hepatic immunopathology. These findings may be relevant for treatment of immune-mediated liver diseases such as PSC and beyond. Competing Interest Statement Michael Trauner has served as speaker for Falk Foundation, Gilead, Intercept and MSD; he has advised for Albireo, BiomX, Boehringer Ingelheim, Falk Pharma GmbH, Genfit, Gilead, Intercept, Jannsen, MSD, Novartis, Phenex and Regulus. He further received travel grants from Abbvie, Falk, Gilead and Intercept and research grants from Albireo, Cymabay, Falk, Gilead, Intercept, MSD and Takeda. He is also co-inventor of patents on the medical use of NorUDCA filed by the Medical Universities of Graz and Vienna. All the other authors declare no conflicts. Footnotes * ↵† Shared first authorship.

Cholestasis is characterized by impaired bile formation with insufficient amounts of bile reaching the duodenum resulting in intrahepatic and systemic accumulation of bile acids (BAs) and other potentially toxic cholephiles. This chapter focuses on the pathophysiologic basis for alternative therapies for cholestasis beyond ursodeoxycholic acid (UDCA), the first available drug for cholestasis. While UDCA acts mainly at a post‐transcriptional level, some of these new alternative therapies target key regulatory transcription factors such as farnesoid X receptor, glucocorticoid receptor, and fatty acid activated peroxisome proliferator‐activated receptors. Several of the novel alternative therapeutic approaches targeting BA transport and metabolism exert not only anticholestatic but also profound anti‐inflammatory as well as immune‐modulatory actions which could be key in treating immune‐mediated cholangiopathies such as primary biliary cholangitis/primary sclerosing cholangitis and inflammatory/immune responses secondary to cholestasis irrespective of their underlying etiology.

Antiviral immunity has a profound effect on host metabolism, which can, in turn, modulate immune responses and influences disease pathology. Among its many functions, the liver orchestrates systemic bile acid (BA) metabolism, a pathway disrupted in chronic liver diseases such as viral hepatitis. BAs have become increasingly recognized for their immunomodulatory properties, and multiple BA species are being explored as therapeutic agents in liver diseases. Understanding the interplay between immune responses and BA metabolism could unlock new therapeutic opportunities based on BA modulation. Using lymphocytic choriomeningitis virus (LCMV) as a model, we investigated the interplay between chronic hepatotropic virus infection, BA metabolism and immunity. Our findings reveal that chronic LCMV infection increases BA levels and shifts circulating and liver BA composition towards host-derived, conjugated BAs. At the same time, hepatic BA transport and synthesis genes are broadly downregulated, which is at least partially dependent on CD8+ T cells. Additionally, we found that sustained high BA levels impact CD8+ T cell responses to chronic LCMV infection. Mice with elevated circulating BAs due to the lack of BA transporters OATP1a and OATP1b, showed impaired T cell expansion and reduced liver immunopathology. These findings reveal a reciprocal interplay between CD8+ T cells and BA metabolism, expanding our understanding of adaptive immunity against viral hepatitis. Moreover, it highlights how immuno-metabolic changes in liver disease may affect the body’s ability to fight infections and cancer.

Objective: 24-Nor-ursodeoxycholic acid (NorUDCA) is a novel therapeutic bile acid for treating primary sclerosing cholangitis (PSC), an immune-mediated cholestatic liver disease. Since PSC strongly associates with inflammatory bowel diseases (IBD) driven by TH17/Treg imbalance, we aimed to explore NorUDCA's immunomodulatory potential on intestinal TH17/Treg balance. Design: NorUDCA's impact on TH17/Treg tissue distribution was first assessed in Mdr2-/- mouse model of PSC. We specifically investigated NorUDCA's effect on modulating TH17/Treg balance in a CD4+ T cell driven colitis model induced by adoptive transfer of CD25-CD44lowCD45RBhighCD4+ TNaive cells into Rag2-/- mice, mimicking human IBD. Mechanistic studies were performed using molecular approaches, flow cytometry and metabolic assays in murine TH17 cells in vitro. NorUDCA's signaling effects observed in murine system were further validated in circulating CD4+ T cells from PSC patients with co-existing IBD. Results: NorUDCA promoted Treg generation in both liver and intestine in the Mdr2-/- model. In the experimental IBD model, NorUDCA attenuated intestinal immunopathology. Mechanistically, NorUDCA demonstrated strong immunomodulatory efficacy in counteracting TH17/Treg imbalance by restricting glutaminolysis in differentiating TH17 cells, thus suppressed a-Ketoglutarate-dependent mTORC1 activation, glycolysis and enhanced FOXP3 expression. NorUDCA's impact on mTORC1 signaling was further confirmed in circulating CD4+ T-cells from PSC patients with IBD. Conclusion: NorUDCA possesses direct immunometabolic modulatory potency to counteract TH17/Treg imbalance and ameliorate excessive TH17 cell driven intestinal immunopathology. These findings extend future clinical applications of NorUDCA for treatment of TH17 cell-mediated disorders along the gut-liver axis and beyond. Competing Interest Statement Michael Trauner has served as speaker for Falk Foundation, Gilead, Intercept and MSD; he has advised for Albireo, BiomX, Boehringer Ingelheim, Falk Pharma GmbH, Genfit, Gilead, Intercept, Jannsen, MSD, Novartis, Phenex, Regulus andShire. He further received travel grants from Abbvie, Falk, Gilead and Intercept and research grants from Albireo, Almylam, Cymabay, Falk, Gilead, Intercept, MSD, Takeda and Ultragenyx. He is also co-inventor of patents on the medical use of NorUDCA filed by the Medical Universities of Graz and Vienna. All the other authors declare no conflict of interest.

Resistant hypertension has been recognized as an additional risk in patients with hypertension, leading to an almost 1.5-fold increased risk of cardiovascular events among that population. Patients with obstructive sleep apnea (OSA) have almost five times higher risk of having resistant hypertension. Studies that evaluated the impact of treatment of OSA on blood pressure (BP) control among patients with resistant hypertension have some distinct methodological limitations, and none have included a sham positive airway pressure (PAP) control group. The aim of this study was to evaluate the effect of PAP on BP measured by 24-hour ambulatory BP (ABP) monitoring of patients with true resistant hypertension. Some of the results of our trial have previously been reported in the form of an abstract. 16 references

Background Historical data indicate that surgical resection may benefit select patients with metastatic gastric and gastroesophageal junction cancer. However, randomized clinical trials are lacking. The current RENAISSANCE trial addresses the potential benefits of surgical intervention in gastric and gastroesophageal junction cancer with limited metastases. Methods This is a prospective, multicenter, randomized, investigator-initiated phase III trial. Previously untreated patients with limited metastatic stage (retroperitoneal lymph node metastases only or a maximum of one incurable organ site that is potentially resectable or locally controllable with or without retroperitoneal lymph nodes) receive 4 cycles of FLOT chemotherapy alone or with trastuzumab if Her2+. Patients without disease progression after 4 cycles are randomized 1:1 to receive additional chemotherapy cycles or surgical resection of primary and metastases followed by subsequent chemotherapy. 271 patients are to be allocated to the trial, of which at least 176 patients will proceed to randomization. The primary endpoint is overall survival; main secondary endpoints are quality of life assessed by EORTC-QLQ-C30 questionnaire, progression free survival and surgical morbidity and mortality. Recruitment has already started; currently (Feb 2017) 22 patients have been enrolled. Discussion If the RENAISSANCE concept proves to be effective, this could potentially lead to a new standard of therapy. On the contrary, if the outcome is negative, patients with gastric or GEJ cancer and metastases will no longer be considered candidates for surgical intervention. Trial registration The article reports of a health care intervention on human participants and is registered on October 12, 2015 under ClinicalTrials.gov Identifier: NCT02578368 ; EudraCT: 2014–002665-30.