Telomere biology disorders and hepatic disease

Telomere biology disorders (TBDs) are rare inherited conditions caused by defects in telomere maintenance genes, leading to premature cellular aging and multisystem disease. The liver is the third most affected organ after the bone marrow and the lungs. Liver involvement ranges from asymptomatic biochemical abnormalities to porto-sinusoidal vascular disease, early-onset cirrhosis, and hepatopulmonary syndrome, often presenting without classic extrahepatic features of TBDs and posing significant diagnostic challenges. Disease severity and age of onset are strongly influenced by telomere length and genetic inheritance patterns. Autosomal recessive, X-linked recessive, and de novo TINF2-associated inheritance patterns are associated with severe childhood liver disease, while autosomal dominant inheritance patterns present in adulthood with isolated liver pathology. Acquired liver disease may also independently lead to telomere attrition and accelerate cellular senescence and fibrosis progression. Currently, management of TBD-related liver disease is largely supportive, with limited evidence suggesting potential benefit from androgen therapy, and there is growing experience supporting liver transplantation, particularly for advanced disease or hepatopulmonary syndrome. Early recognition, multidisciplinary care, and genetic counseling are essential to optimize outcomes. Future clinical trials studying telomere-targeted therapies warrant focus on hepatic endpoints.