Wrap-up session: Metabolic and alcohol related liver disease

Fabio Marra Number of abstracts per category 160 140 120 100 80 60 40 20 0 Alcoholic liver NAFLD: NAFLD: NAFLD: NAFLD: disease Clinical Diagnostics Experimental Therapy aspects Alcohol: pathogenesis PS-173 Nagy

Distinct functions for RIP3 and MLKL In murine models of ALD vs NAFL/NASH

Ethanol-induced liver injury: • RIP3 drives injury independently of MLKL

High fat diet-induced liver injury • MLKL drives injury independently RIP3

Alcohol: clinical aspects PS-057 Glyn-Owen

Health Survey for England 2016 • Cross sectional survey of households • Designed to be representative of the general population of England • 7,826 adults of whom 3,791 (48%) provided a blood sample • 89.2% of sample had at least one risk factor for liver disease • 28.4% had two or more risk factors (alcohol>14 units/wk (112g/wk), BMI≥25, waist circumference high/very high, diabetes) • 13% of population are drinking above recommended alcohol (but not high risk alcohol) AND are obese or overweight • we call this group at risk of BAFLD = Both Alcohol And Fatty Liver Disease) • This group is often missed in clinical referral pathways from primary to secondary care PS-057 Glyn-Owen Proportion of the general population with high liver blood tests and fibrosis scores

100%

80%

60%

40%

20% representave sample Proporon of the populaon 0% Male Female 18-24yrs 25-34yrs 35-44yrs 45-54yrs 55-64yrs 65-74yrs 75+ yrs High ALT High AST High Fib4 High APRI≥1.0 High AST:ALT rao

• 10.9% had high ALT or AST (approx. half previous estimates) • AST:ALT ratio high in >70% of general population • Awareness of risk and testing for liver disease was low PS-171 Mueller Fibroscan (LS) predicts long-term survival in a 10-year prospective cohort of heavy drinkers

Aim: Establish long-term survival data in a 10-year prospective cohort of heavy Caucasian drinkers primarily presenting for alcohol detoxification

• 675 patients with mean alcohol consumption 186.5 g/d • Mean duration of heavy drinking was 14.3 years • 106 patients (15.7%) died during the observation period PS-171 Mueller Fibroscan (LS) predicts long-term survival in a 10-year prospective cohort of heavy drinkers 1 0.8 <6 kPa 0.6 6 - 12.5 kPa 0.4 ​ The cause of death could be clarified

Survival >12.5 kPa 0.2 p<0.0001 in 42 patients (39%) and it was liver- related in 16 (38%) 0 0 2 4 6 8 10 12 LS was an independent predictor of Observation time (years) death in multivariate analysis (next to age, ALP, and albumin) <6 kPa 6–12.5 kPa >12.5 kPa AUROC 0.72 at 14 kPa cutoff

3-year survival rate 94% 88% 74% 5-year survival rate 90% 78% 64%

LS monitoring should be mandatory for surveillance of drinkers PS-174 Tyson Serum bile acid profiles distinguish severe alcoholic hepatitis from decompensated cirrhosis

Aim: determine a new non-invasive test that would distinguish SAH acute decompensation of alcohol-related cirrhosis

• SAH patients had biopsy-proven steatohepatitis with MDF ≥32 • Serum BAs measured by mass spectrometry in two cohorts (89 and 105 patients)

Full BA profile GCA TCA Bilirubin The entire BA profile and individual Exploratory cohort AUROC 0.93 0.90 0.87 0.79 BAs of GCA and TCA are promising 95% CI 0.87–0.99 0.83–0.97 0.77–0.97 0.67–0.91 non-invasive biomarkers for SAH, and Validaon Cohort may reduce the need for liver biopsy AUROC 0.93 0.85 0.83 0.65 95% CI 0.88–0.98 0.77–0.92 0.74–0.92 0.54–0.76 GS-011 Forrest Baseline neutrophil-to-lymphocyte ratio in alcoholic hepatitis

Aim: To assess the role of neutrophil-to-lymphocyte ratio (NLR), which reflects sepsis and inflammation, in the prognosis of alcoholic hepatitis

• 789 patients in the STOPAH trial • Prevalent and incident infections treated prior to randomization. Infections developing after inclusion were recorded • Prevalent and incident AKI was recorded.

NLR Present (n=67) 7.5 (6.4, 8.7) Incident AKI p=0.0056 Absent (n=403) 6.0 (5.6, 6.4) Infecon by Day Present (n=94) 7.8 (6.3, 9.2) p=0.035 7 Absent (n=695) 6.1 (5.8, 6.5) Infecon by Day Present (n=185) 7.1 (6.3, 8.0) p=0.025 28 Absent (n=604) 6.1 (5.6, 6.5) GS-011 Forrest Baseline neutrophil-to-lymphocyte ratio in alcoholic hepatitis 100%

80% *p=0.01; OR 1.86 (1.16, 2.99)

* Risk of developing infection 60% and incident AKI after * 40% prednisolone treatment greater if NLR >8 vs ≤8:

% Lille Response 20%

0% NLR <5 NLR ≥5 Prednisolone 63.7% 56.5% Untreated 64.5% 41.1%

High NLR associates with prevalent AKI and infection in alcoholic hepatitis. A Lille response to prednisolone is more likely if NLR ≥5, but development of infection or AKI after prednisolone treatment is greater if NLR >8 NAFLD: basic science and pathogenesis The diet-induced inflammatory polarization of monocytes and myeloid precursors is precursors myeloid and of monocytes polarization inflammatory The diet-induced already stably imprinted in the bone marrow and determines pathogenic responses responses pathogenic determines and marrow the bone in imprinted stably already MoMF

tSNE y PS-004 = tSNE Ly6G Monocyte x Hundermarkt neg non-lymphoid CD45 non-lymphoid

derived Liver

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leukocytes inleukocytes bone and marrow liver inflammatory phenotypeinflammatory of myeloid Western diet triggers a unique pos driving NAFLD in the liver the liver in NAFLD driving

cells

Western Normal Normal diet diet av

MoMF . FC[log]

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MoMF av MoMF . FC[log] I II MoMF III av MoMF . FC[log] MoMF III II Targets for NASH therapy derived from genetic studies

Eslam et al., J Hepatol 2018 PS-006 Meroni Hepatic MBOAT7 silencing by i.p. ASO induces microvesicular steatosis in vivo

1 (AU)

MBOAT7

protein 0.5 *

β-actin Hepatic Scramble MPO MBOAT7 MBOAT7 0

2

1.5 * TG (%) TG 1

0.5

Scramble MPO MBOAT7 Intrahepatic 0 H&E (200X) Scramble MPO MBOAT7 *P <.005 vs Scramble n=6 n=6 PS-006 Meroni Hypothesis of mechanism: Post-prandial state/ hyperinsulinemia/MBOAT7 risk allele carriers

PI3P De novo lipogenesis Saturated-PI TG FATP1 Arachidonoyl- FABP1 CoA MBOAT7 Co-A

Free Arachidonic TG Acid

Eicosanoids Inflammation The miR-34a/SIRT1:AMPK pathway is activated in PS-003 Simao the human NAFLD muscle

steatosis patients NASH patients

miR-34a

AMPK SIRT1

Akt The miR-34a/SIRT1:AMPK pathway and mitochondrial dynamics dysfunction were found Drp1 Mfn2 amplified in the muscle of experimental NAFLD models and human NASH. Insulin Mitochondrial signaling dynamics Targeting of the miR-34a/SIRT1:AMPK pathway may benefit the liver and the muscle improving whole body metabolism Persistence of hepatic and adipose tissue PS-002 Van Eck alterations despite diet reversal in mice

​Although diet reversal N A S V A T T re g c e lls induced metabolic and 8 P<0.001 P<0.01 8 0 P<0.001

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e histological normalization c 6 6 0 + 4

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o Th17, VAT Tc, and VAT 6 0 % 0 0 Treg cells

t t D l D D D l D D 4 0 s ie s ie C k a F F C k a F F were not reversed within D s D s r H s H s w r H s H s w e F k F k e F k F k 2 2 g v H w H w v H w H w 3 e 3 e r 0 2 r 0 2 2 3 2 3 12 weeks. 2 0 C D L iv e r T h 1 7 c e lls V A T T c c e lls D ie t re v e rs a l P<0.01 This finding challenges 2 0 * * 6 0 P<0.001 0 H F H F D s * * * l l

e our current s c l 5 0

1 5 l e 0 4 8 1 2 1 6 2 0 2 4 2 8 3 2 + c 4 understanding of D W e e k s + 4 0 3 C

1 0 D + C 3 3 0 reversibility of NAFLD-

f D o C

5 f 2 0 %

o related inflammation

% 0 1 0 upon lifestyle

t t D e l D D D s e l D D C s i a F F C i a F F modification k D s k D s r H s H s w r H s H s w e F k F k e F k F k 2 v H w H w 2 v H w H w 3 e 3 e r 0 2 r 0 2 2 3 2 3 The glucocorticoid antagonist ST-001 prevents fibrosis PS-129 Caffrey development in the DIAMOND mouse model

Mouse Fibrosis (NASH CRN) Perisinusoidal fibrosis (0–2) NAS SAF acvity score Posive control 0.67 1.00 4.56 1.78 High dose 0.00 p=0.0006 0.10 p=0.0069 4.10 1.1 Low dose 0.00 p=0.0010 0.11 p=0.0110 4.00 1.00

While ST-001’s effect on NASH development is inconclusive, improvements in measures of fibrosis and NAFLD were demonstrated. NAFLD: clinical aspects GS-08 Abeseykera Non-alcoholic fatty liver disease in young adults

A previous cross-sectional analysis of the ALSPAC cohort in late teens identified a NAFLD prevalence of 2.5% by ultrasound criteria This study aimed to identify the prevalence of NAFLD in this cohort, now young adults, using TE to measure fibrosis and steatosis with CAP (4,021 participants, exclusion excessive daily alcohol intake)

! ALT, AST, and GGT all rose with F score and CAP score ! CAP associated with F score ! BMI rose with rising F score and CAP score

Using TE, 1 in 5 patients had steatosis and 1 in 40 had fibrosis at 24 years, an increase on the previous estimate within the same cohort 6 years prior. Greater public health awareness of NAFLD is needed in young adults in the UK PS-203 Noureddin Dietary risk factors for non-alcoholic fatty liver disease by cirrhosis status

Aim: examine dietary factors in NAFLD by cirrhosis status in the US Multiethnic Cohort, a large prospective study with >215,000 participants in Hawaii and California

• Nested case-control study • NAFLD cases identified using Medicare claims • Diet assessed at baseline via a validated quantitative food frequency questionnaire

2,974 NAFLD cases (518 with cirrhosis; 2,456 non-cirrhotic) and 29,474 matched controls

! Red meat, processed red meat, poultry, and cholesterol independently associate with risk of NAFLD ! Dietary fiber is a protective factor ! Red meat and cholesterol also associated with NAFLD-related cirrhosis

LBP-01 Aberg NAFLD, alcohol drinking habits and genetics predict progression

Aim: analyze risk factors for the development of advanced liver disease in the general population with NAFLD

• Data from national health surveys: FINRISK 1992–2012 and Health 2000 • Linkage with national registers for hospitalization, death, and cancer • NAFLD defined as a fatty liver index >30 + alcohol use ≤20g/d (women)/≤30g/d (men)

! 6,462 NAFLD subjects, 58 liver events ! 43% rise in risk of liver events per each additional alcohol drink/day ! Potential misclassification negligible based on validation against CDT ​

Alcohol drinking habits and genetics (TM6SF2, PNPLA3) are important co- factors in the progression of NAFLD PS-157 Younes Longitudinal prognostic value of the most common NITs for fibrosis

• 918 patients underwent a liver biopsy for suspicion of NAFLD in main referral tertiary centres in Italy and the United Kingdom • The following scores were calculated: NAFLD Fibrosis Score (NFS), APRI, FIB-4, BAAT and BARD

• Liver-related events (ascites, varices or encephalopathy) " 75 • HCC " 15 • Cardiovascular events " 91

• NFS and FIB4 à prediction of liver events and HCC • BAAT and BARD à prediction of CV events • Values of NFS, FIB4, APRI and BARD are associated with poor survival PS-201 External validation in NAFLD cohorts of the FibroScan-based FAST score combining liver stiffness, controlled attenuation parameter and AST to identify patients

PS-201 External validation in NAFLD cohorts of the FibroScan-based FAST score combining liver stiffness, controlled attenuation parameter and AST to identify patients with active NASH (NAS ≥ 4) and significant fibrosis (F ≥ 2)

PS-202 Genome-wide association studies of abdominal MRI scans identifies loci associated with liver fat and liver iron in the UK Biobank PS-157 Caussy Gut-microbiome signature as a biomarker of NAFLD- Total n= 203 participants cirrhosis Gut-microbiome 16S rRNA sequencing

Probands Probands with Probands Non-NAFLD controls NAFLD without AF NAFLD-cirrhosis n=54 n=18 n=26

1.Familial gut-microbiome similarity driven by shared housing

1rst degree relative 1rst degree relative 1rst degree relative n= 44 n =17 n = 37

2.Gut-microbiome derived signature of NAFLD-cirrhosis : 27 bacterial features and age, sex and BMI

High diagnostic accuracy for the detection of NAFLD-cirrhosis in NAFLD PS-064 Chhatwal

• Objective: to develop an open-access, interactive tool for patients and providers that help them understand the risk of long-term outcomes associated with NAFLD/NASH • Secondary objective: create awareness about adverse consequences of NAFLD/NASH PS-061 Petta Mean annual all-cause healthcare costs by liver disease severity

NAFLD/NASH paents in Italy have a high comorbidity burden. Those with AdvLD have significantly higher costs, Early idenficaon and effecve management are needed to minimize disease progression and resource ulizaon NASH: therapy Data from some ongoing studies

Friedman et al., Nat Med 2018 SAT-357: Tropifexor, a farnesoid X receptor agonist for the treatment of non-alcoholic steatohepatitis: Interim results based on baseline body mass index from first two parts of Phase 2b study FLIGHT-FXR

PS-108: NGM313, a novel activator of beta-Klotho/FGFR1c: A single dose significantly reduces steatosis (liver fat by MRI-PDFF), inflammation (ALT, AST) and fibrogenic activity (Pro-C3) in NAFLD subjects (FGF21)

PS-111: Six month interim results of MSDC-0602 K in a large phase 2b NASH study demonstrate significant improvement in liver enzymes and glycemic control (TZDs)

LBP-20: VK2809, a Novel Liver-Directed Thyroid Receptor Beta Agonist, Significantly Reduces Liver Fat with Both Low and High Doses in Patients with Non-Alcoholic Fatty Liver Disease: A Phase 2 Randomized, Placebo-Controlled Trial

LBP-04: Investigation of synbiotic treatment in non-alcoholic fatty liver disease (NAFLD): Results of the INSYTE study LBP-10: A structurally engineered fatty acid, icosabutate, rapidly normalises elevated plasma ALT and gamma-glutamyl transferase (GGT) concentrations in a study population at high risk of NAFLD/NASH

PS-109: Partial inhibition of de novo lipogenesis with the acetyl-CoA carboxylase inhibitor PF-05221304 does not increase circulating triglycerides in humans and is sufficient to lower steatosis in rats

PS-110: Ketohexokinase inhibitor PF-06835919 administered for 6 weeks reduces whole liver fat as measured by magnetic resonance imaging-proton density fat fraction in subjects with non- alcoholic fatty liver disease (fructose, DNL)

PS-106: An international, randomized, placebo-controlled phase 2 trial demonstrates novel effects of DGAT2 antisense inhibition in reducing steatosis (TG synthesis) GS-01 Kessoku Lubiprostone for NAFLD: The LUBIPRONE Phase 2 study

Aim: Double-blind, placebo-controlled, randomized, Phase 2 trial to determine whether lubiprostone (LUB) improves gut permeability in NAFLD patients, resulting in reduction of ALT

C D • Parameters of gut permeabilty were significantly lower in LUB vs. placebo • ≥15% MRI- PDFF reduction significantly higher in LUB vs. placebo (Figure C)

• LUB24 had a higher rate of AEs (33%) vs. Mean ± SEM placebo (7%, p=0.0025)* and LUB12 (7%) (*p<0.05)

Manipulating gut permeability may be a promising novel approach in NAFLD ​ GS-06 Younossi REGENERATE: a Phase 3 trial of obeticholic acid (OCA) for NASH

• In the Phase 2b FLINT study, the potent FXR agonist OCA 25 mg for 72 weeks improved fibrosis and other histological features of NASH • Month 18 interim analysis of REGENERATE evaluated OCA on liver histology in NASH patients with F2/F3 fibrosis GS-06 Younossi REGENERATE: a Phase 3 trial of obeticholic acid (OCA) for NASH

Primary endpoint (ITT): fibrosis improvement Primary endpoint (ITT): NASH resolution Fibrosis improvement or worsening by ≥1 stage by ≥1 stage with no worsening of NASH with no worsening of fibrosis (per protocol with post-baseline biopsy) 40 *p=0.0002 40

p=0.13 30 p=0.04 30 s s t t n n e i e i t p=0.18 23.1% t a 20

a 20 P

P

%

17.6% %

10 11.9% 10 11.2% 11.7% 8.0%

0 0 Placebo OCA 10 mg OCA 25 mg Placebo OCA 10 mg OCA 25 mg (n=311) (n=312) (n=308) (n=311) (n=312) (n=308)

• OCA 25 mg QD met the primary endpoint of improvement in liver fibrosis with no worsening of NASH • Although the additional primary endpoint of NASH resolution with no worsening of fibrosis was not met, resolution of NASH based on the overall pathologist’s assessment was more frequent with OCA 25 mg GS-06 Younossi REGENERATE: a Phase 3 trial of obeticholic acid (OCA) for NASH

• 65.6% in OCA 25 mg normalized ALT vs. 37.3% in placebo • Safety: Increase in LDL-C with both doses of OCA, with an eventual decrease over time • Treatment emergent AEs: Pruritus was reported by 51% of patients with OCA 25 mg vs. 19% in the placebo group • Treatment discontinuation was similar in the three groups. More patients in the OCA 25 mg group (9%) discontinued due to pruritus.

First successful phase 3 trial in patients with NASH Study is ongoing to confirm benefit on clinically relevant outcomes PS-105 O’Gorman Regression in fibrosis following a 12-week aerobic exercise intervention

• Aim: Investigate the effects of a 12-week exercise intervention (EI) on hepatic fibrosis in individuals with biopsy-proven NAFLD • Assessments at baseline (T0), after EI (T1), and 12 weeks after T1 (T2)* • Liver biopsy, transient elastography, cardiorespiratory fitness (VO2max), physical activity levels, and anthropometry • EI group: 2 supervised and ≤3 unsupervised sessions per week, increasing intensity (45–75% heart rate reserve) and duration (24–45 minutes), for 12 weeks. Control group: 3 physical assessments 25 individuals (16 exercise, 9 controls) p<0.05 58% of individuals demonstrated fibrosis regression at T1, despite only 3/12 achieving ≥5% weight loss By VTCE, stiffness reduction was not maintained at T2 PS-112 Aithal Endoscopic duodenal mucosal resurfacing in type 2 diabetes

• Aim: : Evaluate effect of DMR on glycaemia, hepatic fat, and mechanistic endpoints

Putative role of duodenal mucosal hyperplasia in metabolic disease DMR: REVITA single catheter Schematic of DMR Nutrient-induced stem Duodenal endocrine cell division1 hyperactivity2 Duodenal Insulin High fat + mucosal resistance sugar diets hyperplasia syndrome

Can reversal of hyperplasia alone reverse/ameliorate insulin resistance?

Multicenter study with early open-label cohort (training purposes, n=24) and randomized double- blind cohort (n=108) PS-112 Aithal Endoscopic duodenal mucosal resurfacing in type 2 diabetes

Absolute MRI-PDFF: -7.0 ± 1.6 (p<0.001) ALT (U/L): -8.5 ± 2.17 (p<0.001) 40 25.0% Relative (-35.8% ± 7.8, p<0.001) fat fraction reduction 38 36 20.0% 34 15.0% 32 ALT (U/L) 30 10.0% 28 5.0%

26 Absolute MRI-PDFF (%) 24 0 4 12 0.0% Weeks Baseline 3 Month

Favorable safety/ tolerability profile Promising potential treatment for T2D and NAFLD/NASH. Myokines FFA Adipokine imbalance Inflammatory cytokines

Inflammatory cells ROS JNK NF-kB Hep Bacterial products TNF ER stress Bile acids Kupffer IL-1b Hormones cells CCL2 Specific nutrients TGF-b

HSC

Fibrosis

Modified from Rosselli et al., Curr Pharm Des 2014 LB-1 Garcia-Tsao Emricasan in NASH cirrhosis with severe portal hypertension (PH)

Patients with NASH cirrhosis and BL HVPG ≥12 mmHg randomized 1:1:1:1 Mean change Emricasan Emricasan Emricasan from baseline at 5 mg 25 mg 50 mg Placebo to emricasan (pan-caspase Wk 24 N=65 N=65 N=66 N=67 inhibitor), 5, 25, 50 mg or placebo -0.6; -0.8; -1.0; HVPG (Overall) -0.4 orally twice daily for 48 wks p=0.96 p=0.79 p=0.65 – Primary endpoint: Follow-up HVPG at HVPG (compensated, -1.6; -1.7; -1.5; Wk 24 +0.5 HVPG ≥16 p=0.01 p<0.01 p=0.02 – 263 subjects randomized at 59 US/EU mmHg) sites " central HVPG reading

Primary endpoint was not met. Data suggest that emricasan for 24 wks reduced portal pressure in compensated NASH cirrhosis with higher BL HVPG In memoriam…

Valerio Nobili, 1966 - 2019