Modelling anaerobic sulfide removal by sulfide shuttling bacteria.

Sulfide oxidizing bacteria are used in industrial biodesulfurization processes to convert sulfide to sulfur. These bacteria can spatially separate sulfide removal from terminal electron transfer, thereby acting as sulfide shuttles. The mechanisms underlying sulfide shuttling are not yet clear. In this work, newly obtained sulfide removal data were used to develop a new model for anaerobic sulfide removal and this model was shown to be an improvement over two previously published models. The new model describes a fast chemical step and a consecutive slow enzymatic step. The improved model includes the effect of pH, with higher total sulfide removal at increasing pH, as well as partial sulfide removal at higher sulfide concentrations. The two-stage model is supported by recent developments in anaerobic sulfide removal research and contributes to a better understanding of the underlying mechanisms. The model is a step toward accurately modelling anaerobic sulfide removal in industrial systems.

NSE5 subunit interacts with distant regions of the SMC arms in the Physcomitrium patens SMC5/6 complex.

Structural maintenance of chromosome (SMC) complexes play roles in cohesion, condensation, replication, transcription, and DNA repair. Their cores are composed of SMC proteins with a unique structure consisting of an ATPase head, long arm, and hinge. SMC complexes form long rod-like structures, which can change to ring-like and elbow-bent conformations upon binding ATP, DNA, and other regulatory factors. These SMC dynamic conformational changes are involved in their loading, translocation, and DNA loop extrusion. Here, we examined the binding and role of the PpNSE5 regulatory factor of Physcomitrium patens PpSMC5/6 complex. We found that the PpNSE5 C-terminal half (aa230-505) is required for binding to its PpNSE6 partner, while the N-terminal half (aa1-230) binds PpSMC subunits. Specifically, the first 71 amino acids of PpNSE5 were required for binding to PpSMC6. Interestingly, the PpNSE5 binding required the PpSMC6 head-proximal joint region and PpSMC5 hinge-proximal arm, suggesting a long distance between binding sites on PpSMC5 and PpSMC6 arms. Therefore, we hypothesize that PpNSE5 either links two antiparallel SMC5/6 complexes or binds one SMC5/6 in elbow-bent conformation, the later model being consistent with the role of NSE5/NSE6 dimer as SMC5/6 loading factor to DNA lesions. In addition, we generated the P. patens Ppnse5KO1 mutant line with an N-terminally truncated version of PpNSE5, which exhibited DNA repair defects while keeping a normal number of rDNA repeats. As the first 71 amino acids of PpNSE5 are required for PpSMC6 binding, our results suggest the role of PpNSE5-PpSMC6 interaction in SMC5/6 loading to DNA lesions.

Influence of oxidation-reduction potential and pH on polysulfide concentrations and chain lengths in the biological desulfurization process under haloalkaline conditions.

Biological desulfurization under haloalkaline conditions has been applied worldwide to remove hydrogen sulfide (H2S) from sour gas steams. The process relies on sulfide-oxidizing bacteria (SOB) to oxidize H2S to elemental sulfur (S8), which can then be recovered and reused. Recently, a dual-reactor biological desulfurization system was implemented where an anaerobic (sulfidic) bioreactor was incorporated as an addition to a micro-oxic bioreactor, allowing for higher S8 selectivity by limiting by-product formation. The highly sulfidic bioreactor environment enabled the SOB to remove (poly)sulfides (Sx2-) in the absence of oxygen, with Sx2- speculated as a main substrate in the removal pathway, thus making it vital to understand its role in the process. The SOB are influenced by the oxidation-reduction potential (ORP) set-point of the micro-oxic bioreactor as it is used to control the product of oxidation (S8 vs. SO42-), while the uptake of Sx2- by SOB has been qualitatively linked to pH. Therefore, to quantify these effects, this work determined the concentration and speciation of Sx2- in the biological desulfurization process under various pH values and ORP set-points. The total Sx2- concentrations in the sulfidic zone increased at elevated pH (8.9) compared to low pH (< 8.0), with on average 3.3 ± 1.0 mM-S more Sx2-. Chain lengths varied, with S72- only doubling in concentration while S52- increased 9 fold, which is in contrast with observations from abiotic systems. Changes to the ORP set-point of the micro-oxic reactor did not produce substantial changes in Sx2- concentration in the sulfidic zone. This illustrates that the reduction degree of the SOB in the micro-oxic bioreactor does not enhance their ability to interact with Sx2- in the sulfidic bioreactor. This increased understanding of how both pH and ORP affect changes in Sx2- concentration and chain length can lead to improved efficiency and design of the dual-reactor biological desulfurization process.

Addition of PEG-interferon to long-term nucleos(t)ide analogue therapy enhances HBsAg decline and clearance in HBeAg-negative chronic hepatitis B: Multicentre Randomized Trial (PAS Study).

We studied whether 48 weeks of PEG-IFN alfa-2a add-on increases HBsAg-decline and clearance in HBeAg-negative patients on long-term nucleo(s)tide analogue (NA) therapy. In this investigator-initiated, randomized, controlled trial conducted in Europe and Canada, HBeAg-negative patients treated with NA > 12 months, with HBVDNA < 200 IU/mL, were enrolled. Patients were randomized 2:1 to 48 weeks of PEG-IFN alfa-2a add-on (180 µg per week) or continued NA-monotherapy with subsequent follow-up to Week 72. Endpoints were HBsAg decline (≥1 log10 IU/mL) and HBsAg clearance at Week 48. Of the 86 patients in the modified-intention-to-treat analysis, 58 patients received PEG-IFN add-on, and 28 continued NA monotherapy. At Week 48, 16(28%) patients achieved HBsAg decline ≥1 log10 in the add-on arm versus none on NA-monotherapy (p < .001), and HBsAg clearance was observed in 6 (10%) PEG-IFN add-on patients versus 0% NA-monotherapy (p = .01). HBVRNA was only detected in 2% after PEG-IFN treatment versus 19% in NA-monotherapy (p = .002) at Week 48. PEG-IFN add-on therapy was well tolerated in majority of patients. Low baseline HBsAg levels (<10 IU/mL) identified patients most likely to achieve HBsAg loss with PEG-IFN add-on, whereas an HBsAg level > 200 IU/mL at on-treatment Week 12 was highly predictive of non-response (NPV = 100%). Addition of PEG-IFN to long-term NA enhanced HBsAg decline and increased the chance of HBsAg clearance in HBeAg-negative patients on long-term NA. On-treatment HBsAg levels >200 IU/mL identify patients unlikely to benefit from PEG-IFN add-on and could be used as a potential stopping-rule for PEG-IFN therapy. Our findings support further exploration of immune modulation add-on to antiviral therapy, preferably using response-guided strategies, to increase functional cure rates in patients with CHB.

Integrated hydroponics systems with anaerobic supernatant and aquaculture effluent in desert regions: Nutrient recovery and benefit analysis.

Hydroponics is a resource-efficient system that increases food production and enhances the overall sustainability of agricultural systems, particularly in arid zones with prevalent water scarcity and limited areas of arable land. This study investigated zero-waste hydroponics systems fed by agricultural waste streams as nutrient sources under desert conditions. Three pilot-scale systems were tested and compared. The first hydroponics system ("HPAP") received its nutrient source internally from an aquaponic system, including supernatant from the anaerobic digestion of fish sludge. The second system ("HPAD") was sourced by the supernatant of plant waste anaerobic digestion, and the third served as a control that was fed by commercial Hoagland solution ("HPHS"). Fresh weight production was similar in all treatments, ranging from 488 to 539 g per shoot, corresponding to 5.7 to 6.0 kg total wet weight per m2. The recovery of N and P from wastes and their subsequent uptake by plants was highly efficient, with rates of 77 % for N and 65 % for P. Plants that were fed using supernatants demonstrated slightly higher plant quality compared with those grown in Hoagland solution. Over the duration of the full study (3 months), water was only used to compensate for evapotranspiration, corresponding to ~10 L per kg of lettuce. The potential health risk for heavy metals was negligible, as assessed using the health-risk index (HRI < 1) and targeted hazardous quotient (THQ < 1). The results of this study demonstrate that careful management can significantly reduce pollution, increase the recovery of nutrients and water, and improve hydroponics production.

Polysulfide Concentration and Chain Length in the Biological Desulfurization Process: Effect of Biomass Concentration and the Sulfide Loading Rate.

Removal of hydrogen sulfide (H2S) can be achieved using the sustainable biological desulfurization process, where H2S is converted to elemental sulfur using sulfide-oxidizing bacteria (SOB). A dual-bioreactor process was recently developed where an anaerobic (sulfidic) bioreactor was used between the absorber column and micro-oxic bioreactor. In the absorber column and sulfidic bioreactor, polysulfides (Sx2-) are formed due to the chemical equilibrium between H2S and sulfur (S8). Sx2- is thought to be the intermediate for SOB to produce sulfur via H2S oxidation. In this study, we quantify Sx2-, determine their chain-length distribution under high H2S loading rates, and elucidate the relationship between biomass and the observed biological removal of sulfides under anaerobic conditions. A linear relationship was observed between Sx2- concentration and H2S loading rates at a constant biomass concentration. Increasing biomass concentrations resulted in a lower measured Sx2- concentration at similar H2S loading rates in the sulfidic bioreactor. Sx2- of chain length 6 (S62-) showed a substantial decrease at higher biomass concentrations. Identifying Sx2- concentrations and their chain lengths as a function of biomass concentration and the sulfide loading rate is key in understanding and controlling sulfide uptake by the SOB. This knowledge will contribute to a better understanding of how to reach and maintain a high selectivity for S8 formation in the dual-reactor biological desulfurization process.

Characterization of the conserved features of the NSE6 subunit of the Physcomitrium patens SMC5/6 complex.

Structural maintenance of chromosomes (SMC) complexes are molecular machines ensuring chromatin organization at higher levels. They play direct roles in cohesion, condensation, replication, transcription, and DNA repair. Their cores are composed of long-armed SMC, kleisin, and kleisin-associated subunits. Additional factors, like NSE6 within SMC5/6, bind to SMC core complexes and regulate their activities. In the human HsNSE6/SLF2, we recently identified a new CANIN domain. Here we tracked down its sequence homology to lower plants, selected the bryophyte Physcomitrium patens, and analyzed PpNSE6 protein-protein interactions to explore its conservation in detail. We identified a previously unrecognized core sequence motif conserved from yeasts to humans within the NSE6 CANIN domain. This motif mediates the interaction between NSE6 and its NSE5 partner in yeasts and plants. In addition, the CANIN domain and its preceding PpNSE6 sequences bind both PpSMC5 and PpSMC6 arms. Interestingly, we mapped the PpNSE6-binding site at the PpSMC5 arm right next to the PpNSE2-binding surface. The position of NSE6 at SMC arms suggests its role in the regulation of SMC5/6 dynamics. Consistent with the regulatory role of NSE6 subunits, Ppnse6 mutant lines were viable and sensitive to the DNA-damaging drug bleomycin and lost a large portion of rDNA copies. These moss mutants also exhibited reduced growth and developmental aberrations. Altogether, our data showed the conserved function of the NSE6 subunit and architecture of the SMC5/6 complex across species.

TopEnzyme: a framework and database for structural coverage of the functional enzyme space.

MOTIVATION: TopEnzyme is a database of structural enzyme models created with TopModel and is linked to the SWISS-MODEL repository and AlphaFold Protein Structure Database to provide an overview of structural coverage of the functional enzyme space for over 200 000 enzyme models. It allows the user to quickly obtain representative structural models for 60% of all known enzyme functions. RESULTS: We assessed the models with TopScore and contributed 9039 good-quality and 1297 high-quality structures. Furthermore, we compared these models to AlphaFold2 models with TopScore and found that the TopScore differs only by 0.04 on average in favor of AlphaFold2. We tested TopModel and AlphaFold2 for targets not seen in the respective training databases and found that both methods create qualitatively similar structures. When no experimental structures are available, this database will facilitate quick access to structural models across the currently most extensive structural coverage of the functional enzyme space within Swiss-Prot. AVAILABILITY AND IMPLEMENTATION: We provide a full web interface to the database at https://cpclab.uni-duesseldorf.de/topenzyme/.

RAD51 and RAD51B Play Diverse Roles in the Repair of DNA Double Strand Breaks in Physcomitrium patens.

RAD51 is involved in finding and invading homologous DNA sequences for accurate homologous recombination (HR). Its paralogs have evolved to regulate and promote RAD51 functions. The efficient gene targeting and high HR rates are unique in plants only in the moss Physcomitrium patens (P. patens). In addition to two functionally equivalent RAD51 genes (RAD1-1 and RAD51-2), other RAD51 paralogues were also identified in P. patens. For elucidation of RAD51's involvement during DSB repair, two knockout lines were constructed, one mutated in both RAD51 genes (Pprad51-1-2) and the second with mutated RAD51B gene (Pprad51B). Both lines are equally hypersensitive to bleomycin, in contrast to their very different DSB repair efficiency. Whereas DSB repair in Pprad51-1-2 is even faster than in WT, in Pprad51B, it is slow, particularly during the second phase of repair kinetic. We interpret these results as PpRAD51-1 and -2 being true functional homologs of ancestral RAD51 involved in the homology search during HR. Absence of RAD51 redirects DSB repair to the fast NHEJ pathway and leads to a reduced 5S and 18S rDNA copy number. The exact role of the RAD51B paralog remains unclear, though it is important in damage recognition and orchestrating HR response.

Health-related quality of life in patients with primary sclerosing cholangitis: A longitudinal population-based cohort study.

BACKGROUND & AIMS: Data regarding health-related quality of life (HRQoL) in primary sclerosing cholangitis (PSC) are sparse and have only been studied cross-sectionally in a disease which runs a fluctuating and unpredictable course. We aim to describe HRQoL longitudinally by using repeated measurements in a population-based cohort. METHODS: Every 3 months from May 2017 up to August 2020, patients received digital questionnaires at home. These included the EQ-5D, 5-D Itch, patient-based SCCAI and patient-based HBI. The SF-36, measuring HRQoL over eight dimensions as well as a physical component summary (PCS) and mental component summary (MCS) score, was sent annually. Data were compared with Dutch reference data and a matched IBD disease control from the population-based POBASIC cohort. Mixed-effects modelling was performed to identify factors associated with HRQoL. RESULTS: Three hundred twenty-eight patients completed 2576 questionnaires. A significant reduction of small clinical relevance in several mean HRQoL scores was found compared with the Dutch reference population: 46.4 versus 48.0, p = .018 for PCS and 47.5 versus 50.5, p = .004 for MCS scores. HRQoL outcomes were significantly negatively associated with coexisting active IBD (PCS -12.2, p < .001 and MCS -12.0, p < .001), which was not the case in case of quiescent IBD. Decreasing HRQoL scores were also negatively associated with increasing age (PCS -0.1 per 10 years, p = .002), female sex (PCS -2.8, p < .001), diagnosis of AIH overlap (PCS -3.7, p = .059), end-stage liver disease (PCS -3.7, p = .015) and presence of itch (PCS -9.2, p < .001 and MCS -3.1, p = .078). The odds of reporting a clinically relevant reduction in EQ-5D scores showed seasonal variation, being lowest in summer (OR = 0.48 relative to spring, p = .037). In patients with liver transplant, HRQoL outcomes were comparable to the Dutch general population. CONCLUSIONS: PSC patients report impaired HRQoL of small clinical relevance compared with the general population. After liver transplantation, HRQoL scores are at comparable levels to the general population. HRQoL scores are associated with potentially modifiable factors such as itch and IBD activity.

Disease burden in primary sclerosing cholangitis in the Netherlands: A long-term follow-up study.

BACKGROUND & AIMS: Primary sclerosing cholangitis (PSC) is a progressive, cholestatic liver disease which greatly impacts the lives of individuals. Burden of disease due to shortened life expectancy and impaired quality of life is ill-described. The aim of this study was to assess long-term disease burden in a large population-based registry with regard to survival, clinical course, quality adjusted life years (QALYs), medical consumption and work productivity loss. METHODS: All PSC patients living in a geographically defined area covering ~50% of the Netherlands were included, together with patients from the three liver transplant centres. Survival was estimated by competing risk analysis. Proportional shortfall of QALYs during disease course was measured relative to a matched reference cohort using validated questionnaires. Work productivity loss and medical consumption were evaluated over time. RESULTS: A total of 1208 patients were included with a median follow-up of 11.2 year. Median liver transplant-free survival was 21.0 years. Proportional shortfall of QALYs increased to 48% >25 years after diagnosis. Patients had on average 12.4 hospital contact days among which 3.17 admission days per year, annual medical costs were €12 169 and mean work productivity loss was 25%. CONCLUSIONS: Our data quantify for the first time disease burden in terms of QALYs lost, clinical events, medical consumption, costs as well as work productivity loss, and show that all these are substantial and increase over time.

Liver-related complications before and after successful treatment of chronic hepatitis C virus infection in people with inherited bleeding disorders.

INTRODUCTION: With availability of direct-acting antivirals (DAA), most persons with inherited bleeding disorders are currently cured of hepatitis C virus (HCV) infection. The risk of liver-related complications following HCV cure has not been reported for this population. AIM: Reporting liver-related complications during long-term chronic HCV infection and following sustained virological response (SVR) in this population. METHODS: Retrospective follow-up of a prospective single-centre cohort of HCV antibody-positive persons with inherited bleeding disorders. Primary endpoint was liver-related complications [hepatocellular carcinoma (HCC), decompensated cirrhosis, bleeding gastroesophageal varices]. Liver-related complications were reported separately during chronic HCV and following SVR, stratified for interferon-based and DAA-based SVR. RESULTS: In total 309/381 (81%) HCV antibody-positive individuals developed chronic HCV infection. Median follow-up was 44 years [interquartile range (IQR): 34-50]. Liver-related complications occurred in 36/309 (12%) of individuals with chronic HCV infection after median 31 years of chronic infection. Of 199 individuals with SVR, 97 were cured with interferon-based regimens and 102 with DAA after median infection durations of 29 and 45 years, respectively. At end of follow-up, respectively, 21% and 42% had advanced fibrosis or cirrhosis. Post-SVR, seven (4%) individuals had a liver-related complication, mainly HCC (n = 4). Incidence of liver-related complications per 100 patient-years post-SVR follow-up was .2 for interferon-cured and 1.0 for DAA-cured individuals (p = .01). CONCLUSION: Successful HCV treatment does not eliminate the risk of liver-related complications in persons with inherited bleeding disorders. Due to higher baseline risk, incidence was higher after DAA than interferon-based SVR. We advise continuing HCC surveillance post-SVR in all with advanced fibrosis or cirrhosis.

Systematic review with meta-analysis: Branched-chain amino acid supplementation in liver disease.

BACKGROUND: Dietary supplementation with branched-chain amino acids (BCAA) is often used in cirrhotic patients to improve nutritional status. We wanted to explore the evidence for BCAA supplementation in chronic liver disease. METHODS: We searched MEDLINE and EMBASE for studies with BCAA supplementation with the presence of a disease-control group (placebo or no intervention) using search terms 'liver cirrhosis', 'hepatocellular carcinoma', 'branched chain amino acids' and relevant synonyms. Risk of bias was assessed using ROBINS-I and RoB 2.0 tools. Meta-analyses were performed with a random-effects model. Results were reported following EQUATOR guidelines. RESULTS: Of 3378 studies screened by title and abstract, 54 were included (34 randomized controlled trials, 5 prospective case-control studies, 13 retrospective case-control studies: in total 2308 patients BCAA supplementation, 2876 disease-controls). Risk of bias was high/serious for almost all studies. According to meta-analyses, long-term (at least 6 months) BCAA supplementation in cirrhotic patients significantly improved event-free survival (p = .008; RR .61 95% CI .42-.88) and tended to improve overall survival (p = .05; RR .58 95% CI .34-1.00). Two retrospective studies suggested the beneficial effects during sorafenib for hepatocellular carcinoma. Available studies reported no beneficial effects or contradictory results of BCAA after other specific therapeutic interventions (resection or radiological interventions for hepatocellular carcinoma, liver transplantation, paracentesis or variceal ligation). No convincing beneficial effects of BCAA supplementation on liver function, nutritional status or quality of life were found. No study reported serious side effects of BCAA. CONCLUSIONS: Prophylactic BCAA supplementation appears safe and might improve survival in cirrhotic patients.

Removal of small elemental sulfur particles by polysulfide formation in a sulfidic reactor.

For over 30 years, biological gas desulfurization under halo-alkaline conditions has been studied and optimized. This technology is currently applied in already 270 commercial installations worldwide. Sulfur particle separation, however, remains a challenge; a fraction of sulfur particles is often too small for liquid-solid separation with conventional separation technology. In this article, we report the effects of a novel sulfidic reactor, inserted in the conventional process set-up, on sulfur particle size and morphology. In the sulfidic reactor polysulfide is produced by the reaction of elemental sulfur particles and sulfide, which is again converted to elemental sulfur in a gas-lift reactor. We analyzed sulfur particles produced in continuous, long term lab-scale reactor experiments under various sulfide concentrations and sulfidic retention times. The analyses were performed with laser diffraction particle size analysis and light microscopy. These show that the smallest particles (< 1 µm) have mostly disappeared under the highest sulfide concentration (4.1 mM) and sulfidic retention time (45 min). Under these conditions also agglomeration of sulfur particles was promoted. Model calculations with thermodynamic and previously derived kinetic data on polysulfide formation confirm the experimental data on the removal of the smallest particles. Under the 'highest sulfidic pressure', the model predicts that equilibrium conditions are reached between sulfur, sulfide and polysulfide and that 100% of the sulfur particles <1 µm are dissolved by the (autocatalytic) formation of polysulfides. These experiments and modeling results demonstrate that the insertion of a novel sulfidic reactor in the conventional process set-up promotes the removal of the smallest individual sulfur particles and promotes the production of sulfur agglomerates. The novel sulfidic reactor is therefore a promising process addition with the potential to improve process operation, sulfur separation and sulfur recovery.

Nutritional status in patients with hepatocellular carcinoma: Potential relevance for clinical outcome.

BACKGROUND: Impaired nutritional status is a risk factor for unfavorable outcome in cirrhosis. METHODS: In this prospective cohort study in hepatocellular carcinoma patients referred for tumor-specific therapy, nutritional status was assessed before and 3 months post-treatment using 4 complementary tools: hand-grip strength (HGS), Liver Frailty Index (LFI), Patient-Generated Subjective Global Assessment (PG-SGA) and skeletal muscle index (L3-SMI). Uni- and multivariable analyses were performed using Kaplan Meier curves and Cox's regression analyses with correction for Barcelona Clinic Liver Cancer (BCLC) stage, alpha-fetoprotein and age. RESULTS: 56 patients were evaluated at baseline and 38 patients 3 months post-treatment. Baseline BCLC stage was 0 in 14%, A in 27%, B in 36%, C in 21%, and D in 2%. HGS, LFI, PG-SGA and L3-SMI were impaired in 13%, 95%, 21% and 71% respectively. Of all patients, 52% died after (median, range) 373 (32-962) days. Of the nutritional assessment tools, only HGS was independently associated with complication-free survival (HR 0.304, 95%CI 0.10-0.88: p = 0.028) and, approaching significance, with overall survival (HR 0.323, 95%CI 0.103-1.008: p = 0.052). Tumor-specific therapy was administered in 50 patients (20% radiofrequency / microwave ablation, 4% resection, 74% transarterial radio- or chemoembolization, 2% sorafenib). Three months post-treatment, complete response occurred in 44%, partial response in 20%, stable disease in 20% and progressive disease in 16%. Child-Pugh scores deteriorated and such deterioration was independently associated with reduced overall and complication-free survival. CONCLUSIONS: reduced baseline HGS and deteriorated post-treatment Child-Pugh score are associated with reduced overall and complication-free survival in HCC.

Safety and Efficacy of 166Ho Radioembolization in Hepatocellular Carcinoma: The HEPAR Primary Study.

The safety and efficacy of 166Ho radioembolization was first determined in the HEPAR and HEPAR II studies, which, however, excluded patients with hepatocellular carcinoma (HCC). The aim of this prospective clinical early phase II study was to establish the toxicity profile of 166Ho radioembolization in patients with measurable, liver-dominant HCC; Barcelona clinic liver cancer stage B or C; a Child-Pugh score of no more than B7; and an Eastern Cooperative Oncology Group performance status of 0-1 without curative treatment options. Methods: The primary endpoint was a rate of unacceptable toxicity defined as grade 3 hyperbilirubinemia (Common Terminology Cancer Adverse Events, version 4.03) in combination with a low albumin or ascites level in the absence of disease progression or treatment-related serious adverse events. Secondary endpoints included overall toxicity, response, survival, change in α-fetoprotein, and quality of life. Thirty-one patients with Barcelona clinic liver cancer stage B (71%) or C (29%) HCC were included, mostly multifocal (87%) or bilobar (55%) disease. Results: Common grade 1 or 2 clinical toxicity included fatigue (71%), back pain (55%), ascites (32%), dyspnea (23%), nausea (23%), and abdominal pain (23%), with no more than 10% grade 3-5 toxicity. Grade 3 laboratory toxicity (>10%) included an aspartate transaminase and γ-glutamyltransferase increase (16%), hyperglycemia (19%), and lymphopenia (29%). Treatment-related unacceptable toxicity occurred in 3 of 31 patients. At 3 mo, 54% of target lesions showed a complete or partial response according to modified RECIST. Median overall survival was 14.9 mo (95% CI, 10.4-24.9 mo). No significant changes in quality of life or pain were observed. Conclusion: The safety of 166Ho radioembolization was confirmed in HCC, with less than 10% unacceptable toxicity. Efficacy data support further evaluation.