Abstract
Environmental pollutants, including polychlorinated biphenyls (PCBs), act as endocrine disruptors and impair various physiological processes. PCB 126 is associated with steatohepatitis, fibrosis, cirrhosis, and other hepatic injuries. These disorders can be regulated by microRNAs (miRNAs). Therefore, this study aimed to investigate the role of miRNAs in non-alcoholic fatty liver disease associated with exposure to PCB 126. Adult male C57BL/6 mice were exposed to PCB 126 (5 μmol/kg of body weight) for 10 weeks. The PCB group showed lipid accumulation in the liver in the presence of macro- and microvesicular steatosis and fibrosis with increased inflammatory and profibrotic gene expression, consistent with non-alcoholic steatohepatitis (NASH). PCB exposure also upregulated miR-155 and miR-34a, which induce the expression of proinflammatory cytokines and inflammation in the liver and reduce the expression of peroxisome proliferator-activated receptor α, which, in turn, impairs lipid oxidation and hepatic steatosis. Therefore, the present study showed that PCB 126 induced NASH via potential mechanisms involving miR-155 and miR-34a, which may contribute to the development of new diagnostic markers and therapeutic strategies.
Introduction
Environmental factors such as persistent organic pollutants have been highlighted as endocrine disruptors capable of interfering with physiological processes. Exposure to these pollutants, even at low doses, is associated with obesity and non-alcoholic fatty liver disease (NAFLD) [1–4]. Polychlorinated biphenyls (PCBs) are widely used in industrial processes, and despite their banned production, are still present in the environment because of their high thermodynamic stability and resistance to biodegradation [2, 5, 6]. PCBs, including their more toxic congener PCB 126, are present in the diet [7] and are associated with obesity, NAFLD, insulin resistance, diabetes, oxidative stress, and metabolic syndrome [1–3, 8–12]. Their mechanism of action involves the aryl hydrocarbon receptor (AhR), which regulates the transcription of several genes involved in NAFLD progression [2, 11]. These findings are concerning as the NHANES 2003–2004 showed that 100% of the adult population had detectable serum levels of PCBs [5]. Additionally, a 2010 study involving an American population estimated that the daily intake of PCBs was approximately 30 ng/day [13].
PCBs are associated with inflammation, accumulation of triglycerides in the liver, steatohepatitis, fibrosis, cirrhosis, and hepatocarcinoma [1–3, 8–12]. These disturbances are associated with various molecular markers, such as microRNAs (miRNAs), clarifying their participation in the onset and progression of various pathological processes, either as diagnostic molecular markers or potential therapeutic targets [14–17]. NAFLD is strongly associated with miR-155, miR-34a, and miR-122, as these miRNAs possibly regulate different processes of lipid metabolism and are involved in the inflammatory process characteristic of NAFLD [14–16, 18]. miR-122 downregulation and miR-34a upregulation are consistently found in individuals with NAFLD [16]. In contrast, miR-34a and miR-155 are associated with obesity, accompanied by the accumulation of triglycerides in the liver, as they target the mRNA of molecules such as sirtuin 1, which is reduced in individuals with NAFLD and acts by regulating energy homeostasis through the modulation of transcription factors [14–17].
Although several studies have shown an association between miRNAs and the onset of NAFLD [14–17], to date, no study has investigated the association between the expression patterns of these miRNAs and exposure to PCBs. Therefore, the present study aimed to investigate the participation of miRNAs in the development of NAFLD associated with exposure to PCB 126 to clarify the molecular mechanisms by which these disorders occur, providing candidate diagnostic markers and new therapeutic strategies.
Material and methods
Animals and experimental groups
Male C57BL/6 mice aged 3 months old were maintained on a 12 h/12 h dark/light cycle with controlled humidity (60 ± 10%) and temperature (21 ± 2°C) and free access to food and water. This study was approved by the Animal Ethics Committee of the State University of Rio de Janeiro (protocol number CEUA/013/2019) in accordance with the ARRIVE guidelines and was performed in accordance with the National Research Council’s Guide for the Care and Use of Laboratory Animals. Mice were randomly assigned to two groups (n = 10 for each group) according to treatment with PCB 126 (5 μmol/kg of body weight, diluted in corn oil) [19, 20] or vehicle (corn oil), which was administered through intragastric gavage biweekly at weeks 2, 4, 6, and 8 of the study (Fig 1A).
Fig 1. Characterization of the experimental model.
(A) Overview of the experimental approach: C57BL/6 male mice were allocated to receive vehicle–control group or PCB 126 (5 μM/kg) biweekly for 10 weeks. At the end of 10 weeks, mice were euthanized and blood and liver were collected for further analyses. (B) Average food intake per animal per day. (C) Body mass during 10 weeks of experiment; values expressed as mean ± standard deviation (n = 10 per group).
All animals received a normocaloric and normolipidemic standard diet (14%, 10%, and 76% of energy as protein, fat, and carbohydrates, respectively; total energy, 15 kJ/g). The diet was manufactured by PragSolucoes (Jaú, São Paulo, Brazil) and was in agreement with the recommendations of the American Institute of Nutrition (AIN 93M) [21].
Food intake and body mass were measured weekly. At the end of the experiment (10 weeks), the animals were fasted for 6 h and then deeply anesthetized with an intraperitoneal injection of sodium thiopental [60 mg/kg body mass, associated with 2% lidocaine (10 mg)] to withdraw blood using a heparinized syringe by cardiac puncture. Blood samples were centrifuged at 3000 × g for 15 min at 4°C to obtain the plasma. The samples were stored individually at −20°C until the analytical assays. In addition, livers were carefully dissected, weighed, frozen in liquid nitrogen, and stored at −80°C or fixed in formalin for subsequent analyses and histology, respectively.
Plasma analyses
Total cholesterol, triglyceride, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and fasting glucose concentrations in plasma samples were evaluated using commercial colorimetric kits (Bioclin, Belo Horizonte, Brazil). Insulin (#EZRMI-13-K, Millipore, MO), interleukin 6 (IL-6; #BMS603-2, Invitrogen, CA, USA), and tumor necrosis factor-α (TNF-α; #88-7324-88 Invitrogen, CA, USA) levels in plasma were determined using enzyme-linked immunosorbent assay (ELISA) with commercially available kits.
Histological and stereological analysis of the liver
After being fixed in formalin, hepatic tissue was placed in Paraplast Plus (Sigma-Aldrich, St Louis, MO, USA). Subsequently, 5-μm sections were placed on slides and stained with hematoxylin-eosin and Sirius red. The slides were analyzed and images were captured randomly (JPG format, 36-bit color, 1360 × 1024 pixels) under a light microscope (Olympus BX51 with DP71 digital camera; Olympus Optical, Tokyo, Japan). The volume density (Vv) of hepatocytes was determined using the STEPanizer software version 1.8 via 16-point tests. The results were calculated by dividing the sum of the points found by the sum of the total points of the system and were expressed as percentages [22, 23]. Alternatively, to evaluate interstitial fibrosis, the slides were stained with Sirius red solution for 1 h and counterstained with hematoxylin [24, 25]. Furthermore, the extent of fibrosis was quantitatively measured and characterized as the proportion of tissue area positively stained with Picrosirius Red relative to the total liver tissue area, as described previously [22, 26].
Determination of hepatic cholesterol, triglyceride, and hydroxyproline contents
Liver samples (50 mg) were homogenized in 1 mL isopropanol (Vetec, Rio de Janeiro, Brazil) and centrifuged (50 x g/10 min/4°C). Total cholesterol and triglyceride levels in the supernatant were measured using a colorimetric method with a commercial kit (Bioclin, Belo Horizonte, Brazil). Hydroxyproline levels were quantified using a colorimetric method (catalog # MAK008; Sigma-Aldrich, St. Louis, MO, USA) and expressed as micrograms of hydroxyproline per milligram of liver tissue.
Determination of liver fatty acid composition
Total lipids from the liver were extracted as described by Bligh and Dyer [24], with modifications. After incubation in a chloroform-methanol-water solution (2:1:0.8, v/v), 10 mg of liver sample was centrifuged (1500 × g for 20 min at 4°C). Chloroform was added to the supernatant. After centrifugation (1500 × g for 20 min), the organic phase was removed and dried under a nitrogen stream. The extracted lipids were analyzed using thin-layer chromatography (TLC) for neutral lipids on a DC Silica gel 60 plate (Merck Millipore, HE, Germany) [27]. After the run, the plates were submerged for 10 s in Charring solution (3% CuSO4 and 8% H3PO4 (v/v)), dried, and heated to 110°C for 10 min. The TLC plates were analyzed using densitometry (Image Master software from Total Lab, Auckland, New Zealand). The samples were also analyzed using gas chromatography–mass spectrometry (GC–MS) [28]. Lipid samples were dissolved in 1% sulfuric acid in methanol. The GC-MS analysis was performed on a Shimadzu GCMS-QP 2010 Plus system using an HP Ultra 2 column (5% phenyl methylpolysiloxane; Agilent Technologies, 25 m × 0.20 mm × 0.33 μm). The injector temperature was set to 250°C. The column temperature was programmed from 40 to 160°C at 30°C/min, 160–233°C at 1°C/min, 233–300°C at 30°C/min, and then held at 300°C for 10 min. Electron ionization (EI-70 eV) was performed using a quadrupole mass analyzer operating at scans from 40 to 440 amu. The interface was set at 240°C and the ion source at 240°C. Lipid components were identified by comparing their mass spectra to those of the NIST05 MS library contained in the mass spectrometer. Retention indices were used to confirm the identity of the peaks in the chromatogram using the Supelco 37 Component FAME Mix certified reference material (Sigma-Aldrich, St. Louis, MO, USA).
Total RNA and miRNA extraction and real-time reverse transcription polymerase chain reaction (RT-qPCR)
Total RNA and miRNA were extracted from the liver under RNase-free conditions using RNAzol RT (RN 190) reagent (Molecular Research Center, Cincinnati, OH, USA). Total RNA and miRNA were quantified using a NanoVue Plus Spectrophotometer (GE Healthcare, Buckinghamshire, UK). cDNA was prepared from total RNA using a High-Capacity cDNA Reverse Transcription Kit (catalog #:4368814) (Applied Biosystems, Foster City, CA, USA) and from miRNA using a TaqMan MicroRNA Reverse Transcription Kit (catalog #:4366597) (Applied Biosystems, Foster City, CA, USA). The mRNA levels of Ahr (assay ID: Mm00478932_m1), Mcp1 (assay ID: Mm00656886_m1), Cxcl1 (assay ID: Mm04207460_m1), Il-6 (assay ID: Mm00446190_m1), Tnfa (assay ID: Mm00443258_m1), Tgfβ1 (assay ID: Mm03024091_m1), Smad3 (assay ID: Mm03024086_m1), Collagen1α (assay ID: Mm01309565_m1), Cxcl9 (assay ID: Mm00434946_m1), Caspase3 (assay ID: Mm01195085_m1), Sirt1 (assay ID: Mm01168521_m1), and Ppara (assay ID: Mm00440939_m1) and the miRNA levels of miR-155 (assay ID: 002571), miR-122 (assay ID: 002245), and miR-34a (assay ID: 00426) in the liver were determined. The mRNA and miRNA levels of the markers cited above were measured using TaqMan Fast Advanced Master Mix (catalog #4444963) (Applied Biosystems, Foster City, CA, USA) according to the manufacturer’s instructions. RT-qPCR was performed in triplicate for each sample using an Applied Biosystems 7500 Fast Real-Time PCR System (Applied Biosystems, Foster City, CA, USA). Oligonucleotide primers and probes were prepared by Applied Biosystems (Foster City, CA, USA). Co-amplification of mouse Gapdh mRNA (assay ID: Mm99999915_g1) and U6 snRNA (assay ID: 001973), with various internal controls, was performed for all samples. The results were normalized to GAPDH mRNA and U6 snRNA levels using the 2-ΔΔCT method. This method can be used to calculate relative changes in gene expression, as determined by real-time quantitative PCR [29].
Western blotting analysis
Hepatic protein extraction involved liver homogenization with buffer and protease inhibitors, followed by centrifugation [25]. Supernatants were collected and equal protein amounts were suspended in SDS-buffer, heated, and separated via SDS-PAGE. Electrophoresis used 30 μg protein aliquots, transferred to nitrocellulose membranes. Membranes were blocked with TBS-T solution containing 5% albumin and incubated overnight with cleaved caspase-3 (Cell Signaling, Massachusetts, USA), caspase 3, SMAD 6 and β-actin (Santa Cruz Biotechnology, Santa Cruz, CA, USA) antibody. After washing, membranes were incubated with secondary antibodies, washed again, and protein expression was detected using ECL kit (GE Healthcare, Madison, WI) and ChemiDoc Resolutions System. Quantitative analysis was performed using Image Pro Plus software v 7.01.
Statistical analysis
The results are shown as the means ± standard deviation. GraphPad Prism 10.2 (GraphPad Software, La Jolla, CA, USA) was used for statistical analyses and graphics. All data were tested for normal distribution and homogeneity of variance using Bartlett’s test. Experimental data were analyzed using Student’s t-test, and differences were considered significant at p < 0.05.
Results
Food intake, body mass, and plasma analysis
No differences were observed in average daily food intake (Fig 1B) or body mass (Fig 1C) between the groups during the 10-week experimental period. The PCB group showed higher plasma triglyceride, glucose, and insulin levels (+68%, +68%, and +53%, respectively; p < 0.001; Table 1) than the C group. Plasma markers of hepatic function were also evaluated, and the PCB group showed increased levels of ALT and AST (4.9- and 1.7-fold increase, respectively; p < 0.001; Table 1) compared to the C group. In addition, the PCB group showed higher levels of the proinflammatory cytokines IL-6 and TNF-α (+63% and +43%, respectively; p < 0.001, Table 1) than the C group. Surprisingly, the plasma cholesterol concentration was lower in the PCB group than in the C group (-15%; p < 0.05, Table 1).
Table 1. Biochemical parameters in plasma.
| Plasma analysis | C | PCB |
|---|---|---|
| ALT (U/L) | 9.6 ± 4.1 | 56.9*** ± 16.1 |
| AST (U/L) | 70.4 ± 2.9 | 191.8*** ± 3.1 |
| Cholesterol (mmol/L) | 1.45 ± 0.2 | 1.23* ± 0.2 |
| Triglycerides (mmol/L) | 0.37 ± 0.0 | 0.62*** ± 0.1 |
| Glucose (mmol/L) | 6.50 ± 1.2 | 10.9*** ± 1.2 |
| Insulin (pmol/L) | 93.3 ± 1.6 | 142.8*** ± 2.6 |
| IL-6 (pg/ml) | 45.4 ± 3.3 | 73.8*** ± 3.8 |
| TNF-α (pg/ml) | 14.0 ± 1.5 | 20.0*** ± 1.1 |
C–Control group; PCB–PCB 126 group.
Values expressed as mean ± SD (n = 10).
* p value < 0.05;
** p value < 0.01;
***p value < 0.001.
Liver analysis
Histological and stereological analyses were performed on the liver samples, and the stained sections showed microvesicular and macrovesicular steatosis of small and large lipid droplets dispersed in the livers of animals exposed to PCB (Fig 2A). Vv [steatosis, liver] hepatic steatosis was higher in the PCB group than in the C group (3.5-fold increase; p < 0.001, Fig 2B). Consistent with this result, the PCB group showed higher hepatic triglyceride (+98%; p < 0.001, Fig 2C) and cholesterol (+40%; p < 0.001, Fig 2D) contents than the C group. PCB serves as a classical ligand for the aryl hydrocarbon receptor (AhR), and the activation of this transcription factor is associated with the exacerbation of hepatic steatosis. As anticipated, its expression was elevated in the PCB group compared to that in the control group (2.5-fold increase, p < 0.0001; Fig 2E). In addition to macro- and microsteatosis in the liver, inflammatory infiltrates were observed on histological slides. The expression levels of Mcp1 (3-fold increase; p < 0.0001, Fig 2F) and Cxcl1 (2-fold increase; p < 0.001, Fig 2G) were higher in the PCB group than in the control group. Consistent with systemic inflammation findings, the hepatic expression of Il-6 (0.5-fold increase, p < 0.01, Fig 2H), Tnf-α (2-fold increase, p < 0.01, Fig 2I).
Fig 2. Effects of PCB 126 on cellular, morphological, and molecular features of the liver after 10 weeks of exposure.
(A) Stereology of the liver; (B) Vv steatosis (%) of mouse liver; (C) hepatic triglyceride content; (D) hepatic cholesterol content; (E) aryl hydrocarbon receptor (AhR) gene expression in the liver; gene expression of inflammation-related genes: (F) Mcp1, (G) Cxcl1, (H) Il-6 and (I) Tnf-α. C: Control group; PCB: PCB 126 group. Values are expressed as mean ± standard deviation (n = 10 per group for hepatic lipid content; n = 5 per group for histological and stereological analysis; n = 8 per group for RT-PCR). ** p value < 0.01; *** p value < 0.001; ****p value < 0.0001.
Furthermore, the PCB group exhibited fibrotic areas, suggesting potential progression from hepatic steatosis to non-alcoholic steatohepatitis (NASH) (Fig 3A). To confirm the presence of fibrosis, we quantified the Sirius red staining area, and the PCB group showed a 4.5-fold increase in Sirius red staining than the control group (Fig 3B, p < 0.0001). Hydroxyproline quantification was 6 times higher in the PCB group than in the control group (Fig 3C, p < 0.0001). Genes involved in the development of fibrosis, namely Tgfβ1 (3.5-fold increase, p < 0.0001, Fig 3D), Smad3 (4-fold increase, p < 0.0001, Fig 3E), Collagen1α (3.4-fold increase, p < 0.0001, Fig 3F), and Cxcl9 (3-fold increase, p < 0.0001, Fig 3G), were also upregulated in the PCB group compared to the control group. Hepatic fibrosis, which may result from steatosis, is exacerbated by the death of hepatocytes. The PCB group exhibited increased Caspase 3 gene expression (2-fold increase; Fig 3H) and increased cleaved caspase 3 protein expression (Fig 3I and 3J; p<0.001). Protein level of SMAD 6 was up-regulated in PCB group (Fig 3K and 3L; p < 0.001).
Fig 3. Histological and molecular parameters associated with liver fibrosis after chronic PCB 126 exposure.
(A) Picrosirius red staining; (B) % Picrosirius Red area; (C) hydroxyproline content in the liver; profibrogenic gene expression: (D) Tgfβ1, (E) Smad3, (F) Collagen1α, (G) Cxcl9, and cell death-related gene: (H) Caspase 3. Protein Levels of cleaved caspase 3 (I and J) and SMAD 6 (K and L) were assed. C: Control group; PCB: PCB 126 group. Values are expressed as mean ± standard deviation (n = 8). ** p value < 0.01; *** p value < 0.001.
The fatty acid profile was also evaluated in liver samples, and no differences were observed in the amounts of saturated, monounsaturated, and polyunsaturated fatty acids between groups or in the amounts of n-6 and n-3 essential fatty acids (Table 2).
Table 2. Fatty acids profile in liver samples.
| Fatty acids | C | PCB |
|---|---|---|
| Lauric acid (C12:0) | 0.326 | 0.144 |
| Tridecanoic acid (C13:0) | 0.000 | 0.000 |
| Myristic acid (C14:0) | 0.609 | 0.591 |
| Pentadecanoic acid (C15:0) | 0.190 | 0.145 |
| Palmitic acid (C16:0) | 17.998 | 17.298 |
| Margaric acid (C17:0) | 0.265 | 0.193 |
| Stearic acid (C18:0) | 6.582 | 6.704 |
| Arachidonic acid (C20:0) | 0.271 | 0.228 |
| Behenic acid (C22:0) | 0.211 | 0.190 |
| Tricosanoic acid (C23:0) | 0.000 | 0.069 |
| Lignoceric acid (C24:0) | 0.298 | 0.284 |
| Myristoleic acid (C14:1) | 0.000 | 0.044 |
| Palmitoleic acid (C16:1) | 3.234 | 4.330 |
| Cis-10-heptadecenoic acid (C17:1) | 0.201 | 0.156 |
| Oleic acid (C18:1n9c) | 21.117 | 19.585 |
| Elaidic acid (C18:1n9t) | 4.632 | 6.512 |
| Cis-11-eicosenoic acid (C20:1n9) | 1.220 | 1.229 |
| Erucate acid (C22:1n13) | 0.438 | 0.286 |
| Nervonic acid (C24:1n9) | 0.394 | 0.334 |
| Gamma-linolenic acid (C18:3n6) | 0.237 | 0.164 |
| Linoleic acid (C18:2n6c) | 16.964 | 21.517 |
| Arachidonic acid (C20:4n6) | 9.172 | 6.429 |
| cis-5.8.11.14.17-Eicosapentaenoic acid (C20:5n3) | 0.405 | 0.308 |
| Dihomo-alpha-linolenic acid (C20:3n6) | 1.826 | 2.323 |
| cis-11.14-eicosadienoic acid (C20:2) | 0.799 | 1.097 |
| cis-4,7,10,13,16-docosapentaenoic acid (C22:5n6) | 0.774 | 0.399 |
| cis-4.7.10.13.16.19-Docosahexaenoic acid (C22:6n3) | 9.442 | 6.632 |
| 7,10,13,16-Docosatetraenoic acid (C22:4n6) | 0.984 | 0.799 |
| Docosapentaenoic acid (C22:5n3) | 1.425 | 1.856 |
| Cis-13,16-docosadienoic acid (C22:2) | 0.000 | 0.144 |
| Saturated fatty acids (%) | 26.75 | 25.85 |
| Monounsaturated fatty acids (%) | 31.24 | 32.48 |
| Polyunsaturated fatty acids (%) | 42.03 | 41.67 |
| Total (%) | 100 | 100 |
C–Control group; PCB–PCB 126 group.
Values expressed as percentage (%).
In addition, SIRT1 and PPAR-α, biomarkers associated with steatosis development, were assessed in the liver. No differences were observed in Sirt1 mRNA expression (Fig 4A), whereas the mRNA expression of Ppara decreased in the PCB group compared to the C group (-63%; p < 0.05, Fig 4B). Furthermore, miRNAs associated with NAFLD were evaluated in the liver, and no differences were observed in the expression of miR-122 (Fig 4C); however, the expression of miR-34a (1.7-fold-increase; p < 0.05, Fig 4D) and miRNA-155 (1-fold increase, p < 0.001, Fig 2E) were elevated in animals exposed to PCB when compared with the C group.
Fig 4. Molecular parameters of lipid metabolism in the liver after chronic PCB 126 exposure.
(A) Sirtuin-1 (Sirt1) gene expression in the liver. (B) Peroxisome proliferator-activated receptor alpha (Ppar-α) gene expression in the liver. (C) miR-122 expression in the liver (D) miR-34a expression in the liver. (E) miR-155 expression in the liver. C: Control group; PCB: PCB 126 group. Values are expressed as mean ± standard deviation (n = 8). * p value < 0.05; *** p value <0.001.
Discussion
Organic pollutants, particularly PCBs, have been identified as important factors that promote health problems. In this context, PCB 126 is associated with the development of obesity, inflammatory processes, and NAFLD [1, 2, 4]. The identification of molecular mechanisms and biomarkers that regulate the development of these disorders, such as miRNAs, is of great importance to provide a better understanding of the participation of these compounds in the current health panorama of the population and to guide public policies in the care of exposure to these substances.
The present study evaluated the impact of chronic exposure to PCB 126 for 10 weeks in mice, and, at the end of treatment, no differences were observed in food intake or body mass between the groups. However, the PCB group showed altered biochemical parameters in plasma, such as an increase in markers of hepatic function, ALT and AST, increased levels of triglycerides, glucose, and insulin, and lower levels of cholesterol, indicating that, although this group did not present an altered body composition, exposure to PCB 126 disturbed some metabolic processes. An altered profile of glucose metabolism with elevated plasma glucose concentrations was observed in mice exposed to different types of PCB, including PCB 126 [30, 31]. This hyperglycemic condition possibly results from insulin resistance in the liver, muscle, and adipose tissue through mechanisms involving TNF-α which, at higher levels, impair the insulin signaling cascade and glucose uptake by the GLUT4 transporter in insulin-dependent tissues [30, 32]. Although not the focus of the present study, these results are similar to those observed here, showing that animals exposed to PCB 126 present with impaired glycemic homeostasis.
In addition, the PCB group showed a proinflammatory profile in plasma, with elevated levels of IL-6 and TNF-α. Exposure to PCB 126 induces the expression of inflammatory cytokines, including TNFα and IL-1β, possibly promoting the polarization to the proinflammatory M1 phenotype in a human monocyte cell culture. In addition, an increase in monocyte chemoattractant protein-1 (MCP-1) in PCB 126-activated macrophages suggests the induction of chemokines regulating immune cell recruitment and infiltration of monocytes/macrophages [33]. Additionally, the gene expression of major chemokines for different immune cell infiltrations was higher in the livers of the PCB group, suggesting chemotaxis of the inflammatory cells.
To confirm that PCB 126 promotes NAFLD, liver samples were evaluated and the PCB group showed lipid accumulation in the presence of macro- and microvesicular steatosis and increased hepatic cholesterol and triglyceride contents. Consistent with steatohepatitis, the PCB group exhibited fibrosis and inflammatory infiltration of the liver. PCB 126 interferes with metabolic pathways in the liver and there is an association between this pollutant and the molecular development of NAFLD. Exposure to PCB 126 increases lipid accumulation in hepatocytes and triglyceride concentrations in the liver of rats through mechanisms involving microsomal triglyceride transfer protein and diacylglycerol O-acyltransferase 2 (DGAT-2), which are important molecules in the hepatic synthesis and export of triacylglycerides [1].
Administration of PCB 126 to mice resulted in notable histological damage and vacuolar degeneration in the liver, with the accumulation of lipid droplets, increased inflammation, and collagen accumulation, showing liver fibrosis [34]. Furthermore, similar to the results of the present study, liver injury was confirmed when serum AST and ALT levels increased [34]. These results, which are in agreement with the data presented in this study, demonstrate that PCB 126 induces liver inflammation, fibrosis, and injury in mice.
All the effects described for PCB 126 appear to occur through the AhR, a receptor in the liver to which PCB binds and regulates the transcription of several genes involved in NAFLD development [2, 11]. In the present study, Ahr gene expression increased in the liver of the group exposed to PCB 126, suggesting that this pollutant may promote its effects through this receptor. PCB-126 is a potent endocrine disruptor that interferes with thyroid and steroid hormone receptors, affecting liver lipid metabolism. This exposure may increase cholesterol synthesis or hinder its elimination by altering liver metabolic pathways and enzyme activities like HMG-CoA reductase. PCB-126 also induces oxidative stress and inflammation in the liver, which can damage cells and trigger a defensive increase in cholesterol synthesis. Additionally, it impacts the function and expression of lipid transport proteins, such as LDL and HDL, affecting cholesterol transport and removal [35, 36].
Furthermore, the expression of Tnfa and Il6 was evaluated in the liver, and PCB 126 was found to positively regulate the expression of these cytokines, showing that these animals presented increased inflammation in the liver tissue. This is consistent with the histological and stereological analyses, where lipid accumulation, inflammatory infiltration, and fibrosis were verified, showing the development of NASH. These results corroborate previous studies that showed that PCB 126 promotes an inflammatory state in the liver with an increase in proinflammatory cytokines such as TNF-α, IL-1β, IL-6, MCP-1, C-C Motif Chemokine Ligand 2 (Ccl2), Ccl3, and Ccl5, contributing to the development of liver injury [33, 34].
In the present study, genes involved in lipid metabolism, such as Sirt1 and Ppara, were evaluated in the livers of the animals. SIRT1, a protein deacetylase dependent on NAD+, plays a pivotal role in maintaining the energy balance within the body. Specifically, hepatic SIRT1 governs lipid equilibrium by enhancing the function of PPARα, a nuclear receptor crucial for adapting to fasting and starvation. When SIRT1 is deficient in liver cells, it undermines PPARα activity, diminishing fatty acid oxidation. This disruption contributes to the onset of hepatic steatosis and inflammation, particularly in the context of a high-fat diet. [37]. In the present study, PCB 126 did not alter the expression of Sirt1 but reduced the expression of Ppara. It is important to highlight that the present study evaluated the gene expression of Sirt1. Although no changes were observed in the PCB group, the hypothesis that the protein content or enzymatic activity may be reduced and promote the reduction of gene expression of Ppara cannot be ruled out. In this context, activation of PPARα leads to increased expression of several target genes involved in fatty acid oxidation, and lack of PPARα, in a mouse model, promotes an excessive accumulation of triglycerides in the liver [38, 39].
Accumulation of triglycerides in the liver tissue, inflammation, steatohepatitis, liver fibrosis, and cirrhosis are associated with microRNAs, suggesting their participation in the development and progression of NAFLD [14–17, 40]. The present study evaluated the expression of miRNAs that have already been associated with these disorders, such as miR-155, miR-122, and miR-34a [14–17], to clarify the possible contribution of these markers in regulating the changes observed in the livers of animals exposed to PCB 126. The mechanism by which PCB-126 (polychlorinated biphenyl-126) regulates miR-155 and miR-34a expression is closely tied to its interaction with the aryl hydrocarbon receptor (AhR) signaling pathway [41]. PCB-126 is a potent ligand for AhR, a transcription factor that is activated upon binding with various ligands, including environmental pollutants like dioxins and PCBs. When PCB-126 binds to AHR, it triggers the translocation of the AhR-ligand complex into the nucleus [20, 42]. Once inside the nucleus, the AhR-ligand complex can bind to specific DNA sequences known as xenobiotic response elements (XREs) located in the promoter regions of various genes, including those encoding for miRNAs like miR-155 and miR-34a. This binding can either upregulate or downregulate the transcription of these miRNAs, depending on the context and the specific interactions at the gene promoters. miR-155 and miR-34a are microRNAs that play crucial roles in various biological processes, including inflammation, cell cycle regulation, and apoptosis [33, 36, 43].
The regulation of these miRNAs by AhR signaling can influence these processes, potentially leading to various biological effects. The alteration of miR-155 and miR-34a expression by PCB-126 through AhR signaling can have significant pathophysiological implications [3]. For example, dysregulation of these miRNAs may contribute to the development of diseases like cancer, where they are known to play roles in regulating apoptosis, proliferation, and the immune response. In summary, PCB-126 regulates miR-155 and miR-34a expression primarily through its interaction with AhR, leading to changes in gene transcription that can have broad biological and health implications. This pathway is a critical aspect of understanding the toxicological effects of PCBs and their impact on cellular and molecular processes [20, 43–45].
Liver expression of miR-155 increased in the PCB group, and this miRNA plays a role in the regulation of Kupffer cells (KCs) and is involved in the inflammatory processes in NAFLD [40]. miR-155 is highly expressed in total liver, hepatocytes, and KCs of a mice model of liver disease, and this upregulation contributes to TNF-α production [46]. Furthermore, miR-155 is upregulated in patients with NASH, possibly representing a specific biomarker for this pathological condition [40]. This finding is corroborated by the data presented here, which showed that the animals exposed to PCB 126 developed NASH.
Additionally, increased expression of miR-34a was observed despite the unaltered expression of miR-122 in the liver of the PCB group. miR-34a is upregulated in the liver of patients and rodents with NASH, and its contribution to the development of this disorder appears to occur through mechanisms involving PPARα and SIRT1, which are specific targets of mir-34a [40, 44, 45, 47, 48]. In this context, the upregulation of miR-34a results in the downregulation of hepatic PPARα and SIRT1, which results in reduced fatty acid oxidation and the development of steatosis [44]. These data are in agreement with the results observed in the present study because upregulation of miR-34a and reduced Ppara expression were observed in the PCB group. However, an unchanged expression of Sirt1 suggests that PCB 126 promoted the development of NASH, at least in part, through mechanisms involving reduced fatty acid oxidation in the liver owing to reduced PPARα expression, possibly induced by miR-34a upregulation.
In summary, the present study showed that PCB 126 induced NASH through increased inflammatory processes, impairment of lipid oxidation, and development of hepatic steatosis associated with increased expression of proinflammatory cytokines, reduced expression of PPARα, and upregulation of miR-155 and miR-34a in the liver. To our knowledge, this is the first study to demonstrate the upregulation of miR-155 and miR-34a induced by PCB 126 and their possible contribution to the development of NAFLD. These findings may contribute to the development of novel diagnostic markers and therapeutic strategies.
Supporting information
(XLSX)
Data Availability
All relevant data are within the manuscript and its Supporting information files.
Funding Statement
This research was supported by the Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro-FAPERJ (grant numbers E-26/211.193/202, E-26/201.234/2022, and E-26/210.332/2022) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior-CAPES, 001.
References
- 1.Boucher M-P, Lefebvre C, Chapados NA. The effects of PCB126 on intra-hepatic mechanisms associated with non alcoholic fatty liver disease. J Diabetes Metab Disord. 2015;14: 88. doi: 10.1186/s40200-015-0218-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Kania-Korwel I, Wu X, Wang K, Lehmler H-J. Identification of lipidomic markers of chronic 3,3’,4,4’,5-pentachlorobiphenyl (PCB 126) exposure in the male rat liver. Toxicology. 2017;390: 124–134. doi: 10.1016/j.tox.2017.09.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lai I, Chai Y, Simmons D, Luthe G, Coleman MC, Spitz D, et al. Acute toxicity of 3,3’,4,4’,5-pentachlorobiphenyl (PCB 126) in male Sprague-Dawley rats: effects on hepatic oxidative stress, glutathione and metals status. Environ Int. 2010;36: 918–923. doi: 10.1016/j.envint.2009.11.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.McFarland VA, Clarke JU. Environmental occurrence, abundance, and potential toxicity of polychlorinated biphenyl congeners: considerations for a congener-specific analysis. Environ Health Perspect. 1989;81: 225–239. doi: 10.1289/ehp.8981225 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Cave M, Appana S, Patel M, Falkner KC, McClain CJ, Brock G. Polychlorinated Biphenyls, Lead, and Mercury Are Associated with Liver Disease in American Adults: NHANES 2003–2004. Environ Health Perspect. 2010;118: 1735–1742. doi: 10.1289/ehp.1002720 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Song S, Xue J, Lu Y, Zhang H, Wang C, Cao X, et al. Are unintentionally produced polychlorinated biphenyls the main source of polychlorinated biphenyl occurrence in soils? Environ Pollut. 2018;243: 492–500. doi: 10.1016/j.envpol.2018.09.027 [DOI] [PubMed] [Google Scholar]
- 7.National Toxicology Program. NTP toxicology and carcinogenesis studies of 3,3’,4,4’,5-pentachlorobiphenyl (PCB 126) (CAS No. 57465-28-8) in female Harlan Sprague-Dawley rats (Gavage Studies). Natl Toxicol Program Tech Rep Ser. 2006; 4–246. [PubMed]
- 8.Ghosh S, Murinova L, Trnovec T, Loffredo C, Washington K, Mitra P, et al. Biomarkers Linking PCB Exposure and Obesity. CPB. 2014;15: 1058–1068. doi: 10.2174/1389201015666141122203509 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Lee D-H, Lee I-K, Jin S-H, Steffes M, Jacobs DR. Association Between Serum Concentrations of Persistent Organic Pollutants and Insulin Resistance Among Nondiabetic Adults. Diabetes Care. 2007;30: 622–628. doi: 10.2337/dc06-2190 [DOI] [PubMed] [Google Scholar]
- 10.Lee D-H, Lee I-K, Porta M, Steffes M, Jacobs DR. Relationship between serum concentrations of persistent organic pollutants and the prevalence of metabolic syndrome among non-diabetic adults: results from the National Health and Nutrition Examination Survey 1999–2002. Diabetologia. 2007;50: 1841–1851. doi: 10.1007/s00125-007-0755-4 [DOI] [PubMed] [Google Scholar]
- 11.Moyer BJ, Rojas IY, Kerley-Hamilton JS, Nemani KV, Trask HW, Ringelberg CS, et al. Obesity and fatty liver are prevented by inhibition of the aryl hydrocarbon receptor in both female and male mice. Nutrition Research. 2017;44: 38–50. doi: 10.1016/j.nutres.2017.06.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Tang-Péronard JL, Andersen HR, Jensen TK, Heitmann BL. Endocrine-disrupting chemicals and obesity development in humans: A review: Endocrine-disrupting chemicals and obesity. Obesity Reviews. 2011;12: 622–636. doi: 10.1111/j.1467-789X.2011.00871.x [DOI] [PubMed] [Google Scholar]
- 13.Schecter A, Colacino J, Haffner D, Patel K, Opel M, Päpke O, et al. Perfluorinated Compounds, Polychlorinated Biphenyls, and Organochlorine Pesticide Contamination in Composite Food Samples from Dallas, Texas, USA. Environ Health Perspect. 2010;118: 796–802. doi: 10.1289/ehp.0901347 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Lee J, Padhye A, Sharma A, Song G, Miao J, Mo Y-Y, et al. A Pathway Involving Farnesoid X Receptor and Small Heterodimer Partner Positively Regulates Hepatic Sirtuin 1 Levels via MicroRNA-34a Inhibition. Journal of Biological Chemistry. 2010;285: 12604–12611. doi: 10.1074/jbc.M109.094524 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Panera N. MicroRNAs as controlled systems and controllers in non-alcoholic fatty liver disease. WJG. 2014;20: 15079. doi: 10.3748/wjg.v20.i41.15079 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Su Q, Kumar V, Sud N, Mahato RI. MicroRNAs in the pathogenesis and treatment of progressive liver injury in NAFLD and liver fibrosis. Advanced Drug Delivery Reviews. 2018;129: 54–63. doi: 10.1016/j.addr.2018.01.009 [DOI] [PubMed] [Google Scholar]
- 17.Wang Y, Zhu K, Yu W, Wang H, Liu L, Wu Q, et al. MiR-181b regulates steatosis in nonalcoholic fatty liver disease via targeting SIRT1. Biochemical and Biophysical Research Communications. 2017;493: 227–232. doi: 10.1016/j.bbrc.2017.09.042 [DOI] [PubMed] [Google Scholar]
- 18.Daleprane JB, Freitas V da S, Pacheco A, Rudnicki M, Faine LA, Dörr FA, et al. Anti-atherogenic and anti-angiogenic activities of polyphenols from propolis. J Nutr Biochem. 2012;23: 557–566. doi: 10.1016/j.jnutbio.2011.02.012 [DOI] [PubMed] [Google Scholar]
- 19.Deng P, Barney J, Petriello MC, Morris AJ, Wahlang B, Hennig B. Hepatic metabolomics reveals that liver injury increases PCB 126-induced oxidative stress and metabolic dysfunction. Chemosphere. 2019;217: 140–149. doi: 10.1016/j.chemosphere.2018.10.196 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Wahlang B, Barney J, Thompson B, Wang C, Hamad OM, Hoffman JB, et al. Editor’s Highlight: PCB126 Exposure Increases Risk for Peripheral Vascular Diseases in a Liver Injury Mouse Model. Toxicological Sciences. 2017;160: 256–267. doi: 10.1093/toxsci/kfx180 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Reeves PG, Nielsen FH, Fahey GC. AIN-93 Purified Diets for Laboratory Rodents: Final Report of the American Institute of Nutrition Ad Hoc Writing Committee on the Reformulation of the AIN-76A Rodent Diet. The Journal of Nutrition. 1993;123: 1939–1951. doi: 10.1093/jn/123.11.1939 [DOI] [PubMed] [Google Scholar]
- 22.Soares E, Soares AC, Trindade PL, Monteiro EB, Martins FF, Forgie AJ, et al. Jaboticaba (Myrciaria jaboticaba) powder consumption improves the metabolic profile and regulates gut microbiome composition in high-fat diet-fed mice. Biomedicine & Pharmacotherapy. 2021;144: 112314. doi: 10.1016/j.biopha.2021.112314 [DOI] [PubMed] [Google Scholar]
- 23.Trindade PL, Soares EDR, Inada KOP, Martins FF, Rudnicki M, Perrone D, et al. Consumption of phenolic-rich jabuticaba (Myrciaria jaboticaba) powder ameliorates obesity-related disorders in mice. Br J Nutr. 2022;127: 344–352. doi: 10.1017/S0007114521001136 [DOI] [PubMed] [Google Scholar]
- 24.Rittié L. Method for Picrosirius Red-Polarization Detection of Collagen Fibers in Tissue Sections. In: Rittié L, editor. Fibrosis. New York, NY: Springer New York; 2017. pp. 395–407. [DOI] [PubMed] [Google Scholar]
- 25.Martins BC, da Silva Ribeiro M, Teixeira AVS, Peixoto TC, Lisboa PC, Martins FF, et al. Consumption of interesterified palm oil leads inflammation of white adipose tissue and triggers metabolic disturbances in mice on a high-fat diet. Sci Rep. 2024;14: 12530. doi: 10.1038/s41598-024-63488-9 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Loft A, Alfaro AJ, Schmidt SF, Pedersen FB, Terkelsen MK, Puglia M, et al. Liver-fibrosis-activated transcriptional networks govern hepatocyte reprogramming and intra-hepatic communication. Cell Metabolism. 2021;33: 1685–1700.e9. doi: 10.1016/j.cmet.2021.06.005 [DOI] [PubMed] [Google Scholar]
- 27.Bligh EG, Dyer WJ. A RAPID METHOD OF TOTAL LIPID EXTRACTION AND PURIFICATION. Can J Biochem Physiol. 1959;37: 911–917. doi: 10.1139/o59-099 [DOI] [PubMed] [Google Scholar]
- 28.Harwood J. Gas chromatography and lipids: A practical guide: Phytochemistry. 1989;28: 3251–3252. doi: 10.1016/0031-9422(89)80324-3 [DOI] [Google Scholar]
- 29.Livak KJ, Schmittgen TD. Analysis of Relative Gene Expression Data Using Real-Time Quantitative PCR and the 2−ΔΔCT Method. Methods. 2001;25: 402–408. doi: 10.1006/meth.2001.1262 [DOI] [PubMed] [Google Scholar]
- 30.Baker NA, Karounos M, English V, Fang J, Wei Y, Stromberg A, et al. Coplanar Polychlorinated Biphenyls Impair Glucose Homeostasis in Lean C57BL/6 Mice and Mitigate Beneficial Effects of Weight Loss on Glucose Homeostasis in Obese Mice. Environ Health Perspect. 2013;121: 105–110. doi: 10.1289/ehp.1205421 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31.Everett CJ, Frithsen IL, Diaz VA, Koopman RJ, Simpson WM, Mainous AG. Association of a polychlorinated dibenzo-p-dioxin, a polychlorinated biphenyl, and DDT with diabetes in the 1999–2002 National Health and Nutrition Examination Survey. Environmental Research. 2007;103: 413–418. doi: 10.1016/j.envres.2006.11.002 [DOI] [PubMed] [Google Scholar]
- 32.Peraldi P, Spiegelman B. TNF-alpha and insulin resistance: summary and future prospects. Mol Cell Biochem. 1998;182: 169–175. [PubMed] [Google Scholar]
- 33.Wang C, Petriello MC, Zhu B, Hennig B. PCB 126 induces monocyte/macrophage polarization and inflammation through AhR and NF-κB pathways. Toxicology and Applied Pharmacology. 2019;367: 71–81. doi: 10.1016/j.taap.2019.02.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Su H, Liu J, Wu G, Long Z, Fan J, Xu Z, et al. Homeostasis of gut microbiota protects against polychlorinated biphenyl 126-induced metabolic dysfunction in liver of mice. Science of The Total Environment. 2020;720: 137597. doi: 10.1016/j.scitotenv.2020.137597 [DOI] [PubMed] [Google Scholar]
- 35.Mohammadparast-Tabas P, Arab-Zozani M, Naseri K, Darroudi M, Aramjoo H, Ahmadian H, et al. Polychlorinated biphenyls and thyroid function: a scoping review. Rev Environ Health. 2023. doi: 10.1515/reveh-2022-0156 [DOI] [PubMed] [Google Scholar]
- 36.Yang Y, Mei G, Yang L, Luo T, Wu R, Peng S, et al. PCB126 impairs human sperm functions by affecting post-translational modifications and mitochondrial functions. Chemosphere. 2024;346: 140532. doi: 10.1016/j.chemosphere.2023.140532 [DOI] [PubMed] [Google Scholar]
- 37.Purushotham A, Schug TT, Xu Q, Surapureddi S, Guo X, Li X. Hepatocyte-specific deletion of SIRT1 alters fatty acid metabolism and results in hepatic steatosis and inflammation. Cell Metab. 2009;9: 327–338. doi: 10.1016/j.cmet.2009.02.006 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 38.Hashimoto T, Cook WS, Qi C, Yeldandi AV, Reddy JK, Rao MS. Defect in peroxisome proliferator-activated receptor alpha-inducible fatty acid oxidation determines the severity of hepatic steatosis in response to fasting. J Biol Chem. 2000;275: 28918–28928. doi: 10.1074/jbc.M910350199 [DOI] [PubMed] [Google Scholar]
- 39.Kersten S, Seydoux J, Peters JM, Gonzalez FJ, Desvergne B, Wahli W. Peroxisome proliferator-activated receptor alpha mediates the adaptive response to fasting. J Clin Invest. 1999;103: 1489–1498. doi: 10.1172/JCI6223 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Dongiovanni P, Meroni M, Longo M, Fargion S, Fracanzani A. miRNA Signature in NAFLD: A Turning Point for a Non-Invasive Diagnosis. IJMS. 2018;19: 3966. doi: 10.3390/ijms19123966 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41.Rager JE, Fry RC. The aryl hydrocarbon receptor pathway: a key component of the microRNA-mediated AML signalisome. Int J Environ Res Public Health. 2012;9: 1939–1953. doi: 10.3390/ijerph9051939 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42.Faraoni I, Antonetti FR, Cardone J, Bonmassar E. miR-155 gene: A typical multifunctional microRNA. Biochimica et Biophysica Acta (BBA)—Molecular Basis of Disease. 2009;1792: 497–505. doi: 10.1016/j.bbadis.2009.02.013 [DOI] [PubMed] [Google Scholar]
- 43.Rogers S, De Souza AR, Zago M, Iu M, Guerrina N, Gomez A, et al. Aryl hydrocarbon receptor (AhR)-dependent regulation of pulmonary miRNA by chronic cigarette smoke exposure. Sci Rep. 2017;7: 40539. doi: 10.1038/srep40539 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44.Ding J, Li M, Wan X, Jin X, Chen S, Yu C, et al. Effect of miR-34a in regulating steatosis by targeting PPARα expression in nonalcoholic fatty liver disease. Sci Rep. 2015;5: 13729. doi: 10.1038/srep13729 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45.Cheung O, Puri P, Eicken C, Contos MJ, Mirshahi F, Maher JW, et al. Nonalcoholic steatohepatitis is associated with altered hepatic MicroRNA expression. Hepatology. 2008;48: 1810–1820. doi: 10.1002/hep.22569 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 46.Csak T, Bala S, Lippai D, Kodys K, Catalano D, Iracheta-Vellve A, et al. MicroRNA-155 Deficiency Attenuates Liver Steatosis and Fibrosis without Reducing Inflammation in a Mouse Model of Steatohepatitis. Aldabe R, editor. PLoS ONE. 2015;10: e0129251. doi: 10.1371/journal.pone.0129251 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47.Gjorgjieva M, Sobolewski C, Dolicka D, Correia De Sousa M, Foti M. miRNAs and NAFLD: from pathophysiology to therapy. Gut. 2019;68: 2065–2079. doi: 10.1136/gutjnl-2018-318146 [DOI] [PubMed] [Google Scholar]
- 48.Liu C-H, Ampuero J, Gil-Gómez A, Montero-Vallejo R, Rojas Á, Muñoz-Hernández R, et al. miRNAs in patients with non-alcoholic fatty liver disease: A systematic review and meta-analysis. J Hepatol. 2018;69: 1335–1348. doi: 10.1016/j.jhep.2018.08.008 [DOI] [PubMed] [Google Scholar]




