Genetic Liver Diseases Research Articles

Rapid and reliable diagnosis of Wilson disease using X-ray fluorescence.

Wilson's disease (WD) is a rare autosomal recessive disease due to mutations of the gene encoding the copper‐transporter ATP7B. The diagnosis is hampered by the variability of symptoms induced by copper accumulation, the inconstancy of the pathognomonic signs and the absence of a reliable diagnostic test. We investigated the diagnostic potential of X‐ray fluorescence (XRF) that allows quantitative analysis of multiple elements. Studies were performed on animal models using Wistar rats (n = 10) and Long Evans Cinnamon (LEC) rats (n = 11), and on human samples including normal livers (n = 10), alcohol cirrhosis (n = 8), haemochromatosis (n = 10), cholestasis (n = 6) and WD (n = 22). XRF experiments were first performed using synchrotron radiation to address the elemental composition at the cellular level. High‐resolution mapping of tissue sections allowed measurement of the intensity and the distribution of copper, iron and zinc while preserving the morphology. Investigations were further conducted using a laboratory X‐ray source for irradiating whole pieces of tissue. The sensitivity of XRF was highlighted by the discrimination of LEC rats from wild type even under a regimen using copper deficient food. XRF on whole formalin‐fixed paraffin embedded needle biopsies allowed profiling of the elements in a few minutes. The intensity of copper related to iron and zinc significantly discriminated WD from other genetic or chronic liver diseases with 97.6% specificity and 100% sensitivity. This study established a definite diagnosis of Wilson's disease based on XRF. This rapid and versatile method can be easily implemented in a clinical setting.

481. CRISPR/Cas9-Mediated In Vivo Genome Editing to Correct the OTC spfash Mutation in Newborn Mice

Many genetic liver diseases, including OTC deficiency, present in newborns with repeated, often lethal, metabolic crises. Adeno-associated virus (AAV) neonatal gene therapy in this setting would require multiple vector administrations to maintain the therapeutic effects because the non-integrating genome is lost as developing hepatocytes proliferate. As such, we reasoned that newborn liver may be an ideal setting for AAV-mediated gene correction using CRISPR/Cas9, a powerful genome-editing tool consisting of the Cas9 nuclease and a single-guide RNA (sgRNA). We developed a strategy using an AAV vector with high liver tropism (AAV8) to correct the point mutation in newborn spfash mice using Cas9 enzyme from Staphylococcus aureus (SaCas9). An animal model of OTC deficiency, the male sparse fur ash (spfash) mouse, has a G-to-A point mutation at the donor splice site at the end of exon 4 of the OTC gene, which leads to abnormal splicing and a 20-fold reduction in OTC mRNA and protein.We developed a two-vector approach to incorporate all 3 components of CRISPR/Cas9 into AAV. Vector 1 expresses the SaCas9 gene from a liver-specific TBG promoter, while vector 2 contains both the sgRNA1 sequence expressed from a U6 promoter and the 1.8 kb donor OTC DNA sequence. Spfash pups were injected intravenously on postnatal day 2 with mixtures of vector 1 and vector 2 and subsequently evaluated for indel (insertion and deletion) formation and functional correction of the spfash mutation. Following gene correction (3 and 8 weeks), indels were detected by deep sequencing in 31% of OTC alleles, and HDR-based correction of the G-to-A mutation was observed in 10% of OTC alleles. Liver sections were analyzed by immunohistochemistry for OTC expression, showing 15% OTC-positive cells at 3 weeks and 13% at 8 weeks. Direct measurements of OTC enzyme activity from liver homogenates and OTC mRNA from total cellular RNA from liver revealed similarly high levels of correction in treated animals. We further assessed the impact of gene correction on the clinical manifestations of OTC deficiency by evaluating the tolerance of spfash mice to a one-week course of high-protein diet. Spfash mice treated with the gene-editing vectors had significantly lower plasma ammonia levels and showed a survival improvement as compared with untreated spfash mice. This study provides convincing evidence for efficacy in an authentic animal model of a lethal human metabolic disease following in vivo genome editing.

A monoclonal antibody raised against bacterially expressed MPV17 sequences shows peroxisomal, endosomal and lysosomal localisation in U2OS cells.

Recessive mutations in the MPV17 gene cause mitochondrial DNA depletion syndrome, a fatal infantile genetic liver disease in humans. Loss of function in mice leads to glomerulosclerosis and sensineural deafness accompanied with mitochondrial DNA depletion. Mutations in the yeast homolog Sym1, and in the zebra fish homolog tra cause interesting, but not obviously related phenotypes, although the human gene can complement the yeast Sym1 mutation. The MPV17 protein is a hydrophobic membrane protein of 176 amino acids and unknown function. Initially localised in murine peroxisomes, it was later reported to be a mitochondrial inner membrane protein in humans and in yeast. To resolve this contradiction we tested two new mouse monoclonal antibodies directed against the human MPV17 protein in Western blots and immunohistochemistry on human U2OS cells. One of these monoclonal antibodies showed specific reactivity to a protein of 20 kD absent in MPV17 negative mouse cells. Immunofluorescence studies revealed colocalisation with peroxisomal, endosomal and lysosomal markers, but not with mitochondria. This data reveal a novel connection between a possible peroxisomal/endosomal/lysosomal function and mitochondrial DNA depletion.

Rescue of defective ATP8B1 trafficking by CFTR correctors as a therapeutic strategy for familial intrahepatic cholestasis

ATP8B1 deficiency is an autosomal recessive liver disease characterized by intrahepatic cholestasis. ATP8B1 mutation p.I661T, the most frequent mutation in European patients, results in protein misfolding and impaired targeting to the plasma membrane. Similarly, mutations in cystic fibrosis transmembrane conductance regulator (CFTR), associated with cystic fibrosis, impair protein folding and trafficking. The aim of this study was to investigate whether compounds that rescue CFTR F508del trafficking are capable of improving p.I661T-ATP8B1 plasma membrane expression. The effect of CFTR corrector compounds on plasma membrane expression of p.I661T-ATP8B1 was evaluated by cell surface biotinylation and immunofluorescence. ATPase activity was evaluated of a purified analogue protein carrying a mutation at the matching position (p.L622T-ATP8A2). The clinically used compounds, 4-phenylbutyric acid (4-PBA), suberoylanilide hydroxamic acid (SAHA) and N-butyldeoxynojirimycin (NB-DNJ) improved p.I661T-ATP8B1 plasma membrane targeting. Compounds C4, C5, C13 and C17 also significantly increased plasma membrane expression of p.I661T-ATP8B1. SAHA and compound C17 upregulated ATP8B1 transcription. p.I661T-ATP8B1 was partly targeted to the canalicular membrane in polarized cells, which became more evident upon treatment with SAHA and/or C4. p.L622T-ATP8A2 showed phospholipid-induced ATPase activity, suggesting that mutations at a matching position in ATP8B1 do not block functionality. Combination therapy of SAHA and compound C4 resulted in an additional improvement of ATP8B1 cell surface abundance. This study shows that several CFTR correctors can improve trafficking of p.I661T-ATP8B1 to the plasma membrane in vitro. Hence, these compounds may be suitable to be part of a future therapy for ATP8B1 deficiency and other genetic disorders associated with protein misfolding. Compounds that improve the cellular machinery dealing with protein homeostasis (proteostasis) and allow for proper folding of proteins with (mild) missense mutations are called proteostasis regulators (Balch, Science 2008). Such compounds are potentially of high therapeutic value for many (liver) diseases. In this manuscript, we investigated whether compounds identified in screens as CFTR folding correctors are actually proteostasis regulators and thus have a broader application in other protein folding diseases. Using these compounds, we could indeed show improved trafficking to the (apical) plasma membrane of a mutated ATP8B1 protein, carrying the p.I661T missense mutation. This is the most frequently identified mutation in this rare cholestatic disorder. Importantly, ATP8B1 shows no similarity to CFTR. These data are important in providing support for the concept that rare, genetic liver diseases can potentially be treated using a generalized strategy.

A dual AAV system enables the Cas9-mediated correction of a metabolic liver disease in newborn mice.

Many genetic liver diseases present in newborns with repeated, often lethal, metabolic crises. Gene therapy using non-integrating viruses such as AAV is not optimal in this setting because the non-integrating genome is lost as developing hepatocytes proliferate1,2. We reasoned that newborn liver may be an ideal setting for AAV-mediated gene correction using CRISPR/Cas9. Here we intravenously infuse two AAVs, one expressing Cas9 and the other expressing a guide RNA and the donor DNA, into newborn mice with a partial deficiency in the urea cycle disorder enzyme, ornithine transcarbamylase (OTC). This resulted in reversion of the mutation in 10% (6.7% – 20.1%) of hepatocytes and increased survival in mice challenged with a high-protein diet, which exacerbates disease. Gene correction in adult OTC-deficient mice was lower and accompanied by larger deletions that ablated residual expression from the endogenous OTC gene, leading to diminished protein tolerance and lethal hyperammonemia on a chow diet.

Allocation systems in transplantation medicine: Advantages and disadvantages

Donor organs for transplantations are a scarce commodity; therefore, allocation systems are needed that guarantee an ethically acceptable distribution to patients on the waiting list (equal treatment and fairness) but also take the probability of survival of the transplant in each recipient into consideration. In this article the allocation systems for lung, liver, kidney and pancreas transplants are presented.For lung transplantations an allocation system based on the lung allocation score (LAS) is currently used. The LAS predicts the probability of survival on the waiting list and the survival rate following transplantation. Organs with a limited range of utilization are distributed in a so-called mini-match procedure.For post-mortem kidney and pancreas transplantations a relatively complex but transparent allocation system has been created in which patients are subdivided into groups, each of which has its own allocation rules. The allocation is principally carried out according to criteria of fairness of distribution and according to the prospects of success. The probability of a mismatch also plays a role. The urgency is important for children and for patients who do not have the possibility of dialysis. Combined pancreas and kidney transplantations have priority over kidney transplantations alone.The criterion for the urgency of liver transplantation in Germany is currently the model for end-stage liver disease (MELD), which aims to reduce the waiting list mortality and to prioritize transplantations for those most in need. Because the system insufficiently describes the priority of transplantation for patients with tumors or genetic liver diseases, there is an additional set of rules for so-called standard exceptions.

Hepatocyte Transfection in Small Pigs After Weaning by Hydrodynamic Intraportal Injection of Naked DNA/Minicircle Vectors.

Liver is an attractive organ for gene delivery in order to correct various genetic (metabolic) diseases. Hydrodynamic vein injection of naked DNA/minicircles devoid of viral or plasmid backbones was demonstrated in, for example, murine phenylketonuria to allow sustained therapeutic transduction of hepatocytes. Here we show successful hepatocyte transfusion in domestic small pigs immediately after weaning upon portal vein catheterization and hydrodynamic injection of naked DNA/minicircle vectors expressing the luciferase gene from the CMV or a liver-specific promoter. First, we established a surgical method allowing hydrodynamic portal vein pressurization up to 120 mmHg and infusion of naked DNA in pigs (n = 5) with long-term survival. No acute adverse effects such as changes in liver transaminases or signs of liver cell damage were observed. We then showed efficiency of stable hepatocyte transfection at 10 and 28 days in single experiments (n = 7) where we found that up to 60% of samples (45/75) were polymerase chain reaction (PCR)-positive for minicircle-DNA. Of these samples, 13% of the positive specimen (6/45) showed low but stable luciferase expression when driven by a liver-specific promoter, as well as appropriate copy numbers per diploid genome. In conclusion, we accomplished a safe procedure for stable transfection of liver cells upon hydrodynamic gene delivery using minicircle vectors in small pigs as a prerequisite to potentially treat infants with genetic liver diseases.

358. Non-Viral/Minicircle Vector Transduction of Hepatocytes in Small Pigs By Hydrodynamic Intraportal Injection

Non-viral and non-plasmid-based vectors that express a therapeutic protein from an episomal element have the potential of robust and sustained transgene expression and at the same time bear a very low risk of insertional mutagenesis. While hydrodynamic injection into the tail vein of mice to target the liver is an efficient but experimental approach, delivery of naked DNA/minicircle vectors into large animals and humans remains a challenge. Here we show successful hepatocyte transfection in domestic small pigs treated immediately after weaning with portal vein catheterization and hydrodynamic injection of naked DNA/minicircle vectors expressing the luciferase gene from a liver-specific promoter. We established a surgical method allowing hydrodynamic portal vein pressurization up to 90 mmHg and infusion of naked DNA in pigs with long-term survival. No acute adverse effects such as changes in liver transaminases or signs of liver cell damage were observed. Stable hepatocyte transfections at 10 and 28 days in single experiments were found in up to 60% of samples (45/75 were PCR-positive for minicircle-DNA) and 13% of the positive specimens (6/45) showed low but stable luciferase expression with up to two vector copies per diploid hepatocyte genome. While further optimization to enhance transfection efficiency and transgene expression is required, we conclude that hydrodynamic gene delivery using minicircle vectors in small pigs is a safe procedure for stable transfection of liver cells as a prerequisite to potentially treat infants with genetic liver diseases.

Evaluation of immunity status to routine vaccination in pediatric liver transplant candidates.

Generally, prevention of infections by vaccination is the least invasive and most cost-effective approach to reduce the incidence of infections and the morbidity and mortality in transplant recipients. Genetic diversity and different liver disease among patients contributes to variability in immune responses to vaccines and pathogens. The aim of this study was to evaluate immunity status to different vaccinated organisms in pediatric liver-transplant candidates. The vaccination charts of 90 patients who were referred to Organ Transplant Center of Shiraz University of Medical Sciences were reviewed and compare with National Immunization Program recommendation, after that 10 mL blood was drawn from these patients for serologic studies by ELISA. Eighty percent of the patients had protective antibody titers for poliomyelitis, 65.6% for rubella, 62.3% for diphtheria, 60% for tetanus, 57.7% for pertussis, 55.5% for measles, 42.2% for hepatitis B and 36.7% for mumps. Overall seroconversion rates were not satisfactory for many infections that may be due to lower rate of vaccination or even the underlying liver disease that interfere with optimal immunogenecity of vaccination. Therefore, vaccination charts should be periodically reviewed and updated, also repeated measurements of serum antibodies and appropriate revaccination if titers decline is recommended to prevent the vaccine-preventable disease in liver transplant candidates after transplant.

Development of a pretreatment strategy to enhance the efficiency of hepatocyte transplantation in mice

Hepatocyte transplantation (HTx) is a promising approach for the treatment of genetic liver diseases. However, the poor engrafted efficiency of 0.03‐0.5% of transplanted cells in the recipient livers usually limits the clinical applications. In previous study, we observed an enhanced engraftment of intrasplenically injected cancer cells into the liver of a specific mouse strain due to its narrowed sinusoid, and therefore suspected that narrow sinusoids may enhance the efficiency of HTx. To validate this hypothesis, we transplanted primary hepatocytes by intrasplenic injection into WT C57BL/6 and mice treated with an antibody (Ab) that is known to cause narrow sinusoids of the liver. We found the amount of injected donor cells was nearly 2 times more in the Ab‐treated mice than those in the WT livers at all the time points followed. To confirm the possibility of clinical application of this Ab‐treatment strategy, we tested its therapeutic effect using the hemophilia B disease model. We compared the therapeutic effect between untreated and Ab‐pretreatment strategy on hemophilia B receiving functional hepatocytes for control of bleeding. Transplanted mice were followed for one month, and their sera were analyzed periodically for the activity and antigen levels of coagulant factor IX. We found that mice receiving Ab‐pretreatment strategy had higher FIX antigen and clotting activity than those of untreated groups. Our results showed the Ab that is effective in narrowing the hepatic sinusoids may be useful for improving cell/stem cell therapy for liver diseases in the near future.

Improved respiratory function in a mouse model of Pompe disease treated with BMN 701

Type I Gaucher disease (GD) is an autosomal recessive lysosomal disease caused by glucocerebrosidase deficiency, leading to accumulation of glucocerebroside within the hematological, skeletal and visceral reticuloendothelial system, the last manifested through splenomegaly and hepatomegaly. The presence of cirrhosis has been described in only 5%of theGDpatients, and other concomitant chronic liver diseases have seldom been observed. The objective of this study was to describe and analyze the presence of liver compromise and the concomitance of other liver diseases in patients with type I GD. Thirty-three patients with type I GD, 67% women, median age 37 years were studied. All the patients were investigated for several liver diseases such as HBV, HCV, hemochromatosis, autoimmune hepatitis, alfa-1-antitrypsin deficiency, Wilson disease and NAFLD by analyzing clinical, laboratorial and MRI data. The patients whose findings suggested chronic liver disease were submitted to a liver biopsy. Five (15%) of the GD patients were found to have a liver disease and 4 (12%) of these had cirrhosis. Three women and 2men, aged 19 to 59 years, were on treatment for GD for two years or more. Ten patients had MRI-confirmed hepatomegaly. Four patients had ALT increases lesser than twice the upper range limit of normal value and three of them had MRI image evidence of cirrhosis. The diagnosis of cirrhosis was confirmed by liver biopsy in all four cases. One of them had sclerosing cholangitis confirmed by cholangio-MRI, other had alfa-1-antitrypsin deficiency, and another had a sister with cystic fibrosis. The fifth patient with concomitant liver disease was found to have hemochromatosis. In conclusion, a high prevalence of liver disease and the concomitance of other genetic liver diseases were found in this population. Perhaps these associations may help to unravel liver compromise in type I Gaucher disease.

The role of autophagy in liver diseases: mechanisms and potential therapeutic targets.

The role of autophagy in liver diseases: mechanisms and potential therapeutic targets.

The quality of hereditary haemochromatosis guidelines: A comparative analysis

Hereditary haemochromatosis (HH) is the most prevalent genetic liver disease, with an incidence of 1/200 to 1/400 in the Caucasian population. HH patients are treated by family physicians as well as different specialists. When left untreated or insufficiently treated, the complications can become life threatening. To support and evaluate qualitative care for HH, we evaluated and compared the available structured guidelines on screening, diagnosis and management of HH patients. Seven appraisers systematically reviewed the retrieved guidelines. The Appraisal of Guidelines Research and EvaluationII (AGREEII) was used to score and discuss the quality and reach consensus. The content of recommendations and the evidence behind them, were evaluated. Three guidelines, developed by the American Association for the Study of Liver Diseases (AASLD), the European Association for the Study of the Liver (EASL) and a DUTCH guideline were found. Fifty-seven percent of the recommendations were not shared between the guidelines, pointing to inconsistency of their content. Only two references supporting the recommendations were shared between all three guidelines. The AASLD guideline contains no information about management and follow-up. Moreover, the methodological quality of the AASLD guideline was rated insufficient, except for 'clarity and presentation' (77%). Applicability of the guidelines was scored very low in all three (AASLD: 31%, EASL: 23%, DUTCH: 35%). The DUTCH guideline was judged best. Very poor consistency between available guidelines for HH hampers qualitative care and its evaluation. An updated high-quality and evidence-based guideline that covers follow-up and management of patients with HH is needed.

Sa1007 The Role of Dynamic Contrast Enhanced Ultrasound in Focal Liver Lesion Characterization: Preliminary Results

Background: Recent publications have shown that performing fibroscan of the spleen (fibrospleen) can predict the development of esophageal varices in patients with cirrhosis of the liver. The aim of the present study was to evaluate the fibrospleen as a diagnostic tool in a broader cohort of patients with liver diseases with and without cirrhosis. Methods: 182 consecutive patients [80 female and 102 male, median age 51.8 years] who underwent a fibroscan test at the University Hospital of Essen, Germany, from September 1st to October 10th received a fibroscan of the spleen after obtaining informed consent. The test was performed using Fibroscan touch™ (Echosens™, France). 46 patients were liver transplant recipients, 57 had a viral hepatitis, 28 an autoimmune and 26 a fatty liver disease, further 19 patients suffered from vascular or genetic liver diseases. The patients were further divided in 3 groups regarding their fibroscan of the liver ( 14 kPa n=63). The fibrospleen was correlated to the flow velocity of the portal vein and spleen size. Statistical analyses were performed using GraphPad Prism v 6.0. Results: In a total of 108 patients a valid fibrospleen was possible. The fibrospleen resulted in generally higher values than the fibroscan of the liver. Between the three groups the mean value increased from 28.8 to 33.4 to 52.2 kPa, respectively. The ratio between fibroscan of the liver and fibrospleen increased from 0.33 to 0.44 to 1.15 between the three groups. These differences were statistically significant. The fibrospleen correlated significantly with fibroscan of the liver (pearson coefficient 0.49; p=0.0001) and the size of the spleen (pearson coefficient 0.57; p<0.0001). There was no correlation to the portal flow velocity. The strongest correlation was seen in patients with viral hepatitis, the weakest correlation was seen in patients with a fibroscan of the liver between 7-14 kPa. Conclusion: The fibrospleen shows a linear correlation to liver stiffness in all stages of liver diseases. It correlates to the size of the spleen and is independent of the portal flow velocity. This suggests that fibrospleen may offer further information in the staging of liver disease and a valuable addition to the fibroscan. Prospective analyses are required to evaluate the potential of the fibrospleen in the diagnosis of liver diseases and its complications.

CRISPR in the liver

Although the therapeutic utility of CRISPR-based approaches has yet to be demonstrated, venture dollars are flowing into new companies developing the platform. Proof of concept may come faster than expected as new findings show that a CRISPR-based therapeutic can correct a mutation in adult mice with genetic liver disease.

Clustered, regularly interspaced short palindromic repeats (CRISPR)-based genome editing platform to treat genetic liver disease

Clustered, regularly interspaced short palindromic repeats (CRISPR)-based genome editing platform to treat genetic liver disease

Shortcut Route for Generation of Functional Hepatocyte Cells from Human Skin Allogenically for Autologous Treatment of Chronic Liver Diseases

Zhu Sa, Rezvani Mb, Harbell Jc, Mattis ANb,d,e, Wolfe ARf, Benet LZf, Willenbring Hb,c,d, Ding Sa,g. Mouse liver repopulation with hepatocytes generated from human fibroblasts. Nature. 2014;508(7494):93–97.

Hyperornithinaemia-hyperammonaemia-homocitrullinuria syndrome: a treatable genetic liver disease warranting urgent diagnosis

Hyperornithinaemia-hyperammonaemia-homocitrullinuria syndrome is an autosomal recessive disorder caused by a defect in ornithine translocase. This condition leads to variable clinical presentations, including episodic hyperammonaemia, hepatic derangement, and chronic neurological manifestations. Fewer than 100 affected patients have been reported worldwide. Here we report the first two cases in Hong Kong Chinese, who were compound heterozygous siblings for c.535C>T (p.Arg179*) and c.815C>T (p.Thr272Ile) in the SLC25A15 gene. When the mother refused prenatal diagnosis for the second pregnancy, urgent genetic testing provided the definitive diagnosis within 24 hours to enable specific treatment. Optimal management of these two patients relied on the concerted efforts of a multidisciplinary team and illustrates the importance of an expanded newborn screening service for early detection and treatment of inherited metabolic diseases.

Bone marrow stem-cell therapy for genetic and chronic liver diseases.

There are no permanent remedies for patients suffering from genetic liver diseases (GLDs) and liver cirrhosis (LC). In such cases, liver transplantation has resulted in improved quality of life, but it is not affordable by most patients. Therefore, a cost-effective, safe, and permanent cure for these diseases is desirable. Cell therapy seems an encouraging option for treatment of these liver diseases in the future. Animal experiments and clinical studies have demonstrated that, depending on the nature of the liver disease and the patient, autologous and/or allogeneic bone marrow (BM)-derived stem-cell therapy could be a promising treatment option. Although no clinical trials using BM-derived stem cells for treatment of GLD have yet been conducted, many phase I clinical trials have been conducted and a few such trials for the treatment of LC by use of autologous and/or allogeneic cells are in progress. Overall, the results of these trials are indicative of clinical benefits with no adverse effect on the patients. This review focuses on the current status of BM stem-cell therapy for treatment of GLD and LC in experimental animals and human subjects. It also proposes safer approaches to immune-regulation in allogeneic transplantation of cells.

Capitalizing on the autophagic response for treatment of liver disease caused by alpha-1-antitrypsin deficiency and other genetic diseases.

Alpha-1-antitrypsin deficiency (ATD) is one of the most common genetic causes of liver disease and is a prototype of liver diseases caused by the pathologic accumulation of aggregated mutant alpha-1-antitrypsin Z (ATZ) within liver cells. In the case of ATD-associated liver disease, the resulting “gain-of-function” toxicity can lead to serious clinical manifestations, including cirrhosis and hepatocellular carcinoma. Currently, the only definitive therapy for ATD-associated liver disease is liver transplantation, but recent efforts have demonstrated the exciting potential for novel therapies that target disposal of the mutant protein aggregates by harnessing a cellular homeostasis mechanism called autophagy. In this review, we will summarize research advances on autophagy and genetic liver diseases. We will discuss autophagy enhancer strategies for liver disease due to ATD and another genetic liver disease, inherited hypofibrinogenemia, caused by the proteotoxic effects of a misfolded protein. On the basis of recent evidence that autophagy plays a role in cellular lipid degradation, we also speculate about autophagy enhancer strategies for treatment of hepatic lipid storage diseases such as cholesterol ester storage disease.