Kathy Guo

Glucagon-like peptide 1 decreases lipotoxicity in non-alcoholic steatohepatitis.

Graphical abstract

Abdominal subcutaneous adipose tissue insulin resistance and lipolysis in patients with non-alcoholic steatohepatitis

Systemic insulin resistance (IR) is a primary feature in non‐alcoholic steatohepatitis (NASH), however, there remain limited data on tissue‐specific insulin sensitivity in vivo.

REpeated AutoLogous Infusions of STem cells In Cirrhosis (REALISTIC): a multicentre, phase II, open-label, randomised controlled trial of repeated autologous infusions of granulocyte colony- stimulating factor (GCSF) mobilised CD133+ bone marrow stem cells in patients with cirrhosis. A study protocol for a randomised controlled trial

Introduction Liver disease mortality and morbidity are rapidly rising and liver transplantation is limited by organ availability. Small scale human studies have shown that stem cell therapy is safe and feasible and has suggested clinical benefit. No published studies have yet examined the effect of stem cell therapy in a randomised controlled trial and evaluated the effect of repeated therapy. Methods and analysis Patients with liver cirrhosis will be randomised to one of three trial groups: group 1: Control group, Standard conservative management; group 2 treatment: granulocyte colony-stimulating factor (G-CSF; lenograstim) 15 µg/kg body weight daily on days 1–5; group 3 treatment: G-CSF 15 µg/kg body weight daily on days 1–5 followed by leukapheresis, isolation and aliquoting of CD133+ cells. Patients will receive an infusion of freshly isolated CD133+ cells immediately and frozen doses at days 30 and 60 via peripheral vein (0.2×106 cells/kg for each of the three doses). Primary objective is to demonstrate an improvement in the severity of liver disease over 3 months using either G-CSF alone or G-CSF followed by repeated infusions of haematopoietic stem cells compared with standard conservative management. The trial is powered to answer two hypotheses of each treatment compared to control but not powered to detect smaller expected differences between the two treatment groups. As such, the overall α=0.05 for the trial is split equally between the two hypotheses. Conventionally, to detect a relevant standardised effect size of 0.8 point reduction in Model for End-stage Liver Disease score using two-sided α=0.05(overall α=0.1 split equally between the two hypotheses) and 80% power requires 27 participants to be randomised per group (81 participants in total). Ethics and dissemination The trial is registered at Current Controlled Trials on 18 November 2009 (ISRCTN number 91288089, EuDRACT number 2009-010335-41). The findings of this trial will be disseminated to patients and through peer-reviewed publications and international presentations.

Granulocyte colony-stimulating factor and autologous CD133-positive stem-cell therapy in liver cirrhosis (REALISTIC): an open-label, randomised, controlled phase 2 trial

Summary Background Results of small-scale studies have suggested that stem-cell therapy is safe and effective in patients with liver cirrhosis, but no adequately powered randomised controlled trials have been done. We assessed the safety and efficacy of granulocyte colony-stimulating factor (G-CSF) and haemopoietic stem-cell infusions in patients with liver cirrhosis. Methods This multicentre, open-label, randomised, controlled phase 2 trial was done in three UK hospitals and recruited patients with compensated liver cirrhosis and MELD scores of 11·0–15·5. Patients were randomly assigned (1:1:1) to receive standard care (control), treatment with subcutaneous G-CSF (lenograstim) 15 μg/kg for 5 days, or treatment with G-CSF for 5 days followed by leukapheresis and intravenous infusion of three doses of CD133-positive haemopoietic stem cells (0·2 × 106 cells per kg per infusion). Randomisation was done by Cancer Research UK Clinical Trials Unit staff with a minimisation algorithm that stratified by trial site and cause of liver disease. The coprimary outcomes were improvement in severity of liver disease (change in MELD) at 3 months and the trend of change in MELD score over time. Analyses were done in the modified intention-to-treat population, which included all patients who received at least one day of treatment. Safety was assessed on the basis of the treatment received. This trial was registered at Current Controlled Trials on Nov 18, 2009; ISRCTN, number 91288089; and the European Clinical Trials Database, number 2009-010335-41. Findings Between May 18, 2010, and Feb 26, 2015, 27 patients were randomly assigned to the standard care, 26 to the G-CSF group, and 28 to the G-CSF plus stem-cell infusion group. Median change in MELD from day 0 to 90 was −0·5 (IQR −1·5 to 1·1) in the standard care group, −0·5 (−1·7 to 0·5) in the G-CSF group, and −0·5 (−1·3 to 1·0) in the G-CSF plus stem-cell infusion group. We found no evidence of differences between the treatment groups and control group in the trends of MELD change over time (p=0·55 for the G-CSF group vs standard care and p=0·75 for the G-CSF plus stem-cell infusion group vs standard care). Serious adverse events were more frequent the in G-CSF and stem-cell infusion group (12 [43%] patients) than in the G-CSF (three [11%] patients) and standard care (three [12%] patients) groups. The most common serious adverse events were ascites (two patients in the G-CSF group and two patients in the G-CSF plus stem-cell infusion group, one of whom was admitted to hospital with ascites twice), sepsis (four patients in the G-CSF plus stem-cell infusion group), and encephalopathy (three patients in the G-CSF plus stem-cell infusion group, one of whom was admitted to hospital with encephalopathy twice). Three patients died, including one in the standard care group (variceal bleed) and two in the G-CSF and stem-cell infusion group (one myocardial infarction and one progressive liver disease). Interpretation G-CSF with or without haemopoietic stem-cell infusion did not improve liver dysfunction or fibrosis and might be associated with increased frequency of adverse events compared with standard care. Funding National Institute of Health Research, The Sir Jules Thorn Charitable Trust.

Effect of liraglutide on adipose insulin resistance and hepatic de-novo lipogenesis in non-alcoholic steatohepatitis: substudy of a phase 2, randomised placebo-controlled trial

Abstract Background Adipose tissue insulin resistance and lipotoxicity are key pathognomonic features in non-alcoholic steatohepatitis (NASH). Liraglutide is a once daily, glucagon-like peptide 1 (GLP-1) analogue that significantly improves glycaemic control, weight, and hepatic steatosis. The aim of this phase 2 study was to determine the effect of liraglutide on insulin sensitivity (hepatic, muscle, adipose), hepatic lipogenesis, and markers of adipose inflammation. Methods 14 patients with biopsy-proven NASH were randomly assigned to either 1·8 mg liraglutide or placebo (once a day subcutaneously) for 12 weeks as part of the metabolic substudy of the double-blind, randomised placebo-controlled LEAN trial. At baseline and 12 weeks, patients underwent paired two-step hyperinsulinaemic euglycaemic clamps incorporating stable isotopes with concomitant adipose tissue microdialysis. Serum adipocytokines were measured with Fluorokine MAP multiplex kits (R&D Systems, UK). In-vitro isotope experiments were performed with Huh-7 and primary human hepatocytes. The LEAN trial is registered with ClinicalTrials.gov, number NCT01237119. Findings Liraglutide significantly decreased weight, waist circumference, HbA 1c , fasting glucose, LDL, and liver enzymes compared with placebo. Liraglutide significantly increased the suppression of hepatic glucose production with low-dose insulin. Liraglutide significantly decreased circulating non-esterified fatty acid (NEFA) in the fasting, low-dose, and high-dose insulin states. Liraglutide significantly reduced the insulin concentration required to half-maximally suppress circulating NEFA and significantly decreased adipose tissue lipolysis, as shown by a reduction in interstitial fluid glycerol concentrations. Furthermore, liraglutide significantly improved serum markers of adipose inflammation—namely, leptin, adiponectin, and chemokine ligand 2. In addition, liraglutide significantly decreased de-novo lipogenesis in vivo, as measured by incorporation of deuterated 2H 2 0 into palmitate, compared with placebo. In support of our clinical observations, in-vitro experiments using both the Huh-7 cell line and primary cultures of human hepatocytes showed decreased de-novo lipogenesis, measured by incorporation of 14C-acetate into cellular lipid after treatment with GLP-1 (exendin-4). Interpretation Liraglutide significantly reduces metabolic dysfunction, hepatic lipogenesis, hepatic and adipose insulin resistance, and adipose inflammation in patients with NASH. GLP-1 analogue therapy might be a novel treatment for patients with this condition. Funding Wellcome Trust, National Institute of Health Research, Novo Nordisk.

Hepatitis C virus kinetics after liver transplantation to study the role of a small molecule inhibitor of viral entry

Abstract Background After liver transplantation in patients infected with hepatitis C virus (HCV), reinfection of the transplanted liver is universal. The targeting of viral entry at the time of transplantation is therefore an attractive strategy. An understanding of the mechanisms and kinetics of this process will allow rational studies of small molecule inhibitors or neutralising antibodies that target HCV entry. Methods As part of a proof of concept study of ITX5061 (a small molecule antagonist of the HCV entry receptor, scavenger receptor B-I), we have studied detailed HCV kinetics. HCV RNA was quantified in plasma before and after liver transplantation. This study is registered with ClinicalTrials.gov, number NCT01292824. Findings 13 patients were studied (median age 57 years, 11 male). Seven patients were infected with genotype 1, four with genotype 3, and one each with genotypes 2 and 4. During the period when no blood flowed through the liver there was a slow decline in plasma HCV RNA. After implantation of the donor liver there was a rapid decrease in HCV RNA in the plasma indicating entry of viral particles into the liver. Typically, there was a 90–99% decrease in HCV RNA at 4 h after implantation. This decrease continued until 12 h after implantation in all patients, and the initial rapidity of HCV RNA decline suggests the presence of specialised clearance systems in the liver. After this decrease, five patients showed a steady increase in plasma HCV RNA, which returned to baseline within 96 h indicating a rapid establishment of productive infection in the allograft. In the remaining eight patients there was a prolonged nadir for up to 21 days after transplant suggesting innate immune control in the transplanted liver. No differences in kinetics were observed between patients infected with different viral genotypes, or in the degree of liver injury at the time of transplantation. Interpretation These marked differences in viral kinetics have major implications for trial design and probably have important biological significance in innate control of infection. Funding National Institute for Health Research.