All right, everybody, let's start with session two of the post-grad course. And this part two, the topic is cross-talk with the immune system and gut-brain access. Our moderators are Dr. Jalan at University College London and Dr. Szabo at Harvard Medical School. And if I can please ask all the speakers for the session to come up on stage. And before this case, real quick, can we just have the Slido slide? So just a request. One is a reminder to please download the app. Second one is on the app, what you'll see is a place for the handouts. You will also see a place where it says Q&A and polls. Look at the green section for questions that Dr. Jalan and Dr. Szabo will go over to answer at this time. You can also submit questions, Q&A, through this app right here, which they will go over at the end. Any questions that we don't get through at the end of the sessions, we will be collating all the questions, getting the answers, and sending it out. Reminder that all of this is also available on demand. So good morning, everybody. Here is the case that we will discuss. This is a 56-year-old male with alcohol-associated liver disease who presents with increasing ascites and has a history of requiring frequent paracentesis. He's unable to stop drinking. The patient is complaining of difficulty in sleeping. He's got no significant family history. On examination, he has got temporal wasting, moderately tense ascites, and peripheral edema. He's on treatment with 40 milligrams of fruzomide every day and 100 milligrams of spironolactone. His labs are the following. His white cell count is 2.2 with 1.4 neutrophils and a meld sodium of 22. His meld is 3. Bilirubin is 4, sodium 128, iron R 1.5, a creatinine of 1.2, and albumin of 2. His alpha-fetoprotein is 6, and his ammonia is elevated at 92. His acidic fluid white cell count is 20 per millimeter cube, is mainly lymphocytes with an albumin of 0.1 grams per DL. The ultrasound shows a 2-centimeter hypoechoic lesion in segment 5, and a triphasic CT shows a LERAD of 3. So here are the questions. The first question is in relation to his insomnia. So what are the reasons for insomnia, sleep apnea? Is it PTSD? Is it alcohol use disorder? Is it hepatic encephalopathy? Or is it all of the above? So the patient should receive norfloxacin, stroke ciprofloxacin, depending upon where you are, rifaximin, trimethoprim, stroke sulfamethoxazole, or none of the above. And finally, the third question is what further evaluation should be performed for this indeterminate liver lesion? Biopsy to evaluate if this is hepatocellular carcinoma, ultrasound every six months to watch for interval change, or no surveillance. The patient has advanced liver disease and is not a transplant candidate. So I would like you to go ahead and vote for your best choice of answers, and perhaps the answers could come up in another 30 seconds or so. So you're voting for your best answers? Okay. So here is case number one, question number one. What are the reasons for insomnia? And 49% of you thought it is, 52% of you thought it's all of the above, 38% think it's hepatic encephalopathy, 7% think it's alcohol use disorders, none of you think it is sleep apnea, and none of you think it is PTSD. Do we have the answers for the next question, please? So the patient should receive, should the patient receive, 66% of you thought should receive rifaximin, 19% thought none of the above, 11% thought they should receive norfloxacin or ciprofloxacin, and 2% thought they should have trimethoprim, sulfamethoxazole. Do we have the third question, please? What further evaluation should be performed for this indeterminate lesion, and 56% of you thought that ultrasound should be performed every six months, 30% thought a biopsy to evaluate this HCC, if this lesion is a HCC, and 12% of you thought there should be no surveillance and the patient has advanced liver disease and is not a transplant candidate. So thank you, and I'll hand over to Professor Szabo. Thank you, Dr. John. Good morning. So relevant to this case, now we're going to hear from the experts, and we will cover the following topics, cirrhosis and an immune deficiency state, the gut-liver-brain axis, cirrhosis as a premalignant condition, and then we're going to end up with a debate. And it's my great pleasure to start with the first topic and introducing Dr. Richard Murrow from Inserm Paris, who will tell us about the immune effects of cirrhosis. Dr. Murrow. Okay. Dear John G., dear Ajiv, ladies and gentlemen, first I would like to thank the organizer for the invitation to talk today, and this is my disclosure. I will discuss the relevance of the topic, so the question was nicely selected. Then I will use the example of bacterial translocation and SBP to introduce briefly immune deficiency in gut, mucosa, and blood as predisposing factors to infection. Then I will discuss how translational research has been used and should be used to explore immune deficiency in gut, mucosa, and blood. And during my talk where appropriate, I will also discuss how translational research has been used to identify potential therapies against immune deficiency. So immune deficiency is a hallmark of decompensated cirrhosis. It increases the risk of infection, which is a major complication of cirrhosis. Currently, at least in Europe, prevention of infection is based on the long-term use of oral polyabsorbable antibiotics. However, this strategy is associated with major issues such as the emergence of multidrug-resistant strains. And surprisingly, prevention based on therapies against immune deficiency are not yet available. This is an unmet need, and this is why active research should be done. Patients with decompensated cirrhosis have changes in gut microbiome with an increase in pathobionts, which are very bad bacteria, such as E. coli, for example. At the same time, patients have increased intestinal permeability to bacteria, which are greatly related to immune deficiency in gut, mucosa. As a result, bacteria translocate to portal blood. And because of decreased function of the hepatic reticular endothelial system and the existence of portosystemic chance, bacteria reach systemic circulation. Bacteria can then disseminate and cause SBP, and this is greatly due to systemic immune deficiency. How translational research can be used to explore immune deficiency in gut mucosa? First, we should have in mind some characteristics of gut mucosa under normal conditions. Here you recognize the three important structures, the lumen, the epithelium with the classical epithelial cell in gray, tuft cell in blue, and goblet cell in green. At the bottom, you have the lamina propria with resident immune cells. And the epithelium plays a very important role in the barrier function, not only because of its continuity, but also because goblet cells produce mucus, and mucus composes the mucosal barrier. And also, epithelial cells produce antimicrobial peptides, which regulate microbiome. And also, please note that resident immune cells are involved in the regulation of the gut barrier, in particular through the type 3 immune response. And this slide shows a typical type 3 immune response triggered by E. coli. When E. coli breach the epithelial barrier and reach lamina propria, the presence of E. coli is immediately detected by innate immune cells, which are resident dendritic cells, which produce IL-23 to activate a resident type 3 lymphocyte. For example, group 3 innate lymphoid cells referred to as IC3. And this resident lymphocyte produces two cytokines, very important cytokines, IL-17A and IL-22. IL-17A recruits and activates neutrophils to kill bacteria, and IL-22 stimulates epithelial cells to produce antimicrobial peptides. And at the same time, IL-22 is a very important cytokine because it is a signal for the stimulation repair of intestinal epithelium. Therefore, type 3 immune response is, of course, antibacterial, but also homeostatic for the intestinal barrier. This is a cartoon from a paper in the New England Journal showing the leaky gut barrier in decompensated cirrhosis. And you can see immediately that several mechanisms contribute to bacterial translocation in these patients. First, on the left, you have a decreased production of mucosal barrier by gallbladder cells. You have disruptions of digestion in the epithelium. And also a very important point is the decrease in antimicrobial peptide by epithelial cells. And the decrease in antimicrobial peptide production is in great part due to the decrease in bile acid, which is a hallmark of cirrhosis. And one consequence of the decrease in antimicrobial peptide is the contribution to gut dysbiosis. And also, please note that there are major alterations of immune cells that are located in lamina propria. There is a decreased secretion of IgA by plasma cells. There are impaired functions of innate immune cells, including dendritic cells, neutrophils, monocytes, and mycrophages. There are impaired functions of adaptive immune cells, such as CD8 and CD40 cells. But also, this cartoon should be updated and should now include impaired functions of group 3 innate lymphoid cells, and I will explain why later on. So, did translational research identify potential treatment for gut immune deficiency? The answer is yes. You know that bile acids, through the receptor FXR, stimulate intestinal epithelial cells to produce antimicrobial peptides. And Agustin Albilos and colleagues in Madrid reasoned that the administration of FXR agonists, such as obeticholic acid, could rescue intestinal functions that have been lost because of the decrease in bile acids. And therefore, they administered obeticholic acid to rats with cirrhosis, and they found a rescue of intestinal functions because there was an increase in antimicrobial peptides, increase in digestion proteins, and decrease in dysbiosis. Using a mouse model of alcoholic liver disease, Bernstable and colleagues nicely showed that gut dysbiosis in this model was associated with a decreased intestinal level of the metabolite indole-3 acetic acid, which is a ligand for aryl hydrocarbon receptor. Therefore, a decrease in the activation of this receptor resulted in a subsequent decrease in IL-22 expression in J genome, IL-C3. And more importantly, they showed that IL-22-producing engineered bacteria, when administered to the model, induced an increase in antimicrobial peptides, decreased bacterial translocation, and improved liver disease. I need to make two comments. First, these findings clearly show that IL-22 is a major factor of immune deficiency in gut mucosa in this model. And second, they show that the IL-22 replacement therapy could be an interesting option for treating gut immune deficiency in cirrhosis. So, I think that future studies should assess the potential of obeticholic acid and IL-22 for preventing infections in patients with decompensated cirrhosis. We already know that from trials in NASH, PBC, that obeticholic acid can be safely used in humans. And also, a good safety profile and improvement in med score was found in patients who had received IL-22 in the context of phase 2 dose escalating study. Okay. Translational research now to explore immune deficiency in blood. Let me define some abbreviations very quickly. Bacteria express pathogen-associated molecular patterns referred to as PAMs, immediately recognized by a pattern recognition receptor referred to as PRRs, expressed in the innate immune cell. For example, gram-negative bacteria express a PAM called lipopolysaccharide, referred to as LPS, recognized by a toll-like receptor 4. Also, we should have in mind how bacteria in the bloodstream engage innate myeloid cells, I mean neutrophils and monocytes. These cells express PRRs that recognize bacterial PAMs, and recognition stimulates phagocytosis, production of reactive oxygen species, and killing of bacteria. PRR engagement in neutrophils also induce degranulation of antibacterial peptide and formation of neutrophil extracellular traps. How are blood neutrophils in decompensated cirrhosis as compared with the AC subjects? Clinical neutrophil count is unchanged in stable decompensated cirrhosis and markedly increased in ACLF. However, in vitro studies have shown that neutrophils from these two groups of patients have marked effects in antibacterial functions, including a decrease in ROS production, decreased degranulation, and decreased capacity to kill bacteria. How are monocytes in decompensated cirrhosis? Actually, the monocyte count is not dramatically changed in decompensated cirrhosis. However, the composition of the monocyte compartment is dramatically changed regarding three categories of monocytes, which are shown here, AXL-positive monocyte, myeloid-derived suppressor cell, and MRTK-positive monocytes. This slide shows the percentage for each of this subset of monocytes among the large compartment of CD14-positive blood monocytes in three groups, AC subjects, patients with stable SHIPU class C, and patients with ACLF. You can immediately see that in AC subjects the contribution of these three subsets of monocytes is very low. In contrast, the contribution of the three subsets to the blood monocyte compartment dramatically increases in SHI-Pu class C to 67% and culminates in AC left to 86%. In summary, in decompensated cirrhosis, blood neutrophils and monocytes are not harnessed to fight against pathogens in the bloodstream. This predisposes to bacteremia and SVP. When recruited to barrier tissues, defective neutrophils may be ineffective against invading pathogens. What about lymphocytes in patients with decompensated cirrhosis? As compared with clinical lymphocyte count in AC subjects, you can see that there is a decrease in lymphocyte count in stable decompensated cirrhosis, acutely decompensated cirrhosis and ACLF. When flow cytometry or specific RNA signatures were used to dissect the lymphocyte compartment in the blood, you can see that in the three groups of patients there was a marked decrease in CD40 cells, CD80 cells, NK cells, B cells and this change culminated in ACLF. Therefore, there is a very marked lymphopenia in patients with decompensated cirrhosis. This is the current explanation for systemic immune deficiency in decompensated cirrhosis. Again, the impaired gut barrier plays a very important role. Bacterial pumps cross the leaky gut barrier, which causes systemic inflammation, including leukocytosis, elevated levels of CRP, IL-6 and IL-10. At the same time, circulating pumps and or cytokines act on blood immune cells to induce systemic immune deficiency. Please note that liver failure also contributes to systemic immune deficiency through the decreased synthesis of antimicrobial acute phase proteins. In vitro studies have investigated the effect of several drugs on blood immune cell defects in cirrhosis. I will not go into detail, but the take-home message of this experiment is that they clearly show that immune cell defects are reversible in cirrhosis. Therefore, these are good news. Currently in Europe, we are working on the in vivo and ex vivo effect of albumin on innate and adaptive immune cells in patients with decompensated cirrhosis. I hope I will give you soon very interesting results. Dear Jean-Gilles, dear Rajiv, ladies and gentlemen, translational research revealed that decompensated cirrhosis is associated with immune deficiency in gut mucosa and blood. These alterations predispose to infections. Results of future research should give rise to novel therapeutic approaches against immune deficiency and increase the therapeutic arsenal and to prevent bacterial infection in cirrhosis. Thank you. Thanks Professor Moreau. So we're moving on now and we're going to hear about the clinical implications of the gut-liver-brain axis and it's my pleasure to invite Dr. Jasbah Raj from the Medical College of Virginia to tell us about this. Stole not to touch the mic, so I'm not. Thank you to the organizers. Thank you to the ASLD for this rare honor. And my question is meant to be very hard, so that's why there was a lot of things. So hopefully there'll be a lot of teaching points here. So clinical applications of the gut-liver-brain axis, these are my disclosures. So why should we care about this? What factors impact these in patients with cirrhosis? And I can give you three. Etiology of the cirrhosis, consequences of the cirrhosis such as hepatic encephalopathy, and comorbid conditions that the patients already have. Then we'll talk a little bit about the impact of HE, operationalizing management and diagnosis based on the gut-liver-brain axis, and how do direct and indirect approaches using the gut-brain axis can help our patients with cirrhosis. Let's go with the most important thing. Comatose people wake up after bowel movements. We know that. This is the best human model for the gut-brain axis, which is hepatic encephalopathy. The questions are, is everything HE? The spoiler alert is no, which is why that question was asked. How and why do these treatments work are our job to figure it out. So the altered gut-liver-brain axis is not just the microbiota. It's many other things. What the microbes are producing, which are the metabolites, as Richard elegantly told us, the immune system is critically involved. Then you have neurotransmitters either generated from the diet or from the microbiota, then vagal nerve input, as well as the HPA axis that controls the immune system. All of these complicated things go into a patient when you talk about the gut-liver-brain axis. Let's talk about alcohol use disorder. This is meant to be very complicated because that's how our patients are. Our patients tell you one symptom. They're not just that one symptom. There are many, many things that go behind that one symptom, like our patient with alcohol use disorder with decompensated cirrhosis came to you with insomnia. So in patients with alcohol use disorder, anything that you see in the orange is the gut-liver-brain axis. The initiation of the alcohol use in the top right, or top left, in the bottom are the consequences, hepatic encephalopathy, nutritional deficiency, Wernicke's, and this can also anticipate the development of alcohol use disorder remission, as well as relapse. Anywhere you see these stars are where the gut microbiota composition and function in human studies have shown to predict outcomes or be responsible for this happening in the first place. So you can see the gut microbiota function and structure are present all over disease as complex as alcohol use disorder, right from the inception all the way to liver transplant and recurrence. So what are the influences of the gut-brain axis and what are the consequences of misdiagnosis? These are the three things. You know, you can impair the daily function, impair survival, and increase burden of the family. And that's why we care about figuring out why someone has it and how to treat it best. So you have cirrhosis-related, which could be hepatic encephalopathy and other complications, could be etiology and addiction, and could be comorbid conditions. Let's talk about cirrhosis-related. This is the one that we are most familiar with, with hepatic encephalopathy. And going back to the gut-liver-brain axis component of this, there are many kingdoms. It's not just the bacteria in your bowels. You have bacteria, you have archaea, you have fungi, and you have viruses, all of which are impaired in patients with hepatic encephalopathy compared to patients who don't have hepatic encephalopathy. And moreover, many treatments affect these differentially. On the left-hand side is a mouse experiment that we did to prove whether microbes are necessary or not. Long story short, you need microbes to develop brain inflammation, which is a corollary of hepatic encephalopathy. So it is very clear gut microbes are needed, and not just bacteria, but many other parts of the kingdoms are needed. And not just the microbial presence, but their products are needed for hepatic encephalopathy. And this is also done because we actually treat patients with hepatic encephalopathy. But what about covert and minimal hepatic encephalopathy? This person is complaining of, you know, changes in sleep. Does this person have covert encephalopathy? It's present in 35 to 55 percent of patients. Clinical diagnosis, however, is unreliable. And if I come back to the one theme over and over again, one symptom does not include, does not equate to encephalopathy. Clinical outcomes and psychosocial outcomes are very poor. And what can you do? You can test them using hours versus minutes. These tests, such as the animal naming test, the quick stroop, the stroop, as well as some things related to the quality of life, can affect this. But less than 15 percent of us actually have the time, effort, or the energy to spend on this in our real life. So the thing, again, is the patient complains of problems with their sleeping. Let's give them lactulose and see what happens. That's not really a good thing, because many other things contribute to this. Let's talk about comorbid conditions. A beautiful talk in the first talk of this postgraduate course touched upon the social determinants of health. And guess what? They also touch upon the microbes and the gut-brain axis. On the right-hand side is a study in non-patients without cirrhosis, and the left-hand side is a study that we did with the social determinants of health, which impacted the gut microbiota directly. So social determinants of health can affect the microbiota directly and propagate gut-brain injury. We have to think all of these things when we label someone encephalopathy. What about the traditional risk factors that we typically think about with patients and cognitive function? So there are two things here. In the blue are factors that affect the risk of development of overt hepatic encephalopathy, and in the green, that when someone does a cognitive test, does this actually impair the cognitive test or affect the cognitive test beyond the cirrhosis itself? So PPIs, opioids are higher. Beta blockers and neuroactive drugs are associated with the higher risk of HE, so that's something that we need to think about. Affecting cognitive tests, age, as was mentioned before, age affects everything. Opioids affects everything, but antidepressants actually improve it, because patients with untreated depression do badly on cognitive tests. So I want you to open your minds, literally, to say that everything is not just hepatic encephalopathy. Last but not the least is etiology and addiction. Our patient has alcohol use disorder. He's still drinking and has no plans of quitting. So what do we do? In the gut-brain axis theorem, if you look at the non-alcoholic fatty liver disease, or MASLD, and alcohol liver disease, even before cirrhosis, there are changes across the multiple kingdoms in the gut barrier, in the gut microbes. When the patients develop cirrhosis in the top right or hepatocellular cancer in the bottom, there are further changes, but these changes are already impacted before the patient has cirrhosis. What can alcohol do to the brain? On the left-hand side, there are three syndromes that the alcohol can cause clinically. It can cause hepatic encephalopathy because of cirrhosis, it can cause acute withdrawal, and it can cause acute intoxication. And look at all those things. Insomnia is there in between acute withdrawal, hepatic encephalopathy. There's a lot of things that alcohol can do. And the patient with alcohol use disorder with cirrhosis is not just a patient with cirrhosis. It's a patient who also has severe alcohol use disorder, has an end-stage liver disease, but continues to drink. So not only should we be thinking about these cirrhosis, we need to think about the translational aspect of the alcohol in this patient, and figuring out how it contributes to the patient's current symptoms. So we talked about the three parts that affect the gut-brain axis, but how can we use this to improve our diagnosis beyond our clinical acumen, which is unfortunately not as good as we would like it to be? Ammonia levels. The chairperson and many other people have done beautiful studies in the prognostication of ammonia, and it is very clear from some studies in stable outpatients and in inpatients that serial ammonia levels can predict who will get a bad outcome. But can it actually diagnose someone like this person, whose ammonia level is high, that they have hepatic encephalopathy and nothing else? The answer is no. The only way it would have diagnosed it if the ammonia level was normal, if it was 10 or something stone-cold normal, then it is quite likely that this person does not have hepatic encephalopathy. Ammonia levels, like any other lab values, are very dependent on when you actually draw them. After meals are going to be a problem. If the patient is dehydrated, they're going to be high as well. And in the bottom left side, similar to studies that were done on the INR, in studies done across the United States, there were many different changes in the upper limit. So when you order an ammonia level, if you order an ammonia level, please make sure all these caveats are kept in mind. And that should not really be the only way to actually diagnose or exclude. It should be one of the things that you actually put into your decision making. What about sleep? Back to what this patient actually has. There are a million reasons why people's sleep can be affected, but alcohol is one of them. And cirrhosis also. There's a melatonin change in patients with cirrhosis, and that's a problem. Sleep alterations alone are inadequate to diagnose HE, and HE treatment does not necessarily resolve sleep problems. Consider sleep apnea and alcohol or medication-related issues, which are far more common in the population than cirrhosis actually will be. So this is something that is very important with the obesity epidemic, that obstructive sleep apnea should not really be neglected in patients who complain of insomnia or problems like that. So the easiest thing is, that's what we do. Why not laculose for everyone? That's a problem. It puts the poo in poorly tolerated, and that's a big, big problem in these patients. It's cheap, but the human resources that are expended in actually figuring out how to deal with laculose are very expensive. And more importantly, if the patient did not have HE to start with, you're missing the actual cause of the cognitive complaint because you assume that the patient has cirrhosis, has HE. So what do you do? If you really don't have anything, you do a trial of laculose, and you can do it titrated according to the Bristol stool scale as done in the top right. In the bottom is a very nice trial done by Dr. Elliot Tapper's group in which they actually titrated the laculose, but that requires a lot of human resources. Whatever you do, if you start someone on laculose, within two to three weeks, basically check in with them to see how they're doing. If they stop the laculose, then don't pursue this with therapies right now that are not HE. Think about something else. So this is the clinic that we had created in the Veterans Hospital around 10 years ago to find out because this reflexive thing is every cognitive complaint is cirrhosis, HE. The short answer is no. If there's one thing you take away from this, please give our patients a little more respect. They're more than just that one complaint, and that one complaint is more often than not not HE. What we ended up doing, we did a specialized hepatic encephalopathy clinic that was built for. It's not just cognitive testing. It's history taking. Things that we should be doing in clinic anyway, but we do not have time to do so. What we found, less than 50% of patients with cognitive complaints actually had covert HE. Many of them had dementia. Some of them had obstructive sleep apnea, which we diagnosed using a stop-bang questionnaire, which is something you should be employing in your practice. It is very few questions. It's very well validated, and it was alcohol-related as well. So less than 50% of the people in our clinic were not have HE, but they would have been started on lactulose, and that's a problem. So can the microbial composition help us differentiate this in this very crowded and very complicated field? And the answer is yes. Cognitive tests that are associated with addiction disorders have a very different microbial signature than those associated with the hepatic encephalopathy. Post-traumatic stress disorder, which I see a lot as my role as a doctor of veterans, there's a lot of changes in microbiota composition that is different. And the most hardest of all is dementia. Our patients with cirrhosis are growing older. So what we found is amnestic, which is memory-associated disorders, had a different microbial phenotype than those who did not have memory-associated disorders. So with apologies to UPS, what can Brown do for you? What we've actually found is that microbial composition across multiple centers, including Dr. Jackie O'Leary, who's collaborating with us, was able to exclude those who had MHE, differentiate between cirrhosis addiction and PTSD and dementia. We are actually in the process of finalizing this, but actually this may be one of the steps, although it seems very difficult, to actually guide the microbial therapy diagnosis into real-world practice where things are so complicated. So what are the treatment options? Now that we decided that the patients are more than hepatic encephalopathy, there are many, many reasons where our clinical acumen should not be the only way that we should actually talk to these patients. How do we actually treat this? So this is the gut-liver-brain axis. You can add something that is beneficial, you know, things such as whole grains, yogurt, which done with our colleagues from Turkey and Brazil, we found that they were much, much better in their gut function. If you look at rifaximin and lactulose, these are the formulas for that, or FMT in the most extreme circumstances. Importantly, you can remove something that is not beneficial. Proton pump inhibitors, antibiotics, as Dr. Morrow mentioned very beautifully before, and periodontal disease. Please look at your patient's teeth and send them to the dentist. That can have a direct impact on their systemic and brain inflammation. What are the indirect ways? Clearly, if someone has an untreated etiology like our patient did with alcohol use disorder, you need to treat that. Do everything in your power to make sure the patient stops drinking or cuts down. But can you use the microbes to actually treat the things? This has been done in alcohol. This has been done in hepatitis B, E antigen positive patients. And so that's very exciting, using the microbes to in turn impact the etiology. And in this is the traditional use for FMT, you do have the patients with cirrhosis and hepatic encephalopathy, done in many countries around the world, including the United Kingdom and the US. These are our two studies that were done with oral and NMI FMT, where it was safe and effective in patients with cirrhosis, but they were small numbers. Now, this is the more exciting part. When you have patients with alcohol use disorder and cirrhosis like our patient, and they were not able, willing, or had failed all the quitting therapies, when you randomize them to FMT or not, there were reduction in short term craving. And moreover, this translated into better outcomes at six months. And this phenotype was transmissible to germ free mice. So the germ free mice post-FMT stopped drinking compared to the pre-FMT mice for these patients. So this is an exciting thing. I'm not saying we should do FMT in everyone who is doing with alcohol use disorder, but we're in the process of being in the middle of RCT on that. And there's one aspect that we often don't talk about. Many microbes produce alcohol in stealth. So many MACLD patients, not MATLD patients, may actually have endogenous microbes. And this, using Klebsiella pneumoniae and lactobacillus, can produce a lot of alcohol, which if you do an FMT, can also impact the etiology. So this is the indirect way in which the gut-brain axis can actually be taken care of as well. So how do we put it all together? Right now, your answer would have been this, or all of the above because I gave you an easy one. I should have really made it harder and not put the all of the above in there. But this is what really should be. Your patients are way more complex. There are many, many things that go into one symptom in those patients, and we need, in the words of Beyonce, to listen. We need to listen to our patients and do things so that we can help them better. So gut-brain axis determines quantity and quality of life in cirrhosis. This is affected by cirrhosis itself, etiology and addictive processes, and comorbid conditions. Usual clinical approaches are insufficient to determine the exact cause of cognitive complaints, and specialized clinics or approaches may be helpful. Assuming all cognitive complaints or confusion is HE, adds unnecessary medications and ignores the actual underlying disease. Specifically, we need to look out for alcohol and sleep apnea related issues. There are unique microbial signatures for addictive disorders, dementia, et cetera, which are being leveraged in clinical studies. Gut-liver-brain axis treatments directly or indirectly affect clinical and psychosocial outcomes. Thank you so much for your time.

post-grad course

immune system

gut-brain axis

alcohol-associated liver disease

cirrhosis

individualized treatment

microbial data