RE and Probiotics in MAFLD/NAFLD

PRObiotic Mixed With Exercise THErapy USe in MAFLD (PROMETHEUS in MAFLD)

This project aims to evaluate the roles of the autonomic nervous system (ANS) and gut microbiota as correlates of clinical improvement in metabolic dysfunction-associated fatty liver disease (MAFLD) and non-alcoholic fatty liver disease (NAFLD) in response to a therapeutic regimen comprising resistance exercise and probiotic supplementation. The primary objective is to investigate the effects of these non-pharmacological interventions on MAFLD/NAFLD and to identify patient phenotypes based on baseline ANS profiles and gut microbiota composition that predict clinical responses.

Study Overview

• Status: Not yet recruiting
• Conditions: NAFLD; NASH; MAFLD
• Intervention / Treatment: Dietary supplement: Placebo; Behavioral: physical exercise programme; Dietary supplement: probiotics supplementation

Detailed Description

The human microbiome, understood here as the collective community of microorganisms, their genetic material, and metabolic products that colonize the body from birth, is particularly concentrated in the gut. The gut microbiome, dominated primarily by anaerobic bacteria, encompasses thousands of species and millions of genes distributed among the major phyla: Firmicutes, Bacteroidetes, Actinobacteria, Proteobacteria, and Verrucomicrobia. Recent research has increasingly focused on the gut microbiome due to its dysbiosis being linked to numerous diseases that may be modifiable through diet, supplementation, or physical activity. Dysbiosis of the gut microbiome has also been implicated in MAFLD and NAFLD, which are the most prevalent liver diseases globally, affecting approximately 35% of the adult population, with this prevalence expected to rise. The gut-liver axis has been extensively studied in relation to MAFLD/NAFLD due to the bidirectional interactions between the gut microbiota and hepatic function. The portal vein, which supplies approximately 70% of the liver's blood flow, facilitates this interaction by connecting the intestines to the liver. Patients with NAFLD/MAFLD typically exhibit increased intestinal permeability compared to healthy individuals, thereby increasing the liver's exposure to gut-derived bacteria, endotoxins, bacterial products, and inflammatory mediators.

Probiotics, defined as live microorganisms that confer health benefits to the host, have been shown in previous studies to enhance the integrity of the intestinal barrier, regulate the gut microbiota, reduce intestinal permeability, and mitigate immune and metabolic disturbances. These effects are particularly relevant in patients with NAFLD/MAFLD, where probiotics have been observed to reduce hepatic steatosis and inflammation-related damage.

Physical exercise, particularly structured programs, has been demonstrated to significantly improve liver function in patients with NAFLD/MAFLD and positively modulate the gut microbiota. Exercise may attenuate the production of reactive oxygen species (ROS) and other oxidative agents in NAFLD by regulating antioxidant enzymes and anti-inflammatory mediators. Additionally, exercise interventions in these patients have been shown to improve blood lipid profiles, including triglycerides, cholesterol, AST, and ALT levels, offering substantial clinical benefits. Although the existing literature predominantly emphasizes aerobic training, this study seeks to compare the effects of resistance training and probiotic supplementation in patients with NAFLD/MAFLD and to assess potential changes in clinical outcomes. Furthermore, the study will explore the influence of baseline ANS and gut microbiota profiles on the patients' responses to these non-pharmacological therapies.

• Study Type: Interventional
• Enrollment (Estimated): 180
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Sławomir Kujawski, PhD; Phone Number: 0048791448117; Email: skujawski@cm.umk.pl

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult
• Accepts Healthy Volunteers: No

Description

Study population: Patients diagnosed with non-alcoholic or metabolically mediated fatty liver disease (NAFLD/MAFLD), including the inflammatory form (NASH), confirmed by imaging (ultrasound, MRI-PDFF) or histopathological (liver biopsy) methods.

Inclusion criteria:

• Diagnosis of NAFLD/MAFLD or NASH (imaging or histological confirmation of fatty liver disease, e.g., ultrasound, MRI-PDFF, biopsy)
• Age 18-60 years
• Ability to understand the study procedures and provide informed consent.
• Stable clinical condition for at least 3 months prior to study initiation.

Exclusion criteria:

• Lack of fluency in English or Polish
• Significant (structural) limitation of upper and/or lower limb mobility
• Pregnancy or breastfeeding
• Inability to understand instructions
• Shift work
• Participation in any study or research project within the last 3 months
• Participation in an interventional drug study within the last 3 months
• Participants with hepatic steatosis and regular alcohol consumption > 30 g/day
• Individuals with any concomitant liver disease (viral hepatitis, drug-induced liver injury, metabolic/genetic diseases (e.g., Wilson's disease))
• Anticoagulant/antiplatelet therapy, antithrombotic therapy, immunosuppressive medications, prolonged immunosuppression (e.g., recent cytotoxic chemotherapy, HIV infection with CD4 count < 240), antibiotics, corticosteroids, valproic acid, amiodarone, tamoxifen within 3 months prior to study enrollment
• Use of medications such as steroids, methotrexate, metformin
• Use of agents such as vitamin E, omega-3 fatty acids, or medications with evidence of an effect on NAFLD (pioglitazone, GLP-1 analogues, dipeptidyl peptidase IV inhibitors, ursodeoxycholic acid)
• Active or previous history of invasive cancer (excluding curatively treated carcinoma in situ [e.g., cervical] or benign skin cancer), unless complete remission has been achieved
• Regular use of probiotic or prebiotic supplements within 3 months prior to study enrollment
• Known allergy to probiotics
• History of using an alternative diet within 3 months prior to study enrollment or changing diet during study entry
• Previous surgery (bariatric surgery, gastric or intestinal resection)
• Parenteral nutrition (TPN) within the last 6 months
• Insulin therapy
• Uncontrolled diabetes
• Cardiovascular disease (e.g., uncontrolled blood pressure, coronary artery disease, NYHA class III-IV heart failure, severe arrhythmias, orthostatic intolerance)
• Nervous system disorders
• Cognitive impairment and dementia
• Osteoporosis/osteopenia
• Active thyroid disease
• Cushing's syndrome
• Any implanted battery-powered device (e.g., AICD, pacemaker, cardiac rhythm recorder, cochlear implant)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Quadruple

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: placebo	Dietary supplement: Placebo; Placebo
Experimental: Experimental: probiotics supplementation + physical exercise program; Behavioral: physical exercise program in the form of a resistance/hypertrophy-oriented resistance program Dietary Supplement: probiotics supplementation	Behavioral: physical exercise programme; resistance/hypertrophy-oriented resistance programme; Dietary supplement: probiotics supplementation; probiotics supplementation
Active Comparator: Active Comparator: placebo + resistance/hypertrophy-oriented resistance program plus placebo; placebo + resistance/hypertrophy-oriented resistance program	Dietary supplement: Placebo; Placebo; Behavioral: physical exercise programme; resistance/hypertrophy-oriented resistance programme
Experimental: probiotics supplementation; Dietary Supplement: probiotics supplementation	Dietary supplement: probiotics supplementation; probiotics supplementation

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Change in liver fat measured using MRI	12 weeks

Secondary Outcome Measures

Outcome Measure	Time Frame
changes in weight in kilograms using scale	12 weeks
changes in body fat mass in kilograms measured using bioelectrical impedance method	12 weeks
changes in free-fat mass in kilograms measured using bioelectrical impedance method	12 weeks
changes in visceral fat level measured using bioelectrical impedance method	12 weeks
HDL cholesterol concentration measured in mg/dL (or mmol/L) using a standardized direct enzymatic assay from fasting venous blood samples	12 weeks
LDL cholesterol concentration measured in mg/dL (or mmol/L) using a standardized direct enzymatic assay from fasting venous blood samples	12 weeks
Aspartate aminotransferase (AST) activity measured in U/L using a standardized spectrophotometric enzymatic assay from serum samples	12 weeks
Alanine aminotransferase (ALT) activity measured in U/L using a standardized spectrophotometric enzymatic assay from serum samples	12 weeks

Other Outcome Measures

Outcome Measure	Time Frame
changes in RMR measured using CPET	12 weeks
autonomic nervous system function indicated by LF/HF ratio in supine position measured using Task Force Monitor	12 weeks
Changes in maximal strength, operationalized as the heaviest load lifted for exactly 10 repetitions (10RM) on calibrated resistance machines	12 weeks
changes in the dynamics of blood glucose level in response to standardized breakfast intake using continuous glucose monitoring	12 weeks
changes in gut microbiota indicated by Firmicutes/Bacteroidetes (F/B) ratio measured using genomics analysis of fecal samples	12 weeks

Collaborators and Investigators

• Sponsor: Nicolaus Copernicus University
• Collaborators: University of Oxford; Medical University of Warsaw
• Investigators: Study Chair: Lynette Hodges, PhD, Massey University, New Zealand; Study Chair: Agnieszka Cudnoch-Jędrzejewska, Prof., Warsaw Medical University, Poland; Study Chair: Beata Januszko-Giergielewicz, Assoc. Prof., Nicolaus Copernicus University, Poland; Study Chair: Maciej Słupski, Prof., Nicolaus Copernicus University, Poland; Study Chair: Karolina Skonieczna-Żydecka, Prof., Pomeranian Medical University in Szczecin, Poland; Study Director: Sławomir Kujawski, PhD, Nicolaus Copernicus University, Poland; Study Chair: Joanna Słomko, Prof., Nicolaus Copernicus University, Poland; Study Chair: Karl J. Morten, Prof., Oxford University, UK; Study Chair: Hanna Tabisz, MSc, Nicolaus Copernicus University, Poland; Study Chair: Magdalena Krintus, prof, Nicolaus Copernicus Univeristy; Study Chair: Sławomir Manysiak, PhD, Nicolaus Copernicus Univeristy; Study Chair: Aleksandra Modlińska, Nicolaus Copernicus Univeristy; Study Chair: Przemysław Ratajczak, MD, Nicolaus Copernicus Univeristy; Study Chair: Agnieszka Radzimińska, Nicolaus Copernicus Univeristy; Study Chair: Wojciech Kazimierczak, Nicolaus Copernicus Univeristy; Study Chair: Elżbieta Zawada, Nicolaus Copernicus Univeristy

Study record dates

Study Major Dates

• Study Start (Estimated): April 10, 2026
• Primary Completion (Estimated): April 10, 2031
• Study Completion (Estimated): April 10, 2036

Study Registration Dates

• First Submitted: August 12, 2024
• First Submitted That Met QC Criteria: August 18, 2024
• First Posted (Actual): August 21, 2024

Study Record Updates

• Last Update Posted (Actual): April 9, 2026
• Last Update Submitted That Met QC Criteria: April 7, 2026
• Last Verified: April 1, 2026

More Information

Terms related to this study

• Keywords: Probiotics; NAFLD; NASH; Gut microbiota; Resistance training; MAFLD; Hypertrophy training
• Additional Relevant MeSH Terms: Digestive System Diseases; Liver Diseases; Fatty Liver; Non-alcoholic Fatty Liver Disease
• Other Study ID Numbers: MAFLD_NAFLD_probiotics_RE

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: UNDECIDED
• IPD Plan Description: Data would be shared upon a reasonable request from other researches. Requests could be made with a contact Authors after publication of papers on the collected data.

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No