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On the other hand, TMAO decreases expression of two key enzymes, CYP7A1 and CYP27A1, essential for bile acid biosynthesis and multiple bile acid transporters (OATP1, OATP4, MRP2 and NTCP) in the liver, which decreases bile acid pool, resulting in decreased reverse cholesterol efflux (Koeth et al., 2013)

This study provided additional information on the potential effect of ALCAR on disease progression and survival and adds evidence to justify the use of ALCAR in ALS subjects