Correlation between the interleukin-36 subfamily and gut microbiota in patients with liver cirrhosis: Implications for gut-liver axis imbalance

Abstract

BACKGROUND

Liver cirrhosis (LC) affect millions of people worldwide. The pathogenesis of cirrhosis involves complex interactions between immune responses and gut microbiota. Recent studies have highlighted the role of the interleukin-36 (IL-36) subfamily in inflammation and immune regulation. However, the relationship between serum IL-36 subfamily levels and gut microbiota in cirrhosis patients remains unclear. This study aimed to explore the clinical significance of serum IL-36 subfamily levels and their association with gut microbiota in cirrhosis patients.

AIM

To explore the clinical significance of serum IL-36 subfamily levels and their relationship with gut microbiota among cirrhosis patients.

METHODS

Sixty-one cirrhosis patients were enrolled from Lihuili Hospital of Ningbo University from May 2022 to November 2023 as the LC group and 29 healthy volunteers as the healthy control (HC) group. The serum expressions of IL-36α, IL-36β, IL-36γ, IL-36Ra, and IL-38 were measured through ELISA, while 16S rRNA gene sequencing was employed to rate microbial community in human fecal samples.

RESULTS

The serum levels of IL-36α, IL-36γ, IL-36Ra, and IL-38 in the LC group remarkably exceeded those in the HC group (P < 0.05). IL-36α, IL-36γ, and IL-38 were related positively to the Child-Pugh score (P < 0.05) and prominently exceeded those in the Child-Pugh C group (P < 0.05). The absolute abundance of harmful bacteria (Bacteroides, Bifidobacterium, Faecalibacterium) remarkably rose, while the beneficial bacteria (Firmicutes, Bacteroides, Escherichia-Shigella) notably decreased in the LC group (P < 0.05). IL-36α, IL-36γ, and IL-38 related positively to Lactobacillus(P < 0.05), while IL-38 negatively related to Fusicatenibacter (P < 0.05).

CONCLUSION

IL-36γ and IL-38 show promise as potential biomarkers for LC progression, but further validation is required.

Key Words: Interleukin-36; Interleukin-36γ; Interleukin-38; Liver cirrhosis; Gut microbiota

Core Tip: This study investigated the clinical relevance of serum interleukin-36 (IL-36) subfamily levels and their correlation with gut microbiota in 61 patients with liver cirrhosis (LC) and 29 healthy controls. We found that IL-36α, IL-36γ, IL-36Ra, and IL-38 Levels were significantly higher in cirrhosis patients and strongly correlated with disease progression. These cytokines may serve as novel predictive markers for LC. Our findings highlight the potential of IL-36 subfamily members as diagnostic biomarkers, contributing valuable insights to the field.

INTRODUCTION

Liver diseases affect millions of people worldwide, with conditions, like hepatitis B and C[1], nonalcoholic fatty[2], alcoholic[2], and autoimmune liver diseases[3] potentially leading to the development of cirrhosis. Globally, over 1.06 million people live with liver cirrhosis (LC)[4], which accounted for > 1.32 million deaths[5], often due to complications such as gastrointestinal bleeding, sepsis, hepatic encephalopathy (HE), and spontaneous bacterial peritonitis and so on[6].

Studies indicate that patients with LC have severe intestinal microorganism dysbiosis, tightly connected to the disease progression[7-9]. Damage of gut tight junction proteins increases intestinal mucosal permeability, allowing endotoxins from the intestine to enter the liver through the portal vein system[10]. Gut microbiota dysbiosis increases lipopolysaccharide levels, which activates the NF-κB and TLR4 signaling pathways, aggravating inflammatory cytokine release[11-13]. Excessive pro-inflammatory cytokines can exacerbate liver damage and fibrosis, while a relative increase in anti-inflammatory signals may relieve inflammation and potentially slow the progression to end-stage liver disease[14-16]. Therefore, the equilibrium between anti-inflammatory and pro-inflammatory mediators is critical.

Research indicates that the interleukin-36 (IL-36) subfamily is beneficial to the etiology of diverse inflammatory disorders. As a new-found member of the IL-1 family, the IL-36 subfamily contains three receptor agonists (IL-36α, IL-36β, and IL-36γ) as well as two receptor antagonists (IL-36Ra and IL-38)[17]. Three receptor agonists attach to IL-36 receptors and activate NF-κB, promoting inflammatory cytokines secretion. IL-36Ra inhibits the activation of these pathways[18,19]. Additionally, IL-38 and IL-36Ra share 43% sequence homology. Indeed, IL-38 exhibits similar anti-inflammatory efficacy among bodies[20]. IL-36 family cytokines have been affected various inflammations, like psoriatic arthritis, lupus erythematosus, and inflammatory bowel disease (IBD)[21-24]. In recent years, studies have gradually revealed the complex relationship between the IL-36 subfamily and the intestinal microbiota[25]. For example, IL-36γ is upregulated in the biopsy samples of the colonic mucosa of patients with IBD, especially ulcerative colitis (UC). It can induce colonic epithelial cells and fibroblasts to produce pro-inflammatory cytokines, thereby exacerbating intestinal inflammation[21,26]. However, the expression and significance of the IL-36 subfamily among cirrhosis patients are still unknown.

Our research investigated the relation IL-36 subfamily and intestinal microbiota dysbiosis while illustrating the function and importance of IL-36 subfamily in LC progression.

MATERIALS AND METHODS

Participants

Sixty-one cirrhosis patients were enrolled from Lihuili Hospital of Ningbo University as the LC group between May 2022 and November 2023, and 29 healthy volunteers served as the healthy control (HC) group. The inclusion criteria were listed below: (1) Age from 18 to 65 years old; (2) Cirrhosis of various etiologies reaching the diagnostic standards suggested by the "Chinese Guidelines for the Management of LC," which include histological, endoscopic, or radiological evidence[27]; and (3) Understanding and signing an informed consent. The exclusion criteria were listed below: (1) Diagnosed or suspected cases of malignant tumors; (2) Use of antibiotics, hormones, immunosuppressants, or probiotics within 2 weeks before enrollment; (3) Coexistence of autoimmune diseases, like rheumatoid arthritis, psoriasis, etc.; (4) Other health conditions, like infection, fever, diabetes mellitus, coronary heart disease, and chronic obstructive pulmonary disease; (5) Pregnant or lactating women; and (6) Other conditions deemed unsuitable for participation by the researchers. Blood and fecal samples were gathered from the research participants. This study followed the principles of the Helsinki Declaration and receive approvals from the ethics committee of the hospital, with ethics approval number KY2022PJ064.

Collection of clinical and radiological data

Sex, age, etiology of LC, and findings from abdominal ultrasound, magnetic resonance imaging, etc., were recorded. The collected clinical data contained alanine aminotransferase, albumin (Alb), alkaline phosphatase (ALP), aspartate aminotransferase (AST), creatinine, platelet (PLT), hemoglobin (HB), gamma-glutamyltransferase (γ-GGT), total bilirubin (TBIL), white blood cell (WBC), direct bilirubin, and indirect bilirubin levels.

ELISA

Frozen serum samples were preserved at -80 °C. ELISA kits (Wuhan Huamei Biotech Co. Ltd, China) were utilized to gauge the expressions of three receptor agonists and two receptor antagonists following the manufacturer’s specifications.

16S rRNA gene sequencing analysis

Fecal samples were gathered and preserved at -80°C. Absolute quantification sequencing of the gut microbiota 16S rRNA gene was conducted by Shanghai Tianhao Biotechnology Co. Ltd. The primer used was as follows: Target region 16S V3V4 Primer F = Illumina adapter sequence 1 + CCTACGGGNGGCWGCAG, Primer r = Illumina adapter sequence 2 + GACTACHVGGGTATCTAATCC.

Following the library quality was evaluated, a paired-end sequencing strategy of Illumina 2 × 250 bp was used to sequence the libraries on the Illumina NovaSeq 6000 platform. Subsequently, Usearch (v10) software was used for data trimming and clustering analysis, sorting reads by abundance from highest to lowest, followed by clustering at 97% similarity, with the intention of attaining operational taxonomic units (OTUs). Each OTU was taxonomically classified, and the abundance of each species was annotated at various taxonomic levels to generate a species abundance table for in-depth analysis.

Statistical analyses

Statistical analyses were implemented through SPSS Statistics 21.0 (v 21.0). Continuous variables are denoted as mean ± SD, while categorical variables are denoted as medians (interquartile ranges). For continuous variables that conformed to a normal distribution, independent samples t-tests were used, while Fisher's exact probability assays or non-parametric assays were employed for continuous variables that did not conform to a Gaussian distribution and for categorical variables. For pairwise relationship analysis, Pearson's test was applied to Gaussian-distributed data, with Spearman's correlation analysis used for non-Gaussian-distributed data, with the correlation coefficient represented by the r value. For comparisons among multiple groups, one-way analysis of variance (ANOVA) was applied to Gaussian-distributed data, while the Kruskal-Wallis assay was utilized for data without conforming to a normal distribution. As to contrasts between two groups, the Wilcoxon rank-sum assay was employed. A P value threshold of 0.05 was adopted to measure significance.

RESULTS

General information

The LC group comprised 51 males and 10 females, showing an average age of 53.89 ± 9.38 years, while the HC group had 23 males and 6 females, showing a mean age of 49.21 ± 8.49 years. No remarkable disparities emerged in age (P = 0.278) or sex (P = 0.623) between both groups. In the LC group, patients were classified according to etiology: 29 cases (47.54%) were attributed to hepatitis B-related cirrhosis, 20 (32.79%) to alcohol-related cirrhosis, and 12 (19.67%) to other causes of cirrhosis. Furthermore, based on Child-Pugh scores, patients with cirrhosis were stratified into Grade A (n = 20), Grade B (n = 24), and Grade C (n = 17) categories.

Clinical biochemical parameters

The LC group had considerably higher levels of ALP, AST, and TBIL and lower levels of WBC, HB, PLT, and Alb than the HC group (P < 0.05; Table 1).

Table 1 General clinical characteristics of the study population.

Variables	HC (n = 29)	LC (n = 61)	χ²/t	P value
Sex (male)	23.00 (79.30%)	50.00 (82.00%)	0.248	0.763
Age (years)	51.65 ± 8.34	53.89 ± 9.38	-1.091	0.278
WBC (109/L)	5.58 ± 1.21	4.60 ± 2.48	2.024	0.046
HB (g/L)	146.22 ± 35.68	110.82 ± 29.99	4.918	< 0.001
PLT (109/L)	230.10 ± 54.88	109.62 ± 73.07	7.877	< 0.001
Alb (g/L)	47.09 ± 4.74	32.87 ± 6.92	9.990	< 0.001
ALT (U/L)	20.59 ± 6.92	43.64 ± 6.92	-1.803	0.075
AST (U/L)	23.00 ± 9.39	58.62 ± 60.48	-3.145	0.002
ALP (U/L)	70.28 ± 15.33	117.16 ± 52.84	-4.673	< 0.001
γ-GGT (U/L)	23.17 ± 12.72	123.61 ± 333.17	-1.618	0.109
TBIL (umol/L)	10.81 ± 3.52	65.82 ± 93.82	-3.147	0.002
Cr (umol/L)	71.25 ± 8.79	71.93 ± 28.85	-0.149	0.882

LC: Liver cirrhosis; HC: Healthy controls; HB: Hemoglobin; PLT: Blood platelet; Alb: Albumin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; γ-GGT: Gamma-glutamyltransferase; TBIL: Total bilirubin; Cr: Creatinine; WBC: White blood cell.

Serum expression levels of the IL-36 subfamily

Figure 1 exhibits that the serum levels of IL-36α, IL-36γ, IL-36Ra, and IL-38 in the LC group remarkably exceeded those in the HC group (P < 0.05). However, remarkably disparity emerged in serum IL-36β levels between both groups (P > 0.05).

Figure 1 Serum interleukin-36 subfamily levels in liver cirrhosis patients and healthy controls, and their correlation with Child-Pugh scores. A: Serum interleukin-36 (IL-36) subfamily cytokine levels of patients in the liver cirrhosis (LC) and healthy control groups; B: Serum IL-36 subfamily cytokine levels in the LC group with Child-Pugh Scores. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001. LC: Liver cirrhosis; IL: Interleukin.

The serum IL-36 subfamily expressions were compared among cirrhosis patients based on etiology, through which there were no statistically remarkable disparities occurred in serum IL-36α, IL-36β, IL-36γ, IL-36Ra, and IL-38 expression levels among patients with cirrhosis caused by hepatitis B, alcohol and other etiologies (P > 0.05).

Figure 2 presents that the serum expressions of IL-36α were prominently elevated in the B group in contrast with the Child-Pugh A group (P = 0.037). Additionally, the serum expressions of IL-36α (P = 0.007), IL-36β (P = 0.01), IL-36γ (P = 0.001), and IL-38 (P = 0.002) were prominently up-regulated in the C group relative to the A group. The serum expression levels of IL-36γ (P = 0.015) and IL-38 (P = 0.02) were excessively high relative to the C group to the B group.

Figure 2 Analysis of the differential gut microbiota in liver cirrhosis patients and healthy controls. A: Alpha diversity boxplot between the healthy control (HC) and liver cirrhosis (LC) groups. The blue and orange boxplots represent the HC and LC groups, respectively. Each boxplot displays five sample statistics, with the five lines from top to bottom representing the maximum, 75^th percentile, median, 25^th percentile, and minimum. Dots indicate outliers. A P-value of < 0.05 indicates a statistically significant difference between the two groups; B: Principal coordinates analysis (PCoA): The first two component scores of PCoA1 and PCoA2 are 5.98% and 4.45%, respectively. Non-metric multidimensional scaling (NMDS): An NMDS analysis is considered reliable when the STRESS value is < 0.2; C: Rarefaction Curves: The blue and orange solid lines represent the HC and LC groups, respectively. The rarefaction curves level off, indicating that the sampling in this study is sufficient and the sequencing depth adequately covers all species in the samples, reflecting most of the gut microbiota information; D: Analysis of the absolute quantification and compositional differences of gut microbiota at the phylum level between the HC and LC groups; E: Analysis of the absolute quantification and compositional differences of gut microbiota at the genus level between the HC and LC groups. x- and y-axes represent the groups and abundance values, respectively. Each color in the figure represents a species, with the corresponding species identified by the color legend on the right side of the bar chart. HC: Healthy controls; LC: Liver cirrhosis.

Correlation analysis between the IL-36 subfamily and clinical data

IL-36α significantly related positively to PLT, Alb, AST, ALP, γ-GGT, TBil, and Child-Pugh scores (P < 0.05) (Table 2). IL-36γ was related positively to HB, PLT, Alb, AST, ALP, TBil, and Child-Pugh scores (P < 0.05). IL-36Ra was related positively to HB, PLT, and TBil (P < 0.05). IL-38 was related positively to Alb, AST, ALP, TBil, and Child-Pugh scores (P < 0.05).

Table 2 Analysis of the correlation between serum interleukin-36 subfamily cytokines and clinical indicators in study participants.

Variables	IL-36α		IL-36γ		IL-36Ra		IL-38
	R value	P value	R value	P value	R value	P value	R value	P value
WBC (109/L)	0.005	0.963	0.047	0.661	-0.111	0.298	0.048	0.655
HB (g/L)	-0.296	0.005	-0.245	0.020	-0.240	0.023	-0.186	0.079
PLT (109/L)	-0.345	0.001	-0.275	0.009	-0.255	0.015	-0.153	0.151
Alb (g/L)	0.525	< 0.001	-0.437	< 0.001	-0.185	0.082	-0.346	0.001
ALT (U/L)	0.180	0.090	-0.187	0.077	-0.020	0.852	0.165	0.119
AST (U/L)	0.395	< 0.001	0.584	< 0.001	0.172	0.104	0.495	< 0.001
ALP (U/L)	0.482	< 0.001	0.354	< 0.001	0.136	0.202	0.406	< 0.001
γ-GGT (U/L)	0.437	< 0.001	-0.023	0.828	0.036	0.736	-0.043	0.689
TBIL (umol/L)	0.471	< 0.001	0.559	< 0.001	0.228	0.031	0.540	< 0.001
Cr (umol/L)	-0.080	0.451	-0.024	0.823	-0.187	0.078	0.003	0.981
Child-pug score	0.418	0.001	0.387	0.002	0.203	0.117	0.380	0.003

IL: Interleukin; HB: Hemoglobin; PLT: Blood platelet; Alb: Albumin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; γ-GGT: Gamma-glutamyltransferase; TBIL: Total bilirubin; Cr: Creatinine; WBC: White blood cell.

Analysis of gut microbiota in cirrhosis

Figure 2A shows that the alpha diversity in intestinal microorganisms of cirrhosis patients exhibits a decrease in Observe, Chado1, ACE compared with the HC group (P < 0.05), and the Simpson index rose in the LC group (P < 0.05). Additionally, the gut microbiota coverage in the LC and HC groups approached 1, with no remarkable disparity between both groups (P > 0.05), indicating adequate sequencing depth in both groups. As shown in Figure 2B, principal coordinates analysis (PCoA) and non-metric multidimensional scaling analysis exhibited remarkable disparities in beta multiformity of gut microbes between both groups (P < 0.05). These results suggest a marked difference in beta diversity of gut microbiota between both groups.

As shown in Figure 2C, the rarefaction curves were observed for evaluating the sequencing depth of 90 samples. The results indicated that the rarefaction curves tended to flatten, suggesting that the sampling in this study was sufficient and the sequencing depth adequately covered most of the species present in the samples, thereby reflecting the majority of gut microbiota information.

The gut microbiota is primarily composed of the Firmicutes, Bacteroidetes, Actinobacteria, and Proteobacteria. As shown in Figure 2D and E, at the level of phylum, the absolute abundance of Bacteroidetes in the LC group markedly surpassed that in the HC group (P < 0.05), and no statistically substantial difference emerged between both groups for Firmicutes, Actinobacteria, and Proteobacteria (P > 0.05). At the level of genus, the absolute abundance of Bacteroides Veillonella and Fusobacterium in the LC group prominently surpassed that in the HC group. In contrast, the absolute abundance of Lactobacillus, Parabacteroides, Bifidobacterium, Collinsella, and Gemmiger in the LC group remarkably came short of that in the HC group (P < 0.05). No statistically marked disparities emerged between both groups for the genera Blautia, Lachnospira, Faecalibacterium, Escherichia-Shigella, Prevotella, Streptococcus, Rothia, Allobaculum, Akkermansia, Ruminococcus_2, Clostridium_XVIII, Klebsiella, Dorea, Butyricicoccus, Holdemanella, and Clostridium_IV (P > 0.05).

Correlation between the serum IL-36 subfamily and gut microbiota

As shown in Figure 3A, at the phylum level, IL-36γ positively related to Fusobacteriota and Campylobacterota (P < 0.05). IL-36β negatively related to Desulfobacterota, Actinobacteriota, Verrucomicrobiota and Firmicutes and positively correlated with Campylobacterota (P < 0.05).

Figure 3 Heatmap of the correlation analysis between the interleukin-36 subfamily and gut microbiota. A: Heatmap of the correlation analysis between the interleukin-36 (IL-36) subfamily and gut microbiota at the phylum level; B: Heatmap of the correlation analysis between the IL-36 subfamily and gut microbiota at the genus level. ^aP < 0.05, ^bP < 0.01, ^cP < 0.001. IL: Interleukin.

Figure 3B exhibits that, at the level of genus, IL-36Ra positively correlated with Lachnospira (P < 0.05). IL-36γ related positively to Fusobacterium, Lactobacillus, Veillonella, Enterococcus, and Erysipelatoclostridium (P < 0.05) and related negatively to Coprococcus, Collinsella, Negativibacillus (P < 0.05). IL-38 related positively to Fusobacterium, Veillonella, Streptococcus, Atopobium, Lactobacillus, and Enterococcus (P < 0.05) and related negatively to Anaerostipes, and Fusicatenibacter (P < 0.05). IL-36α related positively to Peptoclostridium and Lactobacillus (P < 0.05) and related negatively to Faecalibacterium (P < 0.05). IL-36β related positively to Enterococcus, Veillonella, and Fusobacterium (P < 0.05) and related negatively to Bifidobacterium and Fusicatenibacter (P < 0.05).

DISCUSSION

LC is a severity global health challenge[1]. Recent research has found the important function of intestinal microbes in the development of LC. Research has shown that as high as 50%-70% of cirrhosis patients suffer from HE, which tightly correlates with intestinal microbe imbalance[28,29]. In this study, LC patients possessed much lower alpha diversity indicators (Chao1, observed OTUs, and PD Whole-tree; P < 0.05). The beta diversity of intestinal microbes among LC patients was prominently different from healthy controls (PCoA analysis, P < 0.05), indicating that patients with LC have gut microbiota imbalance. We found that the absolute abundance of harmful bacteria such as Veillonella, Bacteroides and Fusobacterium in the LC group were prominently more elevated than in the HC group (P < 0.05). The absolute abundance of beneficial bacteria, like Lactobacillus and Bifidobacterium in the LC group markedly came short of that in the HC group (P < 0.05). Previous researches have indicated that intestinal microorganism imbalance is capable of exacerbating hepatic inflammation and activating inflammatory pathways, which tightly correlates with the emergence of complications regarding LC[28,30,31]. Hence, investigations on the variations in inflammatory factors among cirrhosis patients contributes to the precision assessment and prediction of the progression of the disease.

Recent research has indicated the function of IL-36 subfamily in both pro-inflammatory and anti-inflammatory reactions across a variety of diseases[32]. For instance, it has been demonstrated that IL-36α is an essential player in the progression of hepatocellular carcinoma (HCC), suggesting that it might become a prospective therapeutic target and a predictive biomarker to treat HCC[33]. In addition, IL-38 Lessens the level of inflammatory factors while impeding inflammations among collagen-induced arthritis mice[34]. However, there have been no reports on the relationship between IL-36 subfamily and LC in literature to date. Our study manifested the serum expressions of pro-inflammatory IL-36α and IL-36γ, along with anti-inflammatory IL-36Ra and IL-38 in the LC group surpassed those in the HC group (P < 0.05). This suggests that in LC, the pro-inflammatory and anti-inflammatory cytokines of IL-36 are compensatorily increased. While pro-inflammatory signaling pathways are activated, the body simultaneously initiates protective mechanisms, increasing anti-inflammatory cytokines. Additionally, we found the expressions of IL-36α, IL-36γ, and IL-38 tightly related positively to the Child-Pugh score (P < 0.05), suggesting their close relationship to cirrhosis progression.

It is still unclear whether IL-36 subfamily engages in the gut-liver axis imbalance in LC. Research has illustrated that IL-36 subfamily participates in adjusting gut microbiota. In conditions with gut microbiota dysbiosis, such as IBD, the level of IL-36 cytokines is altered[35]. Studies have shown that the expression of IL-36γ is regulated by the gut microbiota. For example, after dextran sulfate sodium (DSS) induction, the expression of IL-36γ in the colon tissue of germ-free mice was significantly lower than that in wild - type mice, indicating that the gut microbiota may promote the production of IL-36γ through some mechanisms[26]. In addition, Bacteroides can inhibit the colonization of Klebsiella pneumoniae through the IL-36 signaling pathway, thus maintaining the balance of the intestinal microecology. In IL-36R knockout (IL-36R-/-) mice, the gut microbiota was significantly altered after DSS induction, and the expression of the antibacterial peptide Lcn2 was significantly decreased[36]. These results suggest that IL-36γ not only participates in the intestinal inflammatory response but also affects the balance of the intestinal microecology by regulating the composition of the gut microbiota. As an antagonist of the IL-36 receptor, IL-38 has anti-inflammatory effects and can inhibit the IL-36-mediated inflammatory response. Studies have shown that the expression level of IL-38 is increased in patients with IBD, and it may alleviate disease symptoms by inhibiting the intestinal inflammatory response[37]. In addition, IL-38 may exert its anti-inflammatory effect by regulating the composition of the gut microbiota.

Our study found that pro-inflammatory factor IL-36γ and anti-inflammatory factor IL-38 were the most meaningful indicators, which positively correlated with harmful bacteria Veillonella and Fusobacterium (P < 0.05). It is found that pro-inflammatory factor IL-36γ is elevated in IBD and promotes wound healing and intestinal inflammations, contributing to gut inflammatory disorders, like UC and IBD[35]. Actually, IL-38 is a vital player in IBD, it is elevated among IBD patients and it suppresses intestinal inflammation. IL-38 is an anti-inflammatory cytokine that antagonizes the IL-36R, thereby reducing inflammatory responses[25]. These discoveries illuminate that IL-36γ and IL-38 might be novel warning indicators for LC. IL-36 subfamily are the key players in regulating inflammatory pathways and maintaining intestinal microbe balance.

CONCLUSION

In summary, IL-36γ and IL-38 are linked to gut microbiota imbalances in patients with cirrhosis. Targeted regulation of gut microbiota and inhibition of IL-36 subfamily inflammatory cytokines may provide a theoretical basis for microbiota-based therapies to slow LC progression and improve patient outcomes. Our research still has several restrictions. Initially, we should increase the sample size. Second, emphasizing the demand for further animal experiments to elucidate the regulatory mechanisms linking the IL-36 subfamily with liver damage and gut microbiota dysbiosis in LC.

ACKNOWLEDGEMENTS

We would like to express our sincere gratitude to all the contributors involved in this study. Special thanks go to the patients and their families who participated in this research, as their contributions were essential to our findings.