During the 13th Probiotics, Prebiotics and New Foods Congress, Microbiomepost.com conducted an exclusive interview with Francesca Ponziani from Gemelli University Hospital (Italy). In this interview Ponziani discusses how Gut–liver axis dysfunction is now regarded as a cornerstone in the progression of cirrhosis and, more broadly, chronic liver disease. 

The interview highlights how the gut microbiota can become a clinical tool on three levels: identifying and stratifying patients, clarifying pathogenic mechanisms, and opening up new therapeutic options. In patients with cirrhosis, a typical pattern is a reduction in “beneficial” bacteria (with decreases in taxa such as Faecalibacterium prausnitzii, Akkermansia, and bifidobacteria, along with autochthonous groups such as Lachnospiraceae and Ruminococcaceae) and, in parallel, an increase in potentially pathogenic and oral-derived microbes—often interpreted as a sign of impaired compartmentalization along the gastrointestinal tract. Specific microbial “signatures” also appear to be associated with distinct clinical settings, from MASLD (formerly NAFLD) to alcohol-related liver disease, with potential applications in prognosis and precision medicine—for instance, stratifying patients with hepatocellular carcinoma undergoing immunotherapy or identifying those at higher risk of developing complications. Mechanistically, the microbiota contributes to the production of clinically relevant enzymes and metabolites: from urease, involved in ammonia metabolism, to compounds linked to hepatic encephalopathy; in MASLD, metabolites such as ethanol and choline-derived products also play a role, with implications not only for progression toward steatohepatitis and fibrosis but also for cardiovascular risk. 

Finally, Ponziani underscores the therapeutic promise of microbiota modulation: fecal microbiota transplantation emerges as a particularly promising option—especially for hepatic encephalopathy—with encouraging data also for oral capsule delivery and a favorable safety profile. Looking ahead, next-generation probiotics and targeted molecules designed to interrupt pathological gut–liver signaling may expand the therapeutic armamentarium for obesity and severe syndromes such as acute-on-chronic liver failure.