Serum proteomics of adults with acute liver failure provides mechanistic insights and attractive prognostic biomarkers

Katharina Remih; Franziska-Maria Hufnagel; Anna Sophie Karl; Valerie Durkalski-Mauldin; William Martens Lee; Constantine J Karvellas; Zemin Su; Jody A Rule; Petra Tomanová; Laura Krieg; Isabel Karkossa; Kristin Schubert; Martin von Bergen; Frank Tacke; Sonja Luckhardt; Nicole Ziegler; Aimo Kannt; Bastian Engel; Richard Taubert; Robert John Fontana; Pavel Strnad; US Acute Liver Failure Study Group

doi:10.1016/j.jhepr.2025.101338

Serum proteomics of adults with acute liver failure provides mechanistic insights and attractive prognostic biomarkers

JHEP Rep. 2025 Jan 30;7(5):101338. doi: 10.1016/j.jhepr.2025.101338. eCollection 2025 May.

Authors

Katharina Remih¹, Franziska-Maria Hufnagel¹, Anna Sophie Karl¹, Valerie Durkalski-Mauldin², William Martens Lee³, Constantine J Karvellas⁴, Zemin Su², Jody A Rule³, Petra Tomanová⁵, Laura Krieg⁶, Isabel Karkossa⁶, Kristin Schubert⁶, Martin von Bergen⁶, Frank Tacke⁷, Sonja Luckhardt⁸, Nicole Ziegler⁸, Aimo Kannt^{8

9}, Bastian Engel¹⁰, Richard Taubert¹⁰, Robert John Fontana¹¹, Pavel Strnad¹; US Acute Liver Failure Study Group

Affiliations

¹ Medical Clinic III, Gastroenterology, Metabolic Diseases and Intensive Care, University Hospital RWTH Aachen, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN RARE LIVER), Aachen, Germany.
² Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
³ Department of Internal Medicine, Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX, USA.
⁴ Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada.
⁵ Department of Econometrics, Prague University of Economics and Business, Prague, Czechia.
⁶ Department of Molecular Systems Biology, Helmholtz Centre for Environmental Research, Leipzig, Germany.
⁷ Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin, Campus Charité Mitte and Campus Virchow-Klinikum, Berlin, Germany.
⁸ Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt am Main, Germany.
⁹ Goethe University, Institute of Clinical Pharmacology, Frankfurt am Main, Germany.
¹⁰ Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany.
¹¹ Department of Internal Medicine, Division of Gastroenterology, University of Michigan, Ann Arbor, MI, USA.

Abstract

Background & aims: Acute liver failure (ALF) is defined as rapid onset coagulopathy and encephalopathy in patients without a prior history of liver disease. We performed untargeted and targeted serum proteomics to delineate processes occurring in adult patients with ALF and to identify potential biomarkers.

Methods: Sera of 319 adult patients with ALF (∼50% acetaminophen [APAP]-related cases) were randomly selected from admission samples of the multicenter USA Acute Liver Failure Study Group consortium and subdivided into discovery/validation cohorts. They were analyzed using untargeted proteomics with mass spectroscopy and a serum cytokine profiling and compared with 30 healthy controls. The primary clinical outcome was 21-day transplant-free survival. Single-cell RNAseq data mapped biomarkers to cells of origin; functional enrichment analysis provided mechanistic insights. Novel prognostic scores were compared with the model for end-stage liver disease and ALFSG prognostic index scores.

Results: In the discovery cohort, 117 proteins differed between patients with ALF and healthy controls. There were 167 proteins associated with APAP-related ALF, with the majority being hepatocyte-derived. Three hepatocellular proteins (ALDOB, CAT, and PIGR) robustly and reproducibly discriminated APAP from non-APAP cases (AUROCs ∼0.9). In the discovery cohort, 37 proteins were related to 21-day outcome. The key processes associated with survival were acute-phase response and hepatocyte nuclear factor 1α signaling. SERPINA1 and LRG1 were the best individual discriminators of 21-day transplant-free survival in both cohorts. Two models of blood-based proteomic biomarkers outperformed the model for end-stage liver disease and ALFSG prognostic index and were reproduced in the validation cohort (AUROCs 0.83-0.86) for 21-day transplant-free survival.

Conclusions: Proteomics and cytokine profiling identified new, reproducible biomarkers associated with APAP etiology and 21-day outcome. These biomarkers may improve prognostication and understanding of the etiopathogenesis of ALF but need to be independently validated.

Impact and implications: Acute liver failure (ALF) is a sudden, and severe condition associated with high fatality. More sensitive and specific prognostic scores are urgently needed to facilitate decision-making regarding liver transplantation in patients with ALF. Our proteomic analysis uncovered marked differences between acetaminophen and non-acetaminophen-related ALF. The identification of routinely measurable biomarkers that are associated with 21-day transplant-free survival and the derivation of novel prognostic scores may facilitate clinical management as well as decisions for/against liver transplantation. Further studies are needed to quantify less abundant proteins. Although we used two cohorts, our findings still need to be independently and prospectively validated.

Keywords: ALF subtyping; Acetaminophen; Acute liver injury; Proteomic profiling.