Granulocyte Colony-Stimulating Factor Use in Decompensated Cirrhosis: Lack of Survival Benefit

BACKGROUND

Granulocyte colony-stimulating factor (GCSF) has been utilized in decompensated cirrhosis (DC) for improving transplant-free survival (TFS). Data from multiple centers are conflicting with regard to patient outcomes. In this retrospective study, we present our 'real-world experience' of GCSF use in a large group of DC.

METHODS

From September 2016 to September 2018, 1231 patients with cirrhosis were screened, of which 754 were found to have decompensation(s). Seventy-three patients with active ascites, jaundice, or both completed GCSF treatment (10 mcg/kg per day for 5 days, followed by 5 mcg/kg/day once every third day for total 12 doses). Per-protocol analysis (n = 56) was performed to study clinical events, liver disease severity, and outcomes at 3, 6, and 12 months after treatment. Modified intention-to-treat (mITT, n = 100) analysis was performed to study overall survival at 180 days. Outcomes were compared with a matched historical control (HC) group (n = 24).

RESULTS

Nine (16%, n = 56), 24 (43%, n = 56), and 36 (75%, n = 48) patients died at 3, 6, and 12-month follow-up after GCSF. The commonest cause of death was sepsis (53%) followed by progressive liver failure (33%). Nine percent of patients developed hepatocellular carcinoma on follow-up at the end of 1 year. Acute variceal bleeds, overt hepatic encephalopathy, intensive unit admissions, and liver disease severity scores were higher after treatment at the end of 1 year. The Child-Pugh score >11 and model for end-stage liver disease-sodium score >25 and > 20 predicted worse outcomes at all time points and at 6 and 12 months after GCSF, respectively. Compared to a matched HC group, patients receiving GCSF had higher mortality (75% vs 46%, P = 0.04) at one year. mITT analysis revealed poor overall survival at 6 months compared to HCs (48% vs 75%, P = 0.04).

CONCLUSION

Survival in DC was shorter than what was expected in the natural history of the disease after GCSF use.

A Single-Center Experience on Outcomes of Complementary and Alternative Medicine Use Among Patients With Cirrhosis

Drug‐induced liver injury (DILI) due to complementary and alternative medicine (CAM) use is on the rise throughout the world by patients looking for “safer” alternatives. However, data on acute‐on‐chronic liver failure (ACLF) due to CAM are lacking. In a large cohort of patients with cirrhosis, we retrospectively studied CAM‐related health‐seeking behavior and attempted to identify those who developed possible CAM‐DILI‐related ACLF. In this study, we examine the clinical, biochemical, and liver histopathologic characteristics of possible CAM‐DILI‐related ACLF, describe implicated CAM agents, and discuss predictors of patient outcomes. Out of 1,666 patients with cirrhosis, 68% used CAM at some point. A total of 35.7% (n = 30/84) patients presented with CAM‐related DILI leading to ACLF in the whole CAM‐DILI‐related decompensation cohort. The most common CAM was unlabeled polyherbal Ayurvedic formulations. Of possible patients with ACLF, 63% self‐medicated with CAM based on social media sharing. Mean age ± SD was 51.9 ± 9.9 years, 83% were male patients, median follow‐up duration was 173 (range, 14‐584) days, median Child‐Turcotte‐Pugh score was 13 (range, 10‐14), Model for End‐Stage Liver Disease‐sodium score was 30.1 ± 4.8, median chronic liver failure‐organ failure (CLIF‐C‐OF) score was 11 (range, 8‐14), and median CLIF‐C‐ACLF score was 98 (range, 87‐127). Portal‐based neutrophilic predominant mixed inflammation, hepatocyte ballooning, autoimmune‐like features, and severe cholestasis were seen on liver biopsy. Overall, 53% of patients died (median survival 194 days). Baseline overt hepatic encephalopathy and CLIF‐C‐OF score, total bilirubin, hyponatremia and leukocytosis, and grade of ACLF predicted 1‐, 3‐, 6‐ and 12‐month mortality, respectively. Conclusion: Possible CAM‐DILI‐related ACLF has a high mortality. Strict monitoring and identification of CAM use among people with cirrhosis and an integrative public health educational practice can help ameliorate this modifiable risk factor that potentiates heavy liver disease burden and resource use.