Investigation of the Efficacy of a Probiotic Mixture in Moderate Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Mechanistic Trial

Inclusion criteria

• Patients aged from 18 to 75 years old
• BMI 25 - 42kg/m2
• Diagnosed with MASLD and CAP value > 268 dB/m evaluated by FibroScan®
• High ALT levels (>30 U/L in males and >19 U/L in females)
• Having at least three of the following features compatible with metabolic syndrome:

i. Waist circumference ≥ 102 cm in males and ≥ 88 cm in females. ii. Fasting serum glucose (≥ 5.6 mmol/L or 100 mg/dl). iii. Glycated haemoglobin (HbA1c ≥ 5.7%/ 39 mmol/L). iv. Diagnosed or treated for type 2 diabetes. v. High blood pressure (≥ 130/85 mmHg). vi. High plasma triglycerides (≥ 1.70 mmol/L or 150 mg/dl). vii. Lower plasma of High-Density Lipoprotein (HDL cholesterol) (≤ 1.0 mmol/L or 40 mg/dl for males and ≤ 1.3 mmol/L or 50 mg/dl for females).

• Stable weight in the last 3 months (less than ± 4% weight variation).
• Stable medication or intake of food supplements for a medical condition that can affect study outcomes according to the Investigator's judgement in the last three months prior to study entry (bile salt sequestrants are not permitted).
• Not planning to change their dietary and lifestyle habits during the study.
• Willing and able to provide informed consent and comply with study procedures.

Exclusion criteria

• Fibrosis scores equal or higher than F2 (≥ 8.0 kPa).
• History of acute or chronic hepatitis A, B or C, autoimmune hepatitis, drug-induced liver diseases, severe liver diseases.
• Prior or pending liver transplantation.

Patients with at least one of the following concurrent conditions:

i. Type I diabetes ii. Uncontrolled type II diabetes (HbA1c >8%) iii. Hypertriglyceridemia > 350mg/dl iv. Human Immunodeficiency Virus (HIV) infection v. Diagnosis of hemochromatosis

• Current use of pioglitazone, SGLT-2 inhibitors, or approved drugs for MASLD or steatohepatitis within 8 weeks.
• Current use of bile salt sequestrants within 8 weeks.
• Significant gastrointestinal disease, such as inframmatory bowel disease (IBD, short bowel syndrome, chronic or recurrent diarrhoea, coeliac condition.
• Pancreatic failure, biliary dysfunction (including cholecystectomy and blood bilirubin abnormalities)
• Thyroid dysfunction, as assessed by the investigator (clinical criteria)
• History of:

i. Cardiovascular disease (ischemic heart disease, heart failure, cerebrovascular disease, periphreal vascular disease).

ii. Cancer or immunosuppression. iii. Gastrointestinal surgery in the previous year (with the exception of appendicitis).

• Patients with a history of chronic alcohol or drug abuse: > 14 units/week for females and > 21 units/week for male
• Chronic and heavy smoking (>20 cigarettes a day)
• Regular intake (> 3 days/week) of other probiotics (including food complements or diary foods with other probiotic strains, e.g. Activia®, Actimel® or similar).
• Intake of nutraceuticals with an effect on hepatic function such as > 500 mg/day omega-3 fatty acids, high-dose vitamin E supplements or milk thistle (sylibum marianum) extract ot their active ingredients (silymarin, silybin) regularly (> 7 days) in the 15 days before study entry.
• Current use of systemic corticosteroids, androgens, clopidogrel, digoxin, acenocoumarol, warfarin, phenytoin, topiramate, lithium, tricyclic antidepressants, MAOIs or second-generation antipsychotics, amiodarone, tamixofen and/or diltiazem.
• History of use (> 3 days) of oral or parenteral antibiotics one month before the study initiation.
• Chronic use of laxatives.
• Debilitating illnesses (advanced liver or kidney disease, severe depression, psychotic symptoms, neurological diseases).
• Current pregnancy (positive urine test) or planning to become pregnant during the study.
• Breastfeeding at the time of eligibility assessment.
• Patients who have participated in a clinical trial in the six-month period before the study.