An increased incidence of liver diseases has been observed in recent years and is associated with gut dysbiosis, which causes bacterial infection, intestinal permeability, and further leads to disease-related complications. Probiotics, active microbial strains, are gaining more clinical importance due to their beneficial effect in the management of many diseases, including liver diseases. Clinical scenarios show strong evidence that probiotics have efficacy in treating liver diseases due to their ability to improve epithelial barrier function, prevent bacterial translocation, and boost the immune system. Moreover, probiotics survive both bile and gastric acid to reach the gut and exert their health benefit. Evidence shows that probiotics are a promising approach to prevent several complications in clinical practice. Herein, we discuss the recent evidence, challenges, and appropriate use of probiotics in managing advanced liver diseases, which may have an impact on future therapeutic strategies. Furthermore, the superior effect of strain-specific probiotics and their efficacy and safety in managing liver diseases are discussed.
Get full access to this article
View all access options for this article.
References
1.
AsraniSK, DevarbhaviH, EatonJ, et al.Burden of liver diseases in the world. J Hepatol, 2019; 70(1):151–171; doi: 10.1016/j.jhep.2018.09.014
2.
CastanedaD, GonzalezAJ, AlomariM, et al.From hepatitis A to E: A critical review of viral hepatitis. World J Gastroenterol, 2021; 27(16):1691–1715; doi: 10.3748/wjg.v27.i16.1691
3.
XiaoJ, WangF, WongNK, et al.Global liver disease burdens and research trends: Analysis from a Chinese perspective. J Hepatol, 2019; 71(1):212–221; doi: 10.1016/j.jhep.2019.03.004
WoodhouseCA, PatelVC, SinganayagamA, et al.Review article: The gut microbiome as a therapeutic target in the pathogenesis and treatment of chronic liver disease. Aliment Pharmacol Ther, 2018; 47(2):192–202; doi: 10.1111/apt.14397
6.
WanMLY, El-NezamiH. Targeting gut microbiota in hepatocellular carcinoma: Probiotics as a novel therapy. Hepatobiliary Surg Nutr, 2018; 7(1):11–20; doi: 10.2103/7/hbsn.2017.12.07
7.
YangH, DuanZ. The local defender and functional mediator: Gut microbiome. Digestion, 2018; 97(2):137–145; doi: 10.1159/000484687
8.
BetrapallyNS, GillevetPM, BajajJS. Gut microbiome and liver disease. Transl Res, 2017; 179:49–59; doi: 10.1016/j.trsl.2016.07.005
9.
HaqueTR, BarrittASt. Intestinal microbiota in liver disease. Best Pract Res Clin Gastroenterol, 2016; 30(1):133–142; doi: 10.1016/j.bpg.2016.02.004
10.
CarabottiM, SciroccoA, MaselliMA, et al.The gut-brain axis: Interactions between enteric microbiota, central and enteric nervous systems. Ann Gastroenterol, 2015; 28(2):203–209.
11.
AffoS, Morales-IbanezO, Rodrigo-TorresD, et al.CCL20 mediates lipopolysaccharide induced liver injury and is a potential driver of inflammation and fibrosis in alcoholic hepatitis. Gut, 2014; 63(11):1782–1792; doi: 10.1136/gutjnl-2013-306098
12.
XieC, Halegoua-DeMarzioD. Role of probiotics in non-alcoholic fatty liver disease: Does gut microbiota matter?. Nutrients, 2019; 11(11); doi: 10.3390/nu11112837
13.
SchnablB, BrennerDA. Interactions between the intestinal microbiome and liver diseases. Gastroenterology, 2014; 146(6):1513–1524; doi: 10.1053/j.gastro.2014.01.020
14.
ArabJP, Martin-MateosRM, ShahVH. Gut-liver axis, cirrhosis and portal hypertension: The chicken and the egg. Hepatol Int, 2018; 12(Suppl 1):24–33; doi: 10.1007/s12072-017-9798-x
15.
SkinnerC, ThompsonAJ, ThurszMR, et al.Intestinal permeability and bacterial translocation in patients with liver disease, focusing on alcoholic aetiology: Methods of assessment and therapeutic intervention. Therap Adv Gastroenterol, 2020; 13:1756284820942616; doi: 10.1177/1756284820942616
16.
AlexopoulouA, AgiasotelliD, VasilievaLE, et al.Bacterial translocation markers in liver cirrhosis. Ann Gastroenterol, 2017; 30(5):486–497; doi: 10.2052/4/aog.2017.0178
17.
JayakumarS, CarbonneauM, HotteN, et al.VSL#3 (R) probiotic therapy does not reduce portal pressures in patients with decompensated cirrhosis. Liver Int, 2013; 33(10):1470–1477; doi: 10.1111/liv.12280
18.
InokuchiS, TsukamotoH, ParkE, et al.Toll-like receptor 4 mediates alcohol-induced steatohepatitis through bone marrow-derived and endogenous liver cells in mice. Alcohol Clin Exp Res, 2011; 35(8):1509–1518; doi: 10.1111/j.1530-0277.2011.01487.x
PatangiaDV, Anthony RyanC, DempseyE, et al.Impact of antibiotics on the human microbiome and consequences for host health. Microbiologyopen, 2022; 11(1):e1260; doi: 10.1002/mbo3.1260
22.
Food and Agricultural Organization of the United Nations and World Health Organization. Health and nutritional properties of probiotics in food including powder milk with live lactic acid bacteria. World Health Organization, (2001).
23.
ElzoukiAN. Probiotics and liver disease: Where are we now and where are we going?. J Clin Gastroenterol, 2016; 50Suppl 2, Proceedings from the 8th Probiotics, Prebiotics & New Foods for Microbiota and Human Health meeting held in Rome, Italy, on September 13–15, 2015:S188–S190; doi: 10.1097/MCG.0000000000000712
CireraI, BauerTM, NavasaM, et al.Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol, 2001; 34(1):32–37; doi: 10.1016/s0168-8278(00)00013-1
26.
AhmedB, RasulA, TareenKZ, et al.REVIEW: Contemporary evidence on the dynamic role of probiotics in liver diseases. Pak J Pharm Sci, 2019; 32(6):2765–2770.
HongM, HanDH, HongJ, et al.Are probiotics effective in targeting alcoholic liver diseases?. Probiotics Antimicrob Proteins, 2019; 11(2):335–347; doi: 10.1007/s12602-018-9419-6
29.
MalaguarneraG, GiordanoM, NunnariG, et al.Gut microbiota in alcoholic liver disease: Pathogenetic role and therapeutic perspectives. World J Gastroenterol, 2014; 20(44):16639–16648; doi: 10.3748/wjg.v20.i44.16639
KirpichIA, SolovievaNV, LeikhterSN, et al.Probiotics restore bowel flora and improve liver enzymes in human alcohol-induced liver injury: A pilot study. Alcohol, 2008; 42(8):675–682; doi: 10.1016/j.alcohol.2008.08.006
32.
MookerjeeRP, StadlbauerV, LidderS, et al.Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts the outcome. Hepatology, 2007; 46(3):831–840; doi: 10.1002/hep.21737
33.
WangY, KirpichI, LiuY, et al.Lactobacillus rhamnosus GG treatment potentiates intestinal hypoxia-inducible factor, promotes intestinal integrity and ameliorates alcohol-induced liver injury. Am J Pathol, 2011; 179(6):2866–2875; doi: 10.1016/j.ajpath.2011.08.039
34.
StadlbauerV, MookerjeeRP, HodgesS, et al.Effect of probiotic treatment on deranged neutrophil function and cytokine responses in patients with compensated alcoholic cirrhosis. J Hepatol, 2008; 48(6):945–951; doi: 10.1016/j.jhep.2008.02.015
35.
LataJ, NovotnyI, PribramskaV, et al.The effect of probiotics on gut flora, level of endotoxin and Child-Pugh score in cirrhotic patients: Results of a double-blind randomized study. Eur J Gastroenterol Hepatol, 2007; 19(12):1111–1113; doi: 10.1097/MEG.0b013e3282efa40e
36.
HanSH, SukKT, KimDJ, et al.Effects of probiotics (cultured Lactobacillus subtilis/Streptococcus faecium) in the treatment of alcoholic hepatitis: Randomized-controlled multicenter study. Eur J Gastroenterol Hepatol, 2015; 27(11):1300–1306; doi: 10.1097/MEG.0000000000000458
37.
KogaH, TamiyaY, MitsuyamaK, et al.Probiotics promote rapid-turnover protein production by restoring gut flora in patients with alcoholic liver cirrhosis. Hepatol Int, 2013; 7(2):767–774; doi: 10.1007/s12072-012-9408-x
38.
LiX, HanJ, LiuY, et al.Lactobacillus casei relieves liver injury by regulating immunity and suppression of the enterogenic endotoxin-induced inflammatory response in rats cotreated with alcohol and iron. Food Sci Nutr, 2021; 9(10):5391–5401; doi: 10.1002/fsn3.2486
39.
ChangB, SangL, WangY, et al.The protective effect of VSL#3 on intestinal permeability in a rat model of alcoholic intestinal injury. BMC Gastroenterol, 2013; 13:151; doi: 10.1186/1471-230X-13-151
40.
Imani FooladiAA, Mahmoodzadeh HosseiniH, NouraniMR, et al.Probiotic as a novel treatment strategy against liver disease. Hepat Mon, 2013; 13(2):e7521; doi: 10.5812/hepatmon.7521
41.
YounossiZM, KoenigAB, AbdelatifD, et al.Global epidemiology of nonalcoholic fatty liver disease—meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology, 2016; 64(1):73–84; doi: 10.1002/hep.28431
42.
BuzzettiE, PinzaniM, TsochatzisEA. The multiple-hit pathogenesis of non-alcoholic fatty liver disease (NAFLD). Metabolism, 2016; 65(8):1038–1048; doi: 10.1016/j.metabol.2015.12.012
43.
GuptaH, YounGS, ShinMJ, et al.Role of gut microbiota in hepatocarcinogenesis. Microorganisms, 2019; 7(5); doi: 10.3390/microorganisms7050121
44.
KapilS, DusejaA, SharmaBK, et al.Small intestinal bacterial overgrowth and toll-like receptor signaling in patients with non-alcoholic fatty liver disease. J Gastroenterol Hepatol, 2016; 31(1):213–221; doi: 10.1111/jgh.13058
45.
Del ChiericoF, NobiliV, VernocchiP, et al.Gut microbiota profiling of pediatric nonalcoholic fatty liver disease and obese patients unveiled by an integrated meta-omics-based approach. Hepatology, 2017; 65(2):451–464; doi: 10.1002/hep.28572
46.
Bermudez-BritoM, Plaza-DiazJ, Munoz-QuezadaS, et al.Probiotic mechanisms of action. Ann Nutr Metab, 2012; 61(2):160–174; doi: 10.1159/000342079
47.
NagashimadaM, HondaM. Effect of microbiome on non-alcoholic fatty liver disease and the role of probiotics, prebiotics, and biogenics. Int J Mol Sci, 2021; 22(15); doi: 10.3390/ijms22158008
48.
LiangY, LiangS, ZhangY, et al.Oral administration of compound probiotics ameliorates HFD-induced gut microbe dysbiosis and chronic metabolic inflammation via the G protein-coupled receptor 43 in non-alcoholic fatty liver disease rats. Probiotics Antimicrob Proteins, 2019; 11(1):175–185; doi: 10.1007/s12602-017-9378-3
49.
DusejaA, AcharyaSK, MehtaM, et al.High potency multistrain probiotic improves liver histology in non-alcoholic fatty liver disease (NAFLD): A randomised, double-blind, proof of concept study. BMJ Open Gastroenterol, 2019; 6(1):e000315; doi: 10.1136/bmjgast-2019-000315
50.
AhnSB, JunDW, KangBK, et al.Randomized, double-blind, placebo-controlled study of a multispecies probiotic mixture in nonalcoholic fatty liver disease. Sci Rep, 2019; 9(1):5688; doi: 10.1038/s41598-019-42059-3
51.
NabaviS, RafrafM, SomiMH, et al.Effects of probiotic yogurt consumption on metabolic factors in individuals with nonalcoholic fatty liver disease. J Dairy Sci, 2014; 97(12):7386–7393; doi: 10.3168/jds.2014-8500
52.
KhanA, DingZ, IshaqM, et al.Understanding the effects of gut microbiota dysbiosis on nonalcoholic fatty liver disease and the possible probiotics role: Recent updates. Int J Biol Sci, 2021; 17(3):818–833; doi: 10.7150/ijbs.56214
53.
CarpiRZ, BarbalhoSM, SloanKP, et al.The effects of probiotics, prebiotics and synbiotics in non-alcoholic fat liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH): A systematic review. Int J Mol Sci, 2022; 23(15):8805.
54.
XiaoMW, LinSX, ShenZH, et al.Systematic review with meta-analysis: The effects of probiotics in nonalcoholic fatty liver disease. Gastroenterol Res Pract, 2019; 2019:1484598; doi: 10.1155/2019/1484598
55.
MaYY, LiL, YuCH, et al.Effects of probiotics on nonalcoholic fatty liver disease: A meta-analysis. World J Gastroenterol, 2013; 19(40):6911–6918; doi: 10.3748/wjg.v19.i40.6911
56.
KobyliakN, AbenavoliL, MykhalchyshynG, et al.A multi-strain probiotic reduces the fatty liver index, cytokines and aminotransferase levels in NAFLD patients: Evidence from a randomized clinical trial. J Gastrointestin Liver Dis, 2018; 27(1):41–49; doi: 10.1540/3/jgld.2014.1121.271.kby
57.
CaiGS, SuH, ZhangJ. Protective effect of probiotics in patients with non-alcoholic fatty liver disease. Medicine (Baltimore), 2020; 99(32):e21464; doi: 10.1097/MD.0000000000021464
58.
FamouriF, ShariatZ, HashemipourM, et al.Effects of probiotics on nonalcoholic fatty liver disease in obese children and adolescents. J Pediatr Gastroenterol Nutr, 2017; 64(3):413–417; doi: 10.1097/MPG.0000000000001422
59.
SepidehA, KarimP, HosseinA, et al.Effects of multistrain probiotic supplementation on glycemic and inflammatory indices in patients with nonalcoholic fatty liver disease: A double-blind randomized clinical trial. J Am Coll Nutr, 2016; 35(6):500–505; doi: 10.1080/07315724.2015.1031355
60.
BehrouzV, AryaeianN, ZahediMJ, et al.Effects of probiotic and prebiotic supplementation on metabolic parameters, liver aminotransferases, and systemic inflammation in nonalcoholic fatty liver disease: A randomized clinical trial. J Food Sci, 2020; 85(10):3611–3617; doi: 10.1111/1750-3841.15367
61.
Ebrahimzadeh LeylabadloH, GhotaslouR, Samadi KafilH, et al.Non-alcoholic fatty liver diseases: From role of gut microbiota to microbial-based therapies. Eur J Clin Microbiol Infect Dis, 2020; 39(4):613–627; doi: 10.1007/s10096-019-03746-1
62.
Calzadilla BertotL, AdamsLA. The natural course of non-alcoholic fatty liver disease. Int J Mol Sci, 2016; 17(5); doi: 10.3390/ijms17050774
63.
RasoGM, SimeoliR, IaconoA, et al.Effects of a Lactobacillus paracasei B21060 based synbiotic on steatosis, insulin signaling and toll-like receptor expression in rats fed a high-fat diet. J Nutr Biochem, 2014; 25(1):81–90; doi: 10.1016/j.jnutbio.2013.09.006
64.
LoguercioC, FedericoA, TuccilloC, et al.Beneficial effects of a probiotic VSL#3 on parameters of liver dysfunction in chronic liver diseases. J Clin Gastroenterol, 2005; 39(6):540–543; doi: 10.1097/01.mcg.0000165671.25272.0f
65.
HuangY, WangX, ZhangL, et al.Effect of probiotics therapy on nonalcoholic fatty liver disease. Comput Math Methods Med, 2022; 2022:7888076; doi: 10.1155/2022/7888076
66.
ManzhaliiE, VirchenkoO, FalalyeyevaT, et al.Treatment efficacy of a probiotic preparation for non-alcoholic steatohepatitis: A pilot trial. J Dig Dis, 2017; 18(12):698–703; doi: 10.1111/1751-2980.12561
67.
MalaguarneraM, VacanteM, AnticT, et al.Bifidobacterium longum with fructo-oligosaccharides in patients with non alcoholic steatohepatitis. Dig Dis Sci, 2012; 57(2):545–553; doi: 10.1007/s10620-011-1887-4
68.
LiuY, LiuQ, HeskethJ, et al.Protective effects of selenium-glutathione-enriched probiotics on CCl4-induced liver fibrosis. J Nutr Biochem, 2018; 58:138–149; doi: 10.1016/j.jnutbio.2018.04.011
69.
BarcelosSTA, Silva-SperbAS, MoraesHA, et al.Oral 24-week probiotics supplementation did not decrease cardiovascular risk markers in patients with biopsy proven NASH: A double-blind placebo-controlled randomized study. Ann Hepatol, 2023; 28(1):100769; doi: 10.1016/j.aohep.2022.100769
70.
ShekaAC, AdeyiO, ThompsonJ, et al.Nonalcoholic steatohepatitis: A review. JAMA, 2020; 323(12):1175–1183; doi: 10.1001/jama.2020.2298
71.
DazirogluMEC, YildiranH. Intestinal dysbiosis and probiotic use: Its place in hepatic encephalopathy in cirrhosis. Ann Gastroenterol, 2023; 36(2):141–148; doi: 10.2052/4/aog.2023.0776
72.
LutzP, NischalkeHD, StrassburgCP, et al.Spontaneous bacterial peritonitis: The clinical challenge of a leaky gut and a cirrhotic liver. World J Hepatol, 2015; 7(3):304–314; doi: 10.4254/wjh.v7.i3.304
73.
VilstrupH, AmodioP, BajajJ, et al.Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver. Hepatology, 2014; 60(2):715–735; doi: 10.1002/hep.27210
74.
AlbillosA, LarioM, Alvarez-MonM. Cirrhosis-associated immune dysfunction: Distinctive features and clinical relevance. J Hepatol, 2014; 61(6):1385–1396; doi: 10.1016/j.jhep.2014.08.010
75.
BajajJS, HeumanDM, HylemonPB, et al.Randomised clinical trial: Lactobacillus GG modulates gut microbiome, metabolome and endotoxemia in patients with cirrhosis. Aliment Pharmacol Ther, 2014; 39(10):1113–1125; doi: 10.1111/apt.12695
76.
ChenY, GuoJ, QianG, et al.Gut dysbiosis in acute-on-chronic liver failure and its predictive value for mortality. J Gastroenterol Hepatol, 2015; 30(9):1429–1437; doi: 10.1111/jgh.12932
77.
LiboredoJC, VilelaEG, Ferrari MdeL, et al.Nutrition status and intestinal permeability in patients eligible for liver transplantation. JPEN J Parenter Enteral Nutr, 2015; 39(2):163–170; doi: 10.1177/0148607113513465
78.
FujiiT, SekiT, MaruokaM, et al.Lactulose-L-rhamnose intestinal permeability test in patients with liver cirrhosis. Hepatol Res, 2001; 19(2):158–169; doi: 10.1016/s1386-6346(00)00099-1
79.
Pratap MouliV, BenjaminJ, Bhushan SinghM, et al.Effect of probiotic VSL#3 in the treatment of minimal hepatic encephalopathy: A non-inferiority randomized controlled trial. Hepatol Res, 2015; 45(8):880–889; doi: 10.1111/hepr.12429
80.
RimolaA, Garcia-TsaoG, NavasaM, et al.Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: A consensus document. International Ascites Club. J Hepatol, 2000; 32(1):142–153; doi: 10.1016/s0168-8278(00)80201-9
81.
MacnaughtanJ, FigorilliF, Garcia-LopezE, et al.A double-blind, randomized placebo-controlled trial of probiotic Lactobacillus casei Shirota in stable cirrhotic patients. Nutrients, 2020; 12(6); doi: 10.3390/nu12061651
82.
RamachandranG, PottakkatB, BasuS, et al.Effect of probiotics on nutritional status, biochemical parameters, and disease severity in cirrhotic patients referred for liver transplantation: A randomised double blind, placebo-controlled trial. Clin Nutr ESPEN, 2023; 57:703–710; doi: 10.1016/j.clnesp.2023.08.021
83.
XuJ, MaR, ChenLF, et al.Effects of probiotic therapy on hepatic encephalopathy in patients with liver cirrhosis: An updated meta-analysis of six randomized controlled trials. Hepatobiliary Pancreat Dis Int, 2014; 13(4):354–360; doi: 10.1016/s1499-3872(14)60280-0
84.
CaoQ, YuCB, YangSG, et al.Effect of probiotic treatment on cirrhotic patients with minimal hepatic encephalopathy: A meta-analysis. Hepatobiliary Pancreat Dis Int, 2018; 17(1):9–16; doi: 10.1016/j.hbpd.2018.01.005
85.
LuniaMK, SharmaBC, SharmaP, et al.Probiotics prevent hepatic encephalopathy in patients with cirrhosis: A randomized controlled trial. Clin Gastroenterol Hepatol, 2014; 12(6):1003–1008 e1; doi: 10.1016/j.cgh.2013.11.006
86.
DhimanRK, RanaB, AgrawalS, et al.Probiotic VSL#3 reduces liver disease severity and hospitalization in patients with cirrhosis: A randomized, controlled trial. Gastroenterology, 2014; 147(6):1327–1337 e3; doi: 10.1053/j.gastro.2014.08.031
87.
XiaX, ChenJ, XiaJ, et al.Role of probiotics in the treatment of minimal hepatic encephalopathy in patients with HBV-induced liver cirrhosis. J Int Med Res, 2018; 46(9):3596–3604; doi: 10.1177/0300060518776064
88.
DalalR, McGeeRG, RiordanSM, et al.Probiotics for people with hepatic encephalopathy. Cochrane Database Syst Rev, 2017; 2:CD008716; doi: 10.1002/14651858.CD008716.pub3
89.
RayesN, SeehoferD, HansenS, et al.Early enteral supply of lactobacillus and fiber versus selective bowel decontamination: A controlled trial in liver transplant recipients. Transplantation, 2002; 74(1):123–127; doi: 10.1097/00007890-200207150-00021
90.
ChivaM, SorianoG, RochatI, et al.Effect of Lactobacillus johnsonii La1 and antioxidants on intestinal flora and bacterial translocation in rats with experimental cirrhosis. J Hepatol, 2002; 37(4):456–462; doi: 10.1016/s0168-8278(02)00142-3
91.
SanchezE, NietoJC, BoullosaA, et al.VSL#3 probiotic treatment decreases bacterial translocation in rats with carbon tetrachloride-induced cirrhosis. Liver Int, 2015; 35(3):735–745; doi: 10.1111/liv.12566
92.
ElshaerAM, El-KharashiOA, HamamGG, et al.Involvement of TLR4/CXCL9/PREX-2 pathway in the development of hepatocellular carcinoma (HCC) and the promising role of early administration of Lactobacillus plantarum in Wistar rats. Tissue Cell, 2019; 60:38–47; doi: 10.1016/j.tice.2019.07.010
93.
LiX, LiuY, GuoX, et al.Effect of Lactobacillus casei on lipid metabolism and intestinal microflora in patients with alcoholic liver injury. Eur J Clin Nutr, 2021; 75(8):1227–1236; doi: 10.1038/s41430-020-00852-8
94.
AyobN, Muhammad NawawiKN, Mohamad NorMH, et al.The effects of probiotics on small intestinal microbiota composition, inflammatory cytokines and intestinal permeability in patients with non-alcoholic fatty liver disease. Biomedicines, 2023; 11(2); doi: 10.3390/biomedicines11020640
95.
ChongPL, LaightD, AspinallRJ, et al.A randomised placebo controlled trial of VSL#3((R)) probiotic on biomarkers of cardiovascular risk and liver injury in non-alcoholic fatty liver disease. BMC Gastroenterol, 2021; 21(1):144; doi: 10.1186/s12876-021-01660-5
96.
ZhouX, WangJ, ZhouS, et al.Efficacy of probiotics on nonalcoholic fatty liver disease: A meta-analysis. Medicine (Baltimore), 2023; 102(4):e32734; doi: 10.1097/MD.0000000000032734
97.
LaghiL, RomanE, LanQ, et al.A multistrain probiotic increases the serum glutamine/glutamate ratio in patients with cirrhosis: A metabolomic analysis. Hepatol Commun, 2023; 7(4); doi: 10.1097/HC9.0000000000000072
98.
RomanE, NietoJC, GelyC, et al.Effect of a multistrain probiotic on cognitive function and risk of falls in patients with cirrhosis: A randomized trial. Hepatol Commun, 2019; 3(5):632–645; doi: 10.1002/hep4.1325
99.
ThilakarathnaW, RupasingheHPV, RidgwayND. Mechanisms by which probiotic bacteria attenuate the risk of hepatocellular carcinoma. Int J Mol Sci, 2021; 22(5); doi: 10.3390/ijms22052606
100.
DapitoDH, MencinA, GwakGY, et al.Promotion of hepatocellular carcinoma by the intestinal microbiota and TLR4. Cancer Cell, 2012; 21(4):504–516; doi: 10.1016/j.ccr.2012.02.007
101.
AmbalamP, RamanM, PuramaRK, et al.Probiotics, prebiotics and colorectal cancer prevention. Best Pract Res Clin Gastroenterol, 2016; 30(1):119–131; doi: 10.1016/j.bpg.2016.02.009
102.
LiJ, SungCY, LeeN, et al.Probiotics modulated gut microbiota suppresses hepatocellular carcinoma growth in mice. Proc Natl Acad Sci U S A, 2016; 113(9):E1306–E1315; doi: 10.1073/pnas.1518189113
103.
AbenavoliL, LuzzaF, Mendez-SanchezN. Probiotics supplementation in the management of hepatocellular carcinoma. Hepatobiliary Surg Nutr, 2019; 8(6):632–634; doi: 10.2103/7/hbsn.2019.10.12
104.
LiuWT, JingYY, YuGF, et al.Toll like receptor 4 facilitates invasion and migration as a cancer stem cell marker in hepatocellular carcinoma. Cancer Lett, 2015; 358(2):136–143; doi: 10.1016/j.canlet.2014.12.019
105.
ZhangHL, YuLX, YangW, et al.Profound impact of gut homeostasis on chemically-induced pro-tumorigenic inflammation and hepatocarcinogenesis in rats. J Hepatol, 2012; 57(4):803–812; doi: 10.1016/j.jhep.2012.06.011
