Berberine alleviates concanavalin A-induced autoimmune hepatitis in mice by modulating the gut microbiota.

BACKGROUND: Autoimmune hepatitis (AIH) is an immune-mediated liver disease of unknown etiology accompanied by intestinal dysbiosis and a damaged intestinal barrier. Berberine (BBR) is a traditional antibacterial medicine that has a variety of pharmacological properties. It has been reported that BBR alleviates AIH, but relevant mechanisms remain to be fully explored. METHODS: BBR was orally administered at doses of 100 mg⋅kg-1⋅d-1 for 7 days to mice before concanavalin A-induced AIH model establishment. Histopathological, immunohistochemical, immunofluorescence, western blotting, ELISA, 16S rRNA analysis, flow cytometry, real-time quantitative PCR, and fecal microbiota transplantation studies were performed to ascertain BBR effects and mechanisms in AIH mice. RESULTS: We found that liver necrosis and apoptosis were decreased upon BBR administration; the levels of serum transaminase, serum lipopolysaccharide, liver proinflammatory factors TNF-α, interferon-γ, IL-1ß, and IL-17A, and the proportion of Th17 cells in spleen cells were all reduced, while the anti-inflammatory factor IL-10 and regulatory T cell proportions were increased. Moreover, BBR treatment increased beneficial and reduced harmful bacteria in the gut. BBR also strengthened ileal barrier function by increasing the expression of the tight junction proteins zonula occludens-1 and occludin, thereby blocking lipopolysaccharide translocation, preventing lipopolysaccharide/toll-like receptor 4 (TLR4)/ NF-κB pathway activation, and inhibiting inflammatory factor production in the liver. Fecal microbiota transplantation from BBR to model mice also showed that BBR potentially alleviated AIH by altering the gut microbiota. CONCLUSIONS: BBR alleviated concanavalin A-induced AIH by modulating the gut microbiota and related immune regulation. These results shed more light on potential BBR therapeutic strategies for AIH.

The Gut Microbiome and Acute Leukemia: Implications for Early Diagnostic and New Therapies.

Acute leukemia (AL), one of the hematological malignancies, shows high heterogeneity. Tremendous progresses are achieved in treating AL with novel targeted drugs and allogeneic hematopoietic stem cell transplantation, there are numerous issues including pathogenesis, early diagnosis, and therapeutic efficacy of AL to be solved. In recent years, an increasing number of studies regarding microbiome have shed more lights on the role of gut microbiota in promoting AL progression. Mechanisms related to the role of gut microbiota in enhancing AL genesis are summarized in the present work, especially on critical pathways like leaky gut, bacterial dysbiosis, microorganism-related molecular patterns, and bacterial metabolites, resulting in AL development. Additionally, the potential of gut microbiota as the biomarker for early AL diagnosis is discussed. It also outlooks therapies targeting gut microbiota for preventing AL development.

Gut Microbiome (Bacteria, Fungi, and Viruses) and HIV Infection: Revealing Novel Treatment Strategies.

Plenty of research on microbial-viral interactions has revealed that some commensal microorganisms in the gut, including bacteria, fungi, and viruses, can resist or promote viral infection, whereas other microorganisms are involved in pathogenicity. Therefore, the balance between commensal microorganisms and human organisms is a key factor for determining infection and disease progression, and commensal microorganisms have become a hot research area in the medical field. In this review, the compositional characteristics of gut microbiota (bacteria, fungi, and viruses) during HIV infection are reviewed and changes in gut microbiota among different HIV-infected populations are described. Furthermore, the latest progress of potential microbial therapeutic methods, including a) probiotics, prebiotics, and synbiotics, b) fecal microbiota transplantation (FMT), c) phage therapy, and d) antifungal strategy, microbial enzyme inhibition, and dietary therapeutics, is analyzed based on gut bacteria, fungi, and viruses in the field of HIV infection. This study aims to provide a useful reference for developing novel strategies for the prevention and treatment of HIV infection based on commensal microorganisms.

A Newly Synbiotic Combination Alleviates Obesity by Modulating the Gut Microbiota-Fat Axis and Inhibiting the Hepatic TLR4/NF-κB Signaling Pathway.

SCOPE: Obesity has been recognized as a worldwide public health crisis, this is accompanied by dysregulation of the intestinal microbiota and upregulation of liver steatosis and adipose inflammation. Synbiotic as a novel alternative therapy for obesity have recently gained much attention. METHODS: This study innovatively research the anti-obesity properties of a newly synbiotic composed of Lactobacillus acidophilus, Bifidobacterium infantis and konjac glucomannan oligosaccharides. RESULTS: The synbiotic treatment can reduce body weight, fat mass, blood sugar, liver steatosis and adipose inflammation in obesity mice fed by high-fat diet (HFD). Meanwhile, synbiotic treatment activated brown adipose tissue and improve energy, glucose and lipid metabolism. In addition, synbiotic treatment not solely enhanced the protection of intestinal barrier, but also ameliorated gut microbiota dysbiosis directly by enhancing beneficial microbes and reducing potentially harmful bacteria. Furthermore, the microbiome phenotype and functional prediction showed that synbiotic treatment can improve the gut microbiota functions involving inflammatory state, immune response, metabolism and pathopoiesia. CONCLUSION: The synbiotic may be an effective candidate treatment strategy for the clinical prevention and treatment of obesity and other associated metabolic diseases such as hyperlipidemia, nonalcoholic fatty liver diseases by alleviating inflammatory response, regulating energy metabolism and maintaining the balance of intestinal microecology.

The Gut Microbiome and Autoimmune Hepatitis: Implications for Early Diagnostic Biomarkers and Novel Therapies.

Autoimmune hepatitis (AIH) is a serious chronic liver disease that may last for decades and eventually develop into cirrhosis and liver failure. In recent years, people have paid more attention to the microbiome-gut-liver axis, which provides guidance for all to explore the role of microbiome in the occurrence and development of liver diseases. In this review, the possible mechanism of intestinal microbes promoting the occurrence of AIH, mainly expounding the key ways such as bacterial ecological imbalance, intestinal leakage, and molecular simulation between microbes and autoantigens is summarized. In addition, this paper also discusses that intestinal microbiome has great potential as a biomarker for early diagnosis of AIH, and intestinal microbiome is also a candidate target for prevention and treatment of AIH. Finally, the study summarizes and prospects the targeted therapy of intestinal microorganisms to prevent the occurrence and development of AIH.

Gut microbiota and metabolites in diabetic retinopathy: Insights into pathogenesis for novel therapeutic strategies.

Diabetic retinopathy (DR) is the most common and detrimental microvascular complication of diabetes mellitus. It has become one of the top causes of blindness and visual impairment in the working-age population. However, prevention and treatment options for DR are limited, invasive, and expensive, and most are focused on advanced-stage disease. The gut microbiota is an intricate system that alters the body's microenvironment, and its dysbiosis is strongly associated with DR. Recently, more and more investigations into the relationship between microbiota and DR have enhanced our understanding of how the gut microbiota influences the occurrence, development, prevention, and treatment of DR. In this review, we summarize the changes in the gut microbiota of animals and patients with DR and the function of metabolites and anti-diabetes drugs. Furthermore, we discuss the potential use of gut microbiota as an early diagnostic marker and targeting for DR in the healthy people and diabetic patients. Finally, the microbiota-gut-retina axis is presented to help us understand the mechanisms underlying the effect of gut microbiota on triggering or promoting DR, with a focus on the key pathways (e.g., bacterial dysbiosis and gut barrier dysfunction) that promote inflammation, insulin resistance, retinal cell and acellular capillary damage, leading to DR. Based on these data, we can hope to achieve a non-invasive, inexpensive treatment for DR by modulating the gut microbiota, either by supplementation with probiotics or by fecal transplantation. We outline the gut microbiota-targeting treatments in detail that could prevent DR progression.

Hydrogen gas ameliorates acute alcoholic liver injury via anti-inflammatory and antioxidant effects and regulation of intestinal microbiota.

Alcoholic liver disease (ALD) is a globally prevalent liver-related disorder characterized by severe oxidative stress and inflammatory liver damage, for which no effective treatment is currently available. Hydrogen gas (H2) has been demonstrated to be an efficient antioxidant in various diseases in animals as well as humans. However, the protective effects of H2 on ALD and its underlying mechanisms remain to be elucidated. The present study demonstrated that H2 inhalation ameliorated liver injury, and attenuated liver oxidative stress, inflammation, and steatosis in an ALD mouse model. Moreover, H2 inhalation improved gut microbiota, including increasing the abundance of Lachnospiraceae and Clostridia, and decreasing the abundance of Prevotellaceae and Muribaculaceae, and also improved intestinal barrier integrity. Mechanistically, H2 inhalation blocked activation of the LPS/TLR4/NF-κB pathway in liver. Notably, it was further demonstrated that the reshaped gut microbiota may accelerate alcohol metabolism, regulate lipid homeostasis and maintain immune balance by bacterial functional potential prediction (PICRUSt). Fecal microbiota transplantation from mice that had undergone H2 inhalation significantly alleviated acute alcoholic liver injury. In summary, the present study showed that H2 inhalation alleviated liver injury by reducing oxidative stress and inflammation, while also improving intestinal flora and enhancing the intestinal barrier. H2 inhalation may serve as an effective intervention for preventing and treating ALD in a clinical context.

A Novel Synbiotic Alleviates Autoimmune Hepatitis by Modulating the Gut Microbiota-Liver Axis and Inhibiting the Hepatic TLR4/NF-κB/NLRP3 Signaling Pathway.

Autoimmune hepatitis (AIH) is a liver disease characterized by chronic liver inflammation. The intestinal barrier and microbiome play critical roles in AIH progression. AIH treatment remains challenging because first-line drugs have limited efficacy and many side effects. Thus, there is growing interest in developing synbiotic therapies. This study investigated the effects of a novel synbiotic in an AIH mouse model. We found that this synbiotic (Syn) ameliorated liver injury and improved liver function by reducing hepatic inflammation and pyroptosis. The Syn reversed gut dysbiosis, as indicated by an increase in beneficial bacteria (e.g., Rikenella and Alistipes) and a decrease in potentially harmful bacteria (e.g., Escherichia-Shigella) and lipopolysaccharide (LPS)-bearing Gram-negative bacterial levels. The Syn maintained intestinal barrier integrity, reduced LPS, and inhibited the TLR4/NF-κB and NLRP3/Caspase-1 signaling pathway. In addition, microbiome phenotype prediction by BugBase and bacterial functional potential prediction using Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) showed that Syn improved gut microbiota function involving inflammatory injury, metabolism, immune response, and pathopoiesia. Furthermore, the new Syn was as effective as prednisone against AIH. Therefore, this novel Syn could be a candidate drug for alleviating AIH through its anti-inflammatory and antipyroptosis properties that relieve endothelial dysfunction and gut dysbiosis. IMPORTANCE Synbiotics can ameliorate liver injury and improve liver function by reducing hepatic inflammation and pyroptosis. Our data indicate that our new Syn not only reverses gut dysbiosis by increasing beneficial bacteria and decreasing lipopolysaccharide (LPS)-bearing Gram-negative bacteria but also maintains intestinal barrier integrity. Thus, its mechanism might be associated with modulating gut microbiota composition and intestinal barrier function by inhibiting the TLR4/NF-κB/NLRP3/pyroptosis signaling pathway in the liver. This Syn is as effective as prednisone in treating AIH without side effects. Based on these findings, this novel Syn represents a potential therapeutic agent for AIH in clinical practice.

The Trichinella spiralis-derived antigens alleviate HFD-induced obesity and inflammation in mice.

Obesity, an increasingly prevalent disease worldwide, is accompanied by chronic inflammation and intestinal dysbiosis. Helminth infections have been increasingly proved to exhibit a protective role in several inflammation-associated diseases. Considering the side effects of live parasite therapy, efforts have been made to develop helminth-derived antigens as promising candidates with fewer adverse effects. This study aimed to evaluate the effect and mechanisms of TsAg (T. spiralis-derived antigens) on obesity and the associated inflammation in high-fat diet (HFD)-fed mice. C57BL/6J mice were fed a normal diet or HFD with or without TsAg treatment. The results reported that TsAg treatment alleviated body weight gain and chronic inflammation induced by HFD. In the adipose tissue, TsAg treatment prevented macrophage infiltration, reduced the expression of Th1-type (IFN-γ) and Th17-type (IL-17A) cytokines while upregulating the production of Th2-type (IL-4) cytokines. Furthermore, TsAg treatment enhanced brown adipose tissue activation and energy and lipid metabolism and reduced intestinal dysbiosis, intestinal barrier permeability and LPS/TLR4 axis inflammation. Finally, the protective role of TsAg against obesity was transmissible via the fecal microbiota transplantation approach. For the first time, our findings showed that TsAg alleviated HFD-induced obesity and inflammation via modulation of the gut microbiota and balancing the immune disorders, suggesting that TsAg might be a safer promising therapeutic strategy for obesity.

A Synbiotic Ameliorates Con A-Induced Autoimmune Hepatitis in Mice through Modulation of Gut Microbiota and Immune Imbalance.

SCOPE: Changes in the intestinal flora are related to autoimmune hepatitis (AIH) development. The aim of this study is to investigate the synergistic effects of probiotics and prebiotics on liver injury induced by concanavalin A (Con A). METHODS AND RESULTS: C57BL/6 mice are fed probiotics (Pro), prebiotics (Pre), synbiotic (Syn) for 7 days and then Con A is injected via tail veins to induce AIH. Additionally, methylprednisolone (MP) is gavaged 0.5 h after the Con A injection. It is found that both Pro, Pre, Syn, and MP decrease the levels of serum transaminase, liver F4/80+ macrophage cells, and hepatocellular apoptosis. Pro, Pre, and Syn decrease proinflammatory cytokines, elevate levels of anti-inflammatory as well as restored immune imbalance in AIH. Besides, Pro, Pre, and Syn not only reshape the perturbed gut microbiota, but also maintain intestinal barrier integrity, block the activation of lipopolysaccharide (LPS)/TLR4/NF-κB pathway in the liver. Interestingly, the effects of Syn are superior to Pro or Pre alone in Con A-induced acute liver injury. CONCLUSIONS: Syn obviously facilitates AIH remission. The combined use of Pro and Pre is effective in improving Pro and Pre efficacy and can be an important tool for preventing and adjuvant treating patients for AIH.

Compound Probiotic Ameliorates Acute Alcoholic Liver Disease in Mice by Modulating Gut Microbiota and Maintaining Intestinal Barrier.

Alcoholic liver disease (ALD) is a worldwide health threaten lack of effective treatment. Gut dysbiosis and concomitant augmented intestinal permeability are strongly implicated in the pathogenesis and progression of ALD. Research on the protective effect of probiotics on ALD is limited, and more effective intestinal microecological regulators and the related mechanisms still need to be further explored. In the present study, the protective effects and mechanisms of a compound probiotic against acute alcohol-induced liver injury in vivo were explod. It was showed that the compound probiotic ameliorated liver injury in acute ALD mice and stabilized the levels of ALT, AST, and TG in serum. The compound probiotic reversed acute alcohol-induced gut dysbiosis and maintained the intestinal barrier integrity by upregulating the production of mucus and the expression of tight junction (TJ) proteins and thus reduced LPS level in liver. Meanwhile, the compound probiotic reduced inflammation level by inhibiting TLR4/NF-κB signaling pathway and suppressed oxidative stress level in liver. Furthermore, the compound probiotic alleviated liver lipid accumulation by regulating fatty acid metabolism-associated genes and AMPK-PPARα signaling pathway. Noteworthy, fecal microbiota transplantation (FMT) realized comparable protective effect with that of compound probiotic. In conclusion, present study demonstrates the beneficial effects and underlying mechanism of the compound probiotic against acute alcohol-induced liver injury. It provides clues for development of novel strategy for treatment of ALD.

Gut microbiota and metabolites in myasthenia gravis: Early diagnostic biomarkers and therapeutic strategies.

Myasthenia gravis (MG) is an acquired neurological autoimmune disorder characterized by dysfunctional transmission at the neuromuscular junction. The complex interplay of genetic and environmental influences is important for the occurrence and development of the disease. Recently, some studies have demonstrated the relationship between gut microbiota dysbiosis and MG. Certain gut microbial strains have been shown to attenuate or promote MG. This review summarized the role of gut microbiota and metabolites in MG progression. Meanwhile, we discuss the important potential of gut microbiota and metabolites for the early diagnostic biomarker of MG. Regulating gut microbiota may be novel and effective treatment for MG. Thus, targeted gut microbiota therapies are discussed and prospected to prevent MG progression.

The gut microbiome and Alopecia areata: Implications for early diagnostic biomarkers and novel therapies.

Alopecia areata (AA) accounts for the autoimmune disorder mediated by T cells, whose prognostic outcome cannot be predicted and curative treatment is unavailable at present. The AA pathogenic mechanism remains largely unclear, even though follicular attack has been suggested to result from that attack of immune privilege-losing hair follicles driven by immunity. Recently, gut microbiota is suggested to have an important effect on immunoregulation under autoimmune situations like AA. Fecal microbial transplantation (FMT) may be used to treat AA. Nonetheless, related research remains at the initial stage. To promote the rapid progress of relevant research, the present work aimed to shed more lights on gut microbiota's effect on AA, early diagnostic biomarker and FMT therapeutics.

Future prospect of "Gut microbiome composition can predict the response to nivolumab in advanced hepatocellular carcinoma patients".

Recently, we read the article "Gut microbiome composition can predict the response to nivolumab in advanced hepatocellular carcinoma patients" with interest, and it is preliminary suggested that gut microbiota is closely related to therapeutic effect of nivolumab. Based on the meaningful results of this article, several valuable research directions are proposed to enhance the therapeutic effect of immune checkpoint inhibitors on advanced hepatocellular carcinoma.

Future Prospect of Oral Microbiota Influencing Allergy/Asthma Development.

Allergic diseases have become a primary public health issue in a moderately prosperous society. Colonization of microorganisms early in life appears to be significant in guiding the regulation of childhood immune system maturation and allergy development. Since the oral cavity is the first position where most foreign antigens meet the immune system, the oral microbiota may play a key role in the development of allergies. However, the study on the effects of oral microorganisms on allergy/asthma is very restricted and should be actively investigated. It requires considerable effort to enrich our knowledge in this area of the relationship between the oral cavity and allergy/asthma. To promote the rapid progress of relevant research. In this review, we aimed to provide several insights into the role of the oral microbiota in allergy/asthma while prospecting future directions.

The Gut Microbiome and Hepatocellular Carcinoma: Implications for Early Diagnostic Biomarkers and Novel Therapies.

Hepatocellular carcinoma (HCC) ranks the third place among all causes inducing cancer-associated mortality, worldwide. HCC nearly exclusively occurs in cases suffering from chronic liver disease (CLD), which results from the vicious cycle of liver damage, inflammation, and regeneration possibly lasting for dozens of years. Recently, more and more investigation on microbiome-gut-liver axis enhances our understanding toward how gut microbiota promotes liver disease and even HCC development. In this review, we summarize the mechanisms underlying the effect of gut microbiota on promoting HCC occurrence, with the focus on key pathways such as bacterial dysbiosis, leaky gut, bacterial metabolites, and microorganism-related molecular patterns, which promote liver inflammation, genotoxicity, and fibrosis that finally lead to cancer occurrence. Furthermore, we discuss gut microbiota's important potential to be the early diagnostic biomarker for HCC. Gut microbiota may be the candidate targets to simultaneously prevent CLD and HCC occurrence among advanced liver disease cases. We outlook the gut microbiota-targeting treatments in detail to prevent CLD and HCC progression.

Rapamycin and Paclitaxel Affect Human Aortic Smooth Muscle Cells-Derived Foam Cells Viability and Proliferation

Abstract Introduction: Drug-eluting stents (DES) coated with rapamycin or paclitaxel as antiproliferative substances significantly reduced the incidence of clinical restenosis and had fewer side effects after percutaneous coronary intervention. However, DES coated with rapamycin or paclitaxel still cause restenosis due to abnormal tissue growth which remained a therapeutic problem, particularly in certain subgroups, possibly due to drug concentrations. This study examined the impact of different concentrations of rapamycin and paclitaxel on cytokine, cell viability and proliferation in human aortic smooth muscle cells (HASMC)-derived foam cells. Methods: The foam cell model was established in vitro by incubating HASMC with 20 µg/mL oxidized low-density lipoprotein (ox-LDL) for 48 hours. Subsequently, foam cells were treated with different concentrations (0.01 µg/mL, 0.1 µg/mL, 0.5 µg/mL, 1 µg/mL, 5 µg/mL and 10 µg/mL) of rapamycin or paclitaxel for 48 hours, to measure cytokine, cell viability and proliferation by ELISA and MTT, respectively. Finally, viability and proliferation were measured by MTT after the foam cells were treated with 1 µg/mL rapamycin or paclitaxel combined with cytokine antibody for 48 hours. Results: After incubation of HASMC with ox-LDL, the ratios of cholesterol ester and total cholesterol increased significantly (55.29%) (P<0.01). Lipid staining with Oil Red O showed many lipid vacuoles and red dye particles in the cells. Meanwhile, cell viability and proliferation significantly increased compared with the control. This indicated that HASMC had been transformed into foam cells (P<0.01) while rapamycin or paclitaxel concentrations ≥0.1 µg/mL can significantly decrease the foam cell proliferation (P<0.05 or P<0.01), and 1 µg/mL of rapamycin or paclitaxel appeared the most effective concentration. As for cytokines, rapamycin or paclitaxel concentrations ≥1 ug/mL could significantly increase the level of inflammatory cytokines IL-6 (P<0.05 or P<0.01), which was enhanced with the increase of drug concentration. However, rapamycin or paclitaxel concentrations ≥1 µg/mL could significantly reduce the levels of anti-inflammatory cytokines IL-35 and transforming growth factor beta (TGF-β) (P<0.05 or P<0.01), which decreased with the increase of drug concentration. In addition, rapamycin or paclitaxel combined with anti-IL-1β, anti-IL-6, anti- TNF-α or anti-IL-35 had no significant effect on foam cell proliferation compared to the drug alone. However, rapamycin or paclitaxel combined with anti-IL-10 or anti-TGF-β can significantly enhance foam cell proliferation (P<0.01). In addition, there was no difference in the effects of the same concentrations of rapamycin and paclitaxel on foam cells. Conclusion: Although rapamycin or paclitaxel can reduce foam cell proliferation, too high or too low concentrations could decrease effectiveness. In particular, a high dose can induce foam cells to increase inflammatory cytokines secretion, reduce anti-inflammatory cytokines secretion, and thus affect the inhibiting proliferation. For rapamycin- and paclitaxel-eluting stents, this conclusion may explain the clinical observation of in-stent restenosis after percutaneous coronary intervention. DES coated with an appropriate concentration of rapamycin or paclitaxel may, at least to some extent, contribute significantly to reducing incidence of late in-stent restenosis.

Effects of Konjaku Flour on the Gut Microbiota of Obese Patients.

Objective: Gut microbiota have been thought to play a role in the emergence of obesity and metabolic disorders, thus dietary fiber may be an effective strategy for the management of obesity by modulating the gut microbiota. The aim of the present study was to investigate the effects of konjaku flour (KF) supplementation on treating obesity and regulating intestinal microbiota in obese adults. Methods: In a 5-week, randomized, double-blind, place-controlled trial, sixty-nine obese volunteers aged 25 to 35 with body mass index ≥28 kg/m2 were randomly assigned to receive KF or placebo (lotus root starch). Obesity index, blood parameters, and gut microbiota were analyzed. Results: KF remarkably reduced the body mass index (BMI), fat mass, percentage body fat (PBF), serum triglyceride (TG), glycated hemoglobin A1c (HbA1c), aspartate aminotransferase (AST), and alanine aminotransferase (ALT) levels in the patients (p <0.05 or p <0.01). Meanwhile, high-throughput sequencing and bioinformatics analysis showed that the konjac flour treatment notably increased the α-diversity and changed the ß-diversity of intestinal microflora in patients (p <0.01). Moreover, konjac flour could also evidently increase the abundance of some of the beneficial microorganisms related to obesity of patients, such as Lachnospiraceae, Roseburia, Solobacterium, R. inulinivorans, Clostridium perfringens, and Intestinimonas butyriciproducens, and reduce the abundance of the harmful microorganisms, such as Lactococcus, Bacteroides fragilis, Lactococcus garvieae, B. coprophilus, B. ovatus, and B. thetaiotaomicron (p <0.01). Specifically, C. perfringens was significantly negatively correlated with serum total cholesterol (TC) (p <0.01). Conclusion: These results suggested that KF can achieve positive effects on treating obesity, which manifest on reducing BMI, fat mass, blood glucose, and blood lipid, improving hepatic function, and also regulating intestinal microfloral structure. Therefore, changes in gut microbiota may explain in part the effects of KF.