CD34+ hematopoietic stem cells mobilization, paralleled with multiple cytokines elevated in patients with HBV-related acute-on-chronic liver failure

Impact of Nanotechnology on Differentiation and Augmentation of Stem Cells for Liver Therapy

The liver is one of the crucial organs of the body that performs hundreds of chemical reactions needed by the body to survive. It is also the largest gland of the body. The liver has multiple functions, including the synthesis of chemicals, metabolism of nutrients, and removal of toxins. It also acts as a storage unit. The liver has a unique ability to regenerate itself, but it can lead to permanent damage if the injury is beyond recovery. The only possible treatment of severe liver damage is liver transplant which is a costly procedure and has several other drawbacks. Therefore, attention has been shifted towards the use of stem cells that have shown the ability to differentiate into hepatocytes. Among the numerous kinds of stem cells (SCs), the mesenchymal stem cells (MSCs) are the most famous. Various studies suggest that an MSC transplant can repair liver function, improve the signs and symptoms, and increase the chances of survival. This review discusses the impact of combining stem cell therapy with nanotechnology. By integrating stem cell science and nanotechnology, the information about stem cell differentiation and regulation will increase, resulting in a better comprehension of stem cell-based treatment strategies. The augmentation of SCs with nanoparticles has been shown to boost the effect of stem cell-based therapy. Also, the function of green nanoparticles in liver therapies is discussed.

Effectiveness of granulocyte colony-stimulating factor for patients with acute-on-chronic liver failure: a meta-analysis

BACKGROUND

The safety and efficacy of granulocyte colony-stimulating factor (G-CSF) for the treatment of acute-on-chronic liver failure (ACLF) remain uncertain. Therefore, we conducted a meta-analysis to draw a firmer conclusion.

METHODS

We searched the Cochrane library, PubMed, Embase, and China Biology Medicine disc to identify relevant RCTs performed before January 2020. Risk ratios (RRs) and their 95% confidence intervals (95% CIs) were calculated using a random effects model.

MAIN OUTCOME MEASURES

RRs (95% CI) for 1-, 2-, and 3-month survival rates.

SAMPLE SIZE

Six RCTs, including three open-label studies.

RESULTS

The six studies included 246 subjects (121 in a G-CSF group and 125 in a control group). G-CSF administration significantly improved the 1-, 2-, and 3-month survival rates in patients with ACLF. The pooled RRs (95% CI, P) were 0.43 (0.27-0.69, P=.0004), 0.44 (0.32-0.62, P<.00001), and 0.39 (0.22-0.68, P=.0009), respectively.

CONCLUSION

G-CSF may be beneficial and effective in the treatment of ACLF, but further studies are needed to verify this conclusion.

LIMITATIONS

The sample size was small, and studies were restricted to countries in Asia.

PROSPERO REGISTRATION NUMBER

CRD42021225681 CONFLICT OF INTEREST: None.

Longitudinal effects of modified creatinine index on all-cause mortality in individuals receiving hemodialysis treatment

BACKGROUND

The modified creatinine index (mCI), as a surrogate marker of muscle mass, has been associated with poor outcomes in patients undergoing hemodialysis. However, a single assessment may not reflect the clinical significance before an adverse clinical endpoint.

OBJECTIVE

Analyze mCI trajectories and their association with all-cause mortality in incident hemodialysis patients.

DESIGN

Retrospective observational cohort.

SETTING

Outpatient dialysis facility.

PATIENTS AND METHODS

We followed a cohort of patients who underwent maintenance hemodialysis treatment at least three times weekly for at least three months from 19 June 2010 to 29 December 2017. Clinical and laboratory features were measured at baseline. Longitudinal changes in the mCI were modeled using a joint longitudinal and survival model adjusted for baseline covariates and body mass index trajectories.

MAIN OUTCOME MEASURE

All-cause mortality.

SAMPLE SIZE

408 with 208 males (50.7%).

RESULTS

The mean (SD) age was 62.2 (12.3) years. The mCI changes were evaluated for a median (interquartile range) follow-up of 2.16 (1.13, 3.73) years. Forty-six percent (n=188) of patients reached the endpoint. A steeper slope (per 0.1 unit increase in the decrease rate) in modified creatinine index was associated with increased risk of all-cause mortality (HR, 1.04; 95% CI, 1.02-1.07; P=.011). In addition, an annual 1 mg/kg/day decrease in modified creatinine index level increased the hazard of all-cause mortality by 4% (HR, 1.04; 95% CI, 1.02-1.07; P=.001).

LIMITATIONS

Residual kidney function was not observed in the data. Setting was single center and thus results may not be generalizable to other populations.

CONCLUSION

All-cause death was significantly associated with loss of muscle mass over time. Longitudinal trajectories of nutritional markers may predict the clinical outcomes in patients undergoing hemodialysis. This may also be valuable for individual risk stratification. Furthermore, early management may provide an opportunity to improve patient survival.

CONFLICT OF INTEREST

None.

A novel stem cell therapy for hepatitis B virus-related acute-on-chronic liver failure

The aim of this study was to propose a stem cell therapy for hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) based on plasma exchange (PE) for peripheral blood stem cell (PBSC) collection and examine its safety and efficacy. Sixty patients (n=20 in each group) were randomized to PE (PE alone), granulocyte colony-stimulating factor (G-CSF) (PE after G-CSF treatment), and PBSC transplantation (PBSCT) (G-CSF, PE, PBSC collection and hepatic artery injection) groups. Patients were followed-up for 24 weeks. Liver function and adverse events were recorded. Survival analysis was performed. PBSCT improved blood ammonia levels at 1 week (P<0.05). The level of total bilirubin, international normalized ratio, and creatinine showed significant differences in the 4th week of treatment (P<0.05). The survival rates of the PE, G-CSF, and PBSCT groups were 50, 65, and 85% at 90 days (P=0.034). There was a significant difference in 90-day survival between the PE and PBSCT groups (P=0.021). The preliminary results suggested that PBSCT was safe, with a possibility of improved 90-day survival in patients with HBV-ACLF.

Stem Cell-Based Therapies for Liver Diseases: An Overview and Update

BACKGROUND

Liver disease is one of the top causes of death globally. Although liver transplantation is a very effective treatment strategy, the shortage of available donor organs, waiting list mortality, and high costs of surgery remain huge problems. Stem cells are undifferentiated cells that can differentiate into a variety of cell types. Scientists are exploring the possibilities of generating hepatocytes from stem cells as an alternative for the treatment of liver diseases.

METHODS

In this review, we summarized the updated researches in the field of stem cell-based therapies for liver diseases as well as the current challenges and future expectations for a successful cell-based liver therapy.

RESULTS

Several cell types have been investigated for liver regeneration, such as embryonic stem cells, induced pluripotent stem cells, liver stem cells, mesenchymal stem cells, and hematopoietic stem cells. In vitro and in vivo studies have demonstrated that stem cells are promising cell sources for the liver regeneration.

CONCLUSION

Stem cell-based therapy could be a promising therapeutic method for patients with end-stage liver disease, which may alleviate the need for liver transplantation in the future.

Mesenchymal Stem Cell Transplantation for Liver Cell Failure: A New Direction and Option

Background and Aims

Mesenchymal stem cell transplantation (MSCT) became available with liver failure (LF), while the advantages of MSCs remain controversial. We aimed to assess clinical advantages of MSCT in patients with LF.

Methods

Clinical researches reporting MSCT in LF patients were searched and included.

Results

Nine articles (n = 476) related with LF patients were enrolled. After MSCT, alanine aminotransferase (ALT) baseline decreased largely at half a month (P < 0.05); total bilirubin (TBIL) baseline declined to a certain stable level of 78.57 μmol/L at 2 and 3 months (P < 0.05). Notably, the decreased value (D value) of Model for End-Stage Liver Disease score (MELD) of acute-on-chronic liver failure (ACLF) group was higher than that of chronic liver failure (CLF) group (14.93 ± 1.24 versus 4.6 ± 5.66, P < 0.05). Moreover, MELD baseline of ≥20 group was a higher D value of MELD than MELD baseline of <20 group with a significant statistical difference after MSCT (P = 0.003).

Conclusion

The early assessment of the efficacy of MSCT could be based on variations of ALT at half a month and TBIL at 2 and 3 months. And it had beneficial effects for patients with LF, especially in ACLF based on the D value of MELD.

Circulating CD34+ hematopoietic stem/progenitor cells paralleled with level of viremia in patients chronically infected with hepatitis B virus

Introduction: Liver regeneration is a heterogeneous process involving proliferation of different cell types in response to injury. Bone marrow derived stem cells may be involved in this process, by making contribution to parenchymal restoration and cellular replacement. We aimed to investigate the correlation between level of circulating mobilized CD34+ hematopoietic stem progenitor cells (HSPCs) and viremia level in patients chronically infected with hepatitis B virus (HBV).

Methods: Blood samples were prospectively collected for assessing percentage and absolute counts of circulating CD34+ HSPCs and viral load level using flow cytometry and RT-PCR respectively. Patients with chronic hepatitis B (CHB) (n = 30), Entecavir (ETV) treated subjects (n = 30) and 20 age and gender matched healthy controls were enrolled in this study. Results were expressed as mean ± SD.

Results and discussion: A significant increase in circulating CD34+ HSPCs level was observed in CHB patients (5 ± 3.1, 324 ± 195 × 10³/ml) as compared to ETV treated subjects (0.57 ± 0.27,1022 ± 325) and healthy controls (0.53 ± 0.37, 694 ± 254, P < 0.001) in regards to percentage and absolute counts respectively. Levels of CD34+ HSPCs strongly and positively correlated with HBV DNA viral load levels in CHB patients (r² = 0.8417, 0.649, P < 0.001).Thus, in chronic liver disorders (CHB), when reduced regenerative capacity of hepatocytes is reached, BMSCs mobilization occurs and their level increases in peripheral blood. The level of circulating CD34+ cells in peripheral blood of CHB patients paralleled with the hepatitis B viral load.

Therapeutic plasma exchange versus double plasma molecular absorption system in hepatitis B virus-infected acute-on-chronic liver failure treated by entercavir: A prospective study

BACKGROUND

Therapeutic plasma exchange (TPE) and double plasma molecular absorption system (DPMAS) were two extracorporeal liver support systems. Few studies compared their efficacy profile.

OBJECTIVE

This study was to compare the efficacy of TPE and DPMAS on acute-on-chronic liver failure (ACLF) caused by hepatitis B virus (HBV-ACLF).

METHODS

60 HBV-ACLF patients were enrolled and prospectively studied. All patients received entecavir therapy, and were assigned to TPE group (n = 33) and DPMAS group (n = 27). Primary end-points were the effects of TPE and DPMAS on liver function and serum inflammatory markers.

RESULTS

Serum procalcitonin, interleukin (IL)-6, and high sensitive C-reactive protein (hsCRP) were significantly elevated in patients with HBV-ACLF. TPE achieved significantly higher removal rates of total bilirubin (TBIL, P = .002), direct bilirubin (DBIL, P = .006), and hsCRP (P = .010) than DPMAS, but DPMAS displayed lower loss rate of albumin (P = .000). TPE and DPMAS resulted in similarly increased serum IL-6 levels and comparable 12-week survivals (P > .05). Multivariate analysis showed that hospital stay (Relative Risk [RR]: 1.062, 95% Confidence Interval [CI]: 1.011-1.115, P = .016), prothrombin time (RR: 1.346, 95% CI: 1.077-1.726, P = .010), and international normalized ratio (RR: 0.013, 95% CI: 0.006-0.788, P = .041) were independent predictors for 12-week survival. Both TPE and DPMAS treatments were well-tolerated.

CONCLUSION

Compared to DPMAS, TPE was more efficient in eliminating TBIL, DBIL, and hsCRP, but it was associated with higher loss rate of albumin. TPE and DPMAS were similar in improving 12-week survivals in HBV-ACLF.

Effects of Granulocyte Colony-Stimulating Factor on Patients with Liver Failure: a Meta-Analysis

BACKGROUND AND AIMS

It remains controversial whether granulocyte colony-stimulating factor (G-CSF) prolongs survival in liver failure (LF) patients. This meta-analysis was performed to evaluate the effect of G-CSF on patients with LF.

METHODS

PubMed, EMBASE, and Web of Science databases were searched to identify English language randomized controlled trials comparing G-CSF with control therapy published before14 February 2015. A meta-analysis was performed to examine changes in liver function and patient survival. The association was tested using odds ratio (OR) or risk ratio (RR) with 95% confidence intervals (CI).

RESULTS

Five randomized controlled trials were eligible for the meta-analysis. Significant amelioration of prothrombin time and total bilirubin in LF patients was attributed to G-CSF therapy (OR, -0.064; 95% CI,-0.481 to 0.353; p< 0.001; and OR, -0.803; 95% CI, -1.177 to -0.430; p = 0.000, respectively). Treatment with G-CSF resulted in improved Model for End-Stage Liver Disease and Child-Turcotte-Pugh scores (OR, -1.741; 95% CI, -2.234 to -1.250; p = 0.000; and OR, -0.830, 95% CI, -1.194 to -0.465; p = 0.000, respectively). A lower incidence of sepsis was found in patients treated with G-CSF (RR, 0.367; 95% CI, 0.158 to 0.854; p = 0.020). G-CSF therapy significantly increased survival rate in LF patients (RR, 2.25; 95% CI, 1.517 to 3.338; p = 0.000).

CONCLUSIONS

The results of this meta-analysis indicate that G-CSF treatment in patients with LF significantly improved liver function, reduced the incidence of sepsis, and prolonged short-term survival.

Cytokines elevated in patients with HBV-related acute-on-chronic liver failure promote NK cell mediated cytotoxicity through TRAIL

BACKGROUND AND AIMS

The role of NK cells on inducing liver injury in patients with HBV-related acute-on-chronic liver failure (HBV-ACLF) is not well understood. The aim of this study was to determine the cytotoxicity of tumor necrosis factor-related apoptosis inducing ligand (TRAIL)-expressed NK cells from HBV-ACLF patients and facilitate a better understanding of the immune pathogenesis of HBV-ACLF.

METHODS

Peripheral blood samples were obtained from HBV-ACLF patients, mild chronic hepatitis B (CHB) patients and healthy controls (HC). Circulating NK cells phenotype was determined using flow cytometry. Serum cytokine concentrations were ascertained using the CBA Inflammation kit. Cell apoptosis was analyzed using the FITC-annexin V Apoptosis Detection Kit.

RESULTS

Peripheral NK cells from HBV-ACLF expressed higher levels of TRAIL than those from CHB and HC. Expression of TRAIL on NK cells was correlated positively with serum IL-6 and IL-8 concentrations in HBV-ACLF patients, which is further confirmed by cytokines stimulation in vitro. NK cells caused a significant increase of apoptotic hepatocytes, and further increased the frequency of apoptosis in IL-6 and IL8-stimulated hepatocytes; the apoptosis was then inhibited partially by an anti-TRAIL monoclonal antibody.

CONCLUSION

These results suggested that inflammation cytokines elevated in patients with HBV-ACLF may promote NK cell mediated cytotoxicity through TRAIL pathway.

The hematopoietic stem cell number in the peripheral blood of pediatric recipients correlates with the outcome after living donor liver transplantation

It has been proposed that circulating HSCs play a role in graft survival after liver transplantation. The aim was to analyze the relationship between the number of HSCs before and after LDLT and liver function, immune biomarkers, and clinical outcomes in pediatric patients. We studied 15 pairs of adult healthy liver donors and pediatric recipients with ESLD. The CD34/CD45+ cell number was measured in the blood via flow cytometry, and plasma levels of immune biomarkers - via ELISA. CD34/CD45+ cell number in the recipients decreased within the first week after LDLT. The cell number before LDLT was negatively correlated with the plasma levels of CRP and the development of graft dysfunction in the early post-transplant period. After LDLT, the CD34/CD45+ cell number was positively correlated with the pretransplant plasma level of sCD40L, a T-cell activation marker. In adult liver donors, the cell number did not change within the first week after liver resection and was lower than in pediatric recipients. The results suggest that in pediatric recipients, the HSC number may be associated with graft function and could be regarded as a potential predictor of the clinical outcome after LDLT.

Advanced therapeutic strategies for HBV-related acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is increasingly recognized as a distinct clinical entity and is associated with a high short-term mortality. The most common cause of ACLF is chronic hepatitis B worldwide. Currently, there is no standardized approach for the management of ACLF and the efficacy and safety of therapeutic modalities are uncertain.

DATA SOURCES

PubMed and Web of Science were searched for English-language articles. The search criteria focused on clinical trials and observational studies on the treatment of patients with HBV-related ACLF.

RESULTS

Therapeutic approaches for ACLF in patients with chronic hepatitis B included nucleos(t)ide analogues, artificial liver support systems, immune regulatory therapy, stem cell therapy and liver transplantation. All of these therapeutic approaches have shown the potential to improve liver function and increase patients' survival rate, but most of the studies were not randomized or controlled.

CONCLUSION

Substantial challenges for the treatment of HBV-related ACLF remain and further basic research and randomized controlled clinical trials are needed.

Mobilization of endogenous bone marrow-derived stem cells in a thioacetamide-induced mouse model of liver fibrosis

The clinical significance of enhancing endogenous circulating haematopoietic stem cells is becoming increasingly recognized, and the augmentation of circulating stem cells using granulocyte-colony stimulating factor (G-CSF) has led to promising preclinical and clinical results for several liver fibrotic conditions. However, this approach is largely limited by cost and the infeasibility of maintaining long-term administration. Preclinical studies have reported that StemEnhance, a mild haematopoietic stem cell mobilizer, promotes cardiac muscle regeneration and remedies the manifestation of diabetes. However, the effectiveness of StemEnhance in ameliorating liver cirrhosis has not been studied. This study is the first to evaluate the beneficial effect of StemEnhance administration in a thioacetamide-induced mouse model of liver fibrosis. StemEnhance augmented the number of peripheral CD34-positive cells, reduced hepatic fibrosis, improved histopathological changes, and induced endogenous liver proliferation. In addition, VEGF expression was up-regulated, while TNF-α expression was down-regulated in thioacetamide-induced fibrotic livers after StemEnhance intake. These data suggest that StemEnhance may be useful as a potential therapeutic candidate for liver fibrosis by inducing reparative effects via mobilization of haematopoietic stem cells.

Bone marrow stem cell therapy for liver disease

Liver disease is a rising cause of mortality and morbidity, and treatment options remain limited. Liver transplantation is curative but limited by donor organ availability, operative risk and long-term complications. The contribution of bone marrow (BM)-derived stem cells to tissue regeneration has been recognised and there is considerable interest in the potential benefits of BM stem cells in patients with liver disease. In chronic liver disease, deposition of fibrous scar tissue inhibits hepatocyte proliferation and leads to portal hypertension. Although initial reports had suggested transdifferentiation of stem cells into hepatocytes, the beneficial effects of BM stem cells are more likely derived from the ability to breakdown scar tissue and stimulate hepatocyte proliferation. Studies in animal models have yielded promising results, although the exact mechanisms and cell type responsible have yet to be determined. Small-scale clinical studies have quickly followed and, although primarily designed to examine safety and feasibility of this approach, have reported improvements in liver function in treated patients. Well-designed, controlled studies are required to fully determine the benefits of BM stem cell therapy.

Multiple courses of G-CSF in patients with decompensated cirrhosis: consistent mobilization of immature cells expressing hepatocyte markers and exploratory clinical evaluation

INTRODUCTION

Bone marrow-derived cells (BMCs) include stem cells capable of self-renewal and differentiation into a variety of cell types. Administration of granulocyte colony-stimulating factor (G-CSF) induces the circulation of BMCs in the peripheral blood. A phase II prospective trial was carried out for evaluation of BMC mobilization induced by multiple courses of G-CSF in cirrhotic patients.

PATIENTS AND METHODS

Fifteen patients with advanced liver cirrhosis (Child-Pugh score ≥6 points) were enrolled and treated with a 3-day G-CSF course, administered at 3-month intervals for a total of four courses. BMC mobilization was assessed by evaluating CD34+ve cells using flow cytometry. Expressions of multiple hepatic and stem markers were assessed on mobilized CD34+ve cells. Feasibility and safety were explored; clinical and adverse events were compared to those of a control group. Telomere length was monitored to rule out early cell aging caused by G-CSF.

RESULTS

A significant increase in G-CSF-induced circulating CD34+ve cells was consistently observed, although a progressive reduction of peak values was documented from cycle I to IV (p < 0.005). Mobilized CD34+ve cells expressed both stem and multiple hepatocyte markers, including mRNA of albumin and CYP2B6 (cytochrome P2 B6). Treatment was well tolerated, with no severe adverse events and no significant telomere length shortening following G-CSF. The procedure was safe. Overall, ten patients had either improved or had stable liver function tests (such as the Child-Pugh score), whereas five worsened and died from liver-related causes.

CONCLUSION

This study demonstrates that G-CSF can be safely administrated up to four times over a 1-year period in decompensated cirrhotic patients. The repeated BMC mobilization favors the circulation of stem cells coexpressing hepatic markers and mRNA of liver-related genes.