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Targeting the gut-liver-immune axis to treat cirrhosis
  1. Thomas Henry Tranah1,
  2. Lindsey A Edwards1,
  3. Bernd Schnabl2,
  4. Debbie Lindsay Shawcross1
  1. 1 Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, FoLSM, King's College London, London, UK
  2. 2 Medicine, University of California San Diego, San Diego, California, USA
  1. Correspondence to Professor Debbie Lindsay Shawcross, Institute of Liver Studies and Transplantation, King's College London, London WC2R 2LS, UK; debbie.shawcross{at}


Cirrhotic portal hypertension is characterised by development of the decompensating events of ascites, encephalopathy, portal hypertensive bleeding and hepatorenal syndrome, which arise in a setting of cirrhosis-associated immune dysfunction (CAID) and define morbidity and prognosis. CAID describes the dichotomous observations that systemic immune cells are primed and display an inflammatory phenotype, while failing to mount robust responses to pathogen challenge. Bacterial infections including spontaneous bacterial peritonitis are common complications of advanced chronic liver disease and can precipitate variceal haemorrhage, hepatorenal syndrome and acute-on-chronic liver failure; they frequently arise from gut-derived organisms and are closely linked with dysbiosis of the commensal intestinal microbiota in advanced chronic liver disease.

Here, we review the links between cirrhotic dysbiosis, intestinal barrier dysfunction and deficits of host-microbiome compartmentalisation and mucosal immune homoeostasis that occur in settings of advanced chronic liver disease. We discuss established and emerging therapeutic strategies targeted at restoring intestinal eubiosis, augmenting gut barrier function and ameliorating the mucosal and systemic immune deficits that characterise and define the course of decompensated cirrhosis.

  • chronic liver disease
  • cirrhosis
  • gut immunology
  • bacterial interactions
  • bacterial translocation

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  • Twitter @ThomasTranah, @DrLAEdwards, @DebbieShawcros1

  • Contributors THT wrote the first draft of the review and compiled the tables and figures. This was then extensively edited by LAE and DLS prior to BS making the final revisions. All authors have approved the final submitted version of the manuscript. DLS accepts overall responsibility for the final submitted version of this review.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests BS has consulted for Ferring Research Institute, Intercept Pharmaceuticals, HOST Therabiomics and Patara Pharmaceuticals. BS’s institution UC San Diego has received grant support from BiomX, NGM Biopharmaceuticals, CymaBay Therapeutics, Synlogic Operating Company and Axial Biotherapeutics. DLS has consulted for Norgine, Shionogi, Mallinckrodt and Kaleido Biosciences. She has delivered paid lectures for Falk Pharma, Norgine and Alfa Sigma. DLS institution King’s College London has received grant support from Norgine and European Union’s Horizon 2020 research and innovation programme under grant agreement No 825694. THT and LAE have no conflicts to declare.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Commissioned; externally peer reviewed.

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