Liver regeneration as treatment target for severe alcoholic hepatitis

Table 1 Summary of human studies with granulocyte colony-stimulating factor treatment in patients with alcohol-related liver disease

Study population	Methods	Outcomes	Ref.
RCT included 24 pts with ALC and biopsy proven ASH1	Group A (13 pts) received SMT + G-CSF and group B (11 pts) received SMT only	Higher increase in CD34+ cell count, HGF, proliferating HPCs and Ki67+/cytokeratin 7+ staining in group A	Spahr et al[27], 2008
RCT included 27 pts with ALC presenting with ACLF1	Group A (15 pts) received G-CSF + SMT, and group B (12 pts) received placebo + SMT	Group A had higher median leukocyte and neutrophil counts after 1 w and higher CD34+ cell count after 1 mo, together with improvement in 60-day survival, reduced CTP, MELD and SOFA scores	Garg et al[28], 2012
RCT included 46 pts with severe AH1	Group A (23 pts) received G-CSF, while group B (23 pts) received SMT	In group A, higher CD34+ count was observed together with marked CTP, MELD and mDF score improvements after 1, 2 and 3 mo and higher survival rate at 90 d	Singh et al[29], 2014
RCT included 38 pts with ALC1	Group A (14 pts) received SMT + GH qd for 12 mo + initial G-CSF 5-d treatment and then 4 G-CSF cycles every 3 mo; group B (15 pts) received initial G-CSF 5-d treatment and then 4 G-CSF cycles every 3 mo, and group C received SMT only	Groups A and B had better TFS after 12 mo and higher QOL scores, as well as higher CD34+ mobilization rate at day 6, with lower incidence of sepsis and SBP	Verma et al[36], 2018
RCT included 35 pts with ALC1	Group A (19 pts) received G-CSF + EPO and group B (16 pts) received G-CSF only	Group A had higher improvement of CTP and MELD score, together with lower incidence of AKI, HE and ascites; histologically number of CD163+ macrophages and KI67+ index were increased	Anand et al[33], 2019
RCT included 57 pts with severe AH1	Group A (18 pts) received SMT + G-CSF, group B (19 pts) received SMT + G-CSF + NAC, and group C (20 pts) received SMT alone	Pts in group A and B had higher 90-d survival rate; in group A, improvement in mDF was observed at mo 1, 2 and 3, together with reduction in MELD score after 3 mo	Singh et al[37], 2018
RCT included 28 pts with severe AH1	Group A (14 pts) received G-CSF and group B (14 pts) received placebo	Group A had better MELD score, lower incidence of infections as well as lower 90-d mortality	Shasthry et al[38], 2019
RCT included 48 pts with ALC1	Group A (25 pts) was treated with 4 cycles of 5-d G-CSF therapy and group B (23 pts) was treated with SMT only	Group A had higher CD34+ and neutrophil count at day 6; higher 1-year survival, amelioration in CTP and MELD scores together with better ascites control and lower infection risk were observed after 12 mo	De et al[30], 2021
RCT included 176 pts with ACLF precipitated by alcohol consumption1	Group A (88 pts) was treated with G-CSF + SMT, and group B (88 pts) was treated with SMT	There were no statistically significant differences in respect of TFS, 90-d and 360-d survival rates and infection incidence	Engelmann et al[39], 2021

¹Patient(s) has/have dropped-out, underwent deceased donor liver transplant, or death outcome occurred.

ACLF: Acute-on-chronic liver failure; AKI: Acute kidney injury; ALC: Alcoholic liver cirrhosis; ASH: Alcoholic steatohepatitis; GH: Growth hormone; HE: Hepatic encephalopathy; HPC: Hepatocyte progenitor cell; mDF: Maddrey’s Discriminant Function for alcoholic hepatitis; NAC: N-acetyl-cysteine; pt(s): Patient(s); qd: Quaque die; QOL: Quality of life; SBP: Spontaneous bacterial peritonitis; SMT: Standard medical treatment; SOFA score: Sequential Organ Failure Assessment score; TFS: Transplant-free survival.

Table 2 Summary of human studies using stem cells in patients with alcohol-related liver disease

Study population	Methods	Outcomes	Ref.
5 pts with ALC	G-CSF mobilized mononuclear CD34+ PBSCs collected by leukapheresis and injected via PV (the dose not stated)	Higher mobilization rate was associated with higher CTP and MELD score amelioration	Gaia et al[57], 2006
4 pts with ALC (2 also had HCV, 1 had HBV)1	Between 1 × 106 and 2 × 108 G-CSF mobilized mononuclear CD34+ PBSCs collected by leukapheresis and injected via PV (3 pts) or HA (2 pts)	3/4 pts had improvement in bilirubin and albumin levels after 2 mo[58]; At 12 mo 2/3 pts had and albumin and bilirubin levels lower than the baseline values[59]	Gordon et al[58], 2006; Laxman et al[59], 1993
2 pts with ALC	> 2 × 106 G-CSF mobilized CD34+ PBSCs collected by leukapheresis and injected via PV	2/2 pts had no cirrhosis related hospital admissions afterwards up to 30/34 m, CTP and MELD improved and reached plateau at 12 mo, IL-6 and TNF-𝛼 transiently decreased	Yannaki et al[60], 2006
5 pts with ALC (2 of which had HCV infection)	1.6-5.2 × 108mononuclear CD34+ BMCs were aspirated from BM and injected via HA	At 4 mo CTP score improved, and relative mean change (%) from baseline values of bilirubin, albumin and INR were -24, 7 and -3, respectively	Lyra et al[61], 2007
9 pts with ALC	38.7-349.9 × 106 G-CSF mobilized mononuclear CD34+ PBSCs collected by leukapheresis and injected via HA after cultivation in vitro for 7 d	7/9 patients had improvements in CTP score, 5/9 had resolution of ascites, significant decrease in mean bilirubin levels and insignificant decrease in albumin levels, AST and ALT	Pai et al[62], 2008
1 pt with ALC	MSC taken by BM aspiration were cultured and differentiation into hepatocyte-like cells was induced. Afterwards 3-5 × 107 cells were injected via PV	Reduced MELD score, reduced serum creatinine, increase in serum albumin, better life quality and reduced hospitalization rate	Kharaziha et al[63], 2009
4 pts with ALC (2 of which had HCV)1	2-15 × 108 MN-BMSCs were collected by BM aspiration and injected via HA	After 12 mo, albumin and bilirubin levels were improved (but not significantly) and mean values of CTP and MELD score were unchanged	Couto et al[64], 2011
A case-control study with 5 pts with ALC	8 ± 7.3 × 109 mononuclear CD34+, CD44+, CD45+, CD117+ BMCs were isolated after BM aspiration and injected via cubital vein	Improvement of serum albumin levels, prothrombin time, total protein and average CTP score (from 6.8 ± 1.3 to 5.8 ± 0.8)	Saito et al[65], 2011
RCT included 58 pts with ALC1	Group A (30 pts) received SMT and group B received 0.47 ± 0.15 × 108/kg G-CSF mobilized mononuclear BMCs collected by BM aspiration and injected via HA	Both groups had reduction in steatosis at 4w and improved MELD scores at 12w[66], but higher CD68+ macrophage infiltration was seen in group B at 4w[67]	Spahr et al[66], 2013; Lanthier et al[67], 2017
12 pts with ALC1	5 × 107 BM-MSCs were collected by BM aspiration, amplified for 1 mo and administered twice via HA	Fibrosis score, CTP and MELD score and albumin levels improved	Jang et al[68], 2014
17 patients involved; 5 pts (29.4%) with ASH1	0.05-0.4 × 106 G-CSF mobilized CD133+ PBSCs were collected by leukapheresis and injected via HA, followed by additional G-CSF administration	In CTP class C patients, MELD score worsened during G-CSF application, but at 2 mo overall MELD score improved and at 3 mo INR values were lower and albumin levels higher	Andreone et al[69], 2015
RCT involving 25 patients; 11 pts with ALC (5 in group A, 6 in group B)1	Group A (23 pts) received SMT and group B (22 pts) received G-CSF mobilized CD34+ PBSCs were collected by leukapheresis and injected via HA	At 1 mo albumin levels were improved (P = 0.001) but were not sustained at 3 mo, when creatinine levels and MELD score were significantly improved, and AST and INR improved marginally	Sharma et al[70], 2015
RCT involving 55 pts with ALC (18 in group A and B, and 19 in group C)1	Group A received SMT, group B (once) and group C (twice) received 5 × 107 BM-MSCs collected by BM aspiration, cultured for 1 mo and injected afterwards via HA	At 6 mo fibrosis reduced in both groups in comparison to control, CTP scores also improved in comparison to baseline	Suk et al[71], 2016
RCT involving 4 pts with ALC (2 in group 1, 1 in group 2 and 1 in group 3)	Group 1 received SMT, group 2 received G-CSF alone, and group 3 received 1.67 × 109-2 × 1010/50 mL G-CSF mobilized CD34+ CD133+ mononuclear PBSCs injected via HV	Group 3 showed improvement in median CTP score	Yu et al[72], 2017
6 pts with ALC1	1 × 108 AD-MSCs obtained from abdominal fat tissue and expanded in vitro were injected via HA	2/5 pts had fibrosis score improvement (METAVIR), 1/5 pt had activity score improvement (METAVIR), 5/5 pts improved in CTP scores and MELD score improved in 4/5 pts, while in 1 pt it increased	Huang et al[73], 2019

¹Patient(s) dropped-out, underwent deceased donor liver transplant, or death outcome occurred.

AD-MSC: Adipose derived-mesenchymal stem cell; ALC: Alcoholic liver cirrhosis; AH: Alcoholic hepatitis; BM: Bone marrow; BMC: Bone marrow cell; BM-MSC: Bone marrow mesenchymal stem cell; CTP: Child-Turcotte-Pugh; DDLT: Deceased donor liver transplant; HA: Hepatic artery; HBV: Hepatitis B virus; HCV: Hepatitis C virus; HGF: Hepatocyte growth factor; HPC: Hepatic progenitor cell; MELD: Model for End-Stage Liver Disease; MN-BMSC: Mononuclear bone marrow stem cell; pt(s): Patient(s); PV: Portal vein; RCT: Randomized controlled trial; SMT: Standard medical therapy.