Granulocyte colony stimulating factor: A potential therapeutic rescue in severe alcoholic hepatitis and decompensated cirrhosis

Current insights into pathogenesis and anti-inflammatory treatment strategies for severe alcohol-associated hepatitis: focus on neutrophil-targeted therapies

Alcohol-associated hepatitis (AH) is the leading cause of liver-related mortality, with severe alcohol-associated hepatitis (SAH) showing a short-term mortality rate of 20%-50% even in developed countries. Corticosteroids are the only evidence-based pharmacologic treatment, but their efficacy is limited to short-term survival, with 30%-40% of patients achieving a complete response. Early liver transplantation (LT) has been explored as a salvage therapy for steroid-refractory SAH, but its feasibility is restricted by ethical concerns and donor shortages, particularly in Japan. In the absence of LT eligibility, patients are often left with the best supportive care, underscoring the urgent need for alternative salvage therapies. Recent studies have explored selective anti-inflammatory strategies targeting proinflammatory cytokines, such as TNFα and IL-1β. However, clinical trials have yet to demonstrate sufficient efficacy to outweigh the increased risk of infection. Granulocyte colony-stimulating factor (G-CSF) therapy has been investigated for its potential to promote liver regeneration, but its efficacy remains inconsistent across populations. Neutrophil-targeted therapies, including granulocyte-monocyte/macrophage apheresis (GMA), have emerged as a novel approach. Our recent pilot study demonstrated improved survival in patients with steroid-refractory SAH treated with GMA, supporting its potential as a safe and effective anti-inflammatory therapy. This review summarizes the latest advances in the treatment of SAH and emphasizes the need for novel salvage therapies to address unmet needs in steroid-refractory cases. Further research is essential to validate these new therapies and to optimize treatment strategies to improve the long-term prognosis of SAH.

Alcohol-associated liver disease: Epidemiology and management

Alcohol is the leading cause of preventable liver morbidity and mortality worldwide, as it is also the most frequent cause of advanced liver disease. Alcohol-associated liver disease (ALD) covers different phenotypes ranging from steatosis to the development of inflammation (steatohepatitis), fibrosis and ultimately, in a proportion of patients, the development of liver cirrhosis and its associated complications. ALD has a complex pathogenesis that includes the interplay of both genetic and environmental factors, yet the precise mechanisms are largely unknown. Alcohol-associated hepatitis (AH) is a severe clinical presentation of ALD, which is characterized by abrupt jaundice and clinical decompensations of liver disease. AH occurs in a percentage of patients with underlying ALD and active alcohol consumption. Currently, there are no approved targeted therapies able to interfere in the pathogenesis of ALD and halt the progression of the disease, therefore alcohol abstinence is the most effective measure to improve prognosis in this patient population. In this regard, alcohol cessation remains the first-line treatment in all stages of alcohol disease. In patients with advanced ALD nonresponding to medical therapy, liver transplantation is the only approach that improves prognosis, and it should be considered in patients with decompensated cirrhosis. In the last years, AH has emerged as a new indication of early liver transplantation in non-responders to medical therapy, with promising results in highly selected patients. In this review, we provide an update on the epidemiology, risk factors, natural history, diagnosis, pathogenesis, and current treatments for ALD, taking into account the importance of assessing and managing alcohol consumption as the etiological factor and the main driver of prognosis in patients with ALD.

The efficacy and safety of granulocyte colony-stimulating factor in the treatment of acute-on-chronic liver failure: A systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

The safety and efficacy of granulocyte-colony stimulating factor (G-CSF) for the treatment of acute-on-chronic liver failure (ACLF) remain controversial. This meta-analysis aimed to evaluate the effectiveness and safety of G-CSF in treating ACLF.

METHODS

The estimated pooled risk ratio (RR) and 95% confidence interval (CI) assessed the treatment effects of G-CSF. Mean differences (MD) and 95% confidence intervals were used to analyze continuous data. Heterogeneity was explored by sensitivity analysis. Potential publication bias was assessed using Egger's test.

RESULTS

Ten studies, comprising a total of 603 participants, were included in the analysis. The G-CSF group showed significantly lower MELD scores at 7-day (MD = -2.39, 95%CI: -3.95 to -0.82), CTP scores at 7-day (MD = -0.77, 95%CI: -1.41 to -0.14), and MELD scores at 30-day (MD = -3.01, 95%CI: -5.36 to -0.67) compared to the control group. Furthermore, the G-CSF group was associated with a reduced risk of sepsis (RR = 0.53, 95%CI: 0.35-0.80). The 30-day survival (RR = 1.26, 95%CI:1.10-1.43), 60-day survival (RR = 1.47, 95%CI:1.17-1.84, and 90-day survival (RR = 1.73, 95%CI: 1.27-2.35) of patients with ACLF treated with G-CSF were significantly higher than those of the control group.

CONCLUSIONS

Our meta-analysis suggests that G-CSF therapy may be a promising treatment for ACLF, with significant improvements in liver function and survival rates, however, further studies are needed to verify this conclusion.

A phase II, multicenter, open-label, randomized trial of pegfilgrastim for patients with alcohol-associated hepatitis

Background

In trials conducted in India, recombinant granulocyte colony stimulating factor (GCSF) improved survival in alcohol-associated hepatitis (AH). The aim of this trial was to determine the safety and efficacy of pegfilgrastim, a long-acting recombinant GCSF, in patients with AH in the United States.

Methods

This prospective, randomized, open label trial conducted between March 2017 and March 2020 randomized patients with a clinical diagnosis of AH and a Maddrey discriminant function score ≥32 to standard of care (SOC) or SOC+pegfilgrastim (0.6 mg subcutaneously) on Day 1 and Day 8 (clinicaltrials.gov NCT02776059). SOC was 28 days of either pentoxifylline or prednisolone, as determined by the patient's primary physician. The second injection of pegfilgrastim was not administered if the white blood cell count exceeded 30,000/mm3 on Day 8. Primary outcome was survival at Day 90. Secondary outcomes included the incidence of acute kidney injury (AKI), hepatorenal syndrome (HRS), hepatic encephalopathy, or infections.

Findings

The study was terminated early due to COVID19 pandemic. Eighteen patients were randomized to SOC and 16 to SOC+pegfilgrastim. All patients received prednisolone as SOC. Nine patients failed to receive a second dose of pegfilgrastin due to WBC > 30,000/mm3 on Day 8. Survival at 90 days was similar in both groups (SOC: 0.83 [95% confidence interval [CI]: 0.57-0.94] vs. pegfilgrastim: 0.73 [95% CI: 0.44-0.89]; p > 0.05; CI for difference: -0.18-0.38). The incidences of AKI, HRS, hepatic encephalopathy, and infections were similar in both treatment arms and there were no serious adverse events attributed to pegfilgrastim.

Interpretation

This phase II trial found no survival benefit at 90 days among subjects with AH who received pegfilgrastim+prednisolone compared with subjects receiving prednisolone alone.

Funding

was provided by the United States National Institutes of Health and National Institute on Alcohol Abuse and Alcoholism U01-AA021886 and U01-AA021884.

Multiple cycles of granulocyte colony-stimulating factor in decompensated cirrhosis: a double-blind RCT

BACKGROUND

Liver transplant, the definitive treatment of decompensated cirrhosis (DC), is constrained by donor shortage and long-term complications. Granulocyte colony-stimulating factor (G-CSF) has been explored as an alternative option in open-label studies. This double-blind, randomized, placebo-controlled trial was designed to elucidate the efficacy of G-CSF in DC.

METHODS

Seventy patients were randomized to either G-CSF plus standard medical therapy (group A, n = 35) or placebo plus standard medical therapy (group B, n = 35). Primary outcome was 12-month overall survival in patients who received at least one cycle of intervention. Secondary outcomes were mobilization of CD34+ cells at day 6, improvement in Child-Turcotte-Pugh (CTP), and model for end-stage liver disease (MELD), liver stiffness measurement, quality of life, nutrition, hepatic decompensation, infection, hospitalization, and acute kidney injury.

RESULTS

Survival in group A was higher than that in Group B although the difference was not statistically significant (87.9% vs 66.7%; p = 0.053). CD34+ cells at day 6 were significantly higher in group A as compared to baseline (p < 0.001). Ascites control (p = 0.03) and CTP score improvement (p = 0.02) were better in group A at 12-months. Encephalopathy episodes (p = 0.005), infections (p = 0.005) were fewer in group A than group B at 12 months. Other secondary outcomes did not improve post-therapy. There were no treatment-related discontinuations or severe adverse events.

CONCLUSIONS

G-CSF therapy is safe. The improvement in survival at 12 months is not statistically significant. Better control of ascites, improvement of CTP score, fewer encephalopathy episodes and decreased rate of infections were observed with G-CSF therapy (NCT03911037). Trials Registration NCT03911037.

Therapeutic Effect and Safety of Granulocyte Colony-Stimulating Factor Therapy for Acute-On-Chronic Liver Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background and Aims: Granulocyte colony-stimulating factor (G-CSF) has been proposed as a therapeutic option for patients with acute-on-chronic liver failure (ACLF). However, its clinical efficacy remains debatable. This study aimed to synthesize available evidence on the efficacy of G-CSF in ALCF.

Methods: The Cochrane Library, CNKI, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov were searched from inception until September 2021. After qualitative evaluation of the included literature, the included studies were analyzed.

Results: Seven studies were included in this meta-analysis. Overall, G-CSF therapy was not associated with a reduced risk of death (30-day survival, OR = 1.55, 95% CI: 1.00, 2.38, P = 0.05; 60-day survival, OR = 1.50, 95% CI: 0.95, 2.36, P = 0.08; 90-day survival, OR = 1.61, 95% CI: 0.99, 2.62, P = 0.05) or complication including occurrence of infections infection (OR = 0.66, 95% CI: 0.41, 1.05, P = 0.08), bleeding (OR = 1.50, 95% CI: 0.58, 3.89, P = 0.41), and hepatorenal syndrome (OR = 0.56, 95% CI: 0.25, 1.24, P = 0.15). Moreover, it had no obvious beneficial effects on the model of end-stage liver disease score (30-day SMD = −3.31, 95%CI: −7.42, 0.81, P = 0.12; 60-day SMD = −1.23, 95% CI: −5.21, 2.75, P = 0.54; 90-day SMD = −2.29, 95%CI: −4.94, 0.37, P = 0.09). Sensitivity analyses showed that patients in Asia had improved survival (30-day OR = 2.76, 95%CI: 1.43, 5.35, P = 0.003; 60-day OR = 2.83, 95% CI: 1.39, 5.73, P = 0.004; 90-day OR = 2.92, 95% CI: 1.34, 6.36, P = 0.007).

Conclusions: Our findings suggest that, currently, G-CSF cannot be recommended for the treatment of ACLF.

Novel Use of Intraarticular Granulocyte Colony Stimulating Factor (hG-CSF) Combined with Activated Autologous Peripheral Blood Stem Cells Mobilized with Systemic hG-CSF: Safe and Efficient in Early Osteoarthritis

Osteoarthritis (OA) tends to occur in older individuals frequently burdened with comorbidities and diverse pharmacological interactions. As articular cartilage has low regenerative power, potent local tissue engineering approaches are needed to support chondrogenic differentiation. Acellular preparation methods as well as approaches to coax endogenous reparative cells into the joint space appear to have limited success. Supported by our in-vitro and clinical studies, we propose that our novel intra-articular administration of human granulocyte colony stimulating factor (IA-hG-CSF) combined with autologous activated peripheral blood stem cells (AAPBSC) is safe and offers treatment advantages not seen with other cellular interventions in early osteoarthritis.

Can granulocyte colony stimulating factor (G-CSF) ameliorate acetaminophen-induced hepatotoxicity?

Acetaminophen (APAP) is often used as an antipyretic and analgesic agent. Overdose hepatotoxicity, which often results in liver cell failure and liver transplantation, is a severe complication of APAP usage. To save the liver and save lives from acute liver damage caused by APAP, the search for new strategies for liver defense is important. Wistar rats have been used for the induction of APAP hepatotoxicity. Elevated levels of serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and lactate dehydrogenase (LDH) were evaluated for liver toxicity. In addition, the levels of hepatic tissue oxidative markers such as malondialdehyde (MDA), nitric oxide (NO) increased while glutathione (GSH) was depleted and catalase (CAT) activity was curtailed. The biochemical findings were consistent with the changes in histology that suggested liver damage and inflammation. Treated rats with N-acetylcysteine (N-AC) and granulocyte colony stimulating factor (G-CSF) showed a decrease in serum levels of ALT, AST and LDH, while the level of ALP in the G-CSF group was still high. After administration of APAP, treatment with N-AC or G-CSF substantially reduced the level of MDA and NO while maintaining the GSH content and CAT activity. Treatment with N-AC and G-CSF after administration of APAP has also attenuated inflammation and hepatocytes necrosis. The results of this study showed that G-CSF could be viewed as an alternative hepatoprotective agent against APAP-induced acute liver injury compared to N-AC.

Immunological mechanisms and therapeutic targets of fatty liver diseases

Alcoholic liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) are the two major types of chronic liver disease worldwide. Inflammatory processes play key roles in the pathogeneses of fatty liver diseases, and continuous inflammation promotes the progression of alcoholic steatohepatitis (ASH) and nonalcoholic steatohepatitis (NASH). Although both ALD and NAFLD are closely related to inflammation, their respective developmental mechanisms differ to some extent. Here, we review the roles of multiple immunological mechanisms and therapeutic targets related to the inflammation associated with fatty liver diseases and the differences in the progression of ASH and NASH. Multiple cell types in the liver, including macrophages, neutrophils, other immune cell types and hepatocytes, are involved in fatty liver disease inflammation. In addition, microRNAs (miRNAs), extracellular vesicles (EVs), and complement also contribute to the inflammatory process, as does intertissue crosstalk between the liver and the intestine, adipose tissue, and the nervous system. We point out that inflammation also plays important roles in promoting liver repair and controlling bacterial infections. Understanding the complex regulatory process of disrupted homeostasis during the development of fatty liver diseases may lead to the development of improved targeted therapeutic intervention strategies.