Remote limb ischemic conditioning alleviates nonalcoholic steatohepatitis via extracellular vesicle-mediated muscle-liver crosstalk [hEV_RNAseq]

Nonalcoholic steatohepatitis (NASH) is an advanced form of nonalcoholic fatty liver disease with adverse outcomes that currently lacks approved medication. Muscle-liver interaction has emerged as one of the critical determinants governing NASH progression. Here, we report that remote limb ischemic conditioning (RIC), a clinically validated therapy for distant ischemic organ protection by transient muscle ischemia, significantly alleviated NASH in different mouse models. The anti-NASH effect of chronic RIC treatment was mediated by the muscle-to-liver transfer of extracellular vesicles (EVs) and their cargo microRNAs, leading to elevation of miR-181d-5p in the liver. Hepatic miR-181d-5p overexpression faithfully mirrored the benefits of RIC treatment via suppression of nuclear receptor 4A3. Furthermore, administration of circulating EVs from human volunteers undergoing RIC treatment improved NASH phenotypes and transcriptomic perturbations in primary human hepatocytes and animal models. Our data underscore the translational potential of RIC treatment for NASH management and extend our understanding of muscle-liver crosstalk.