Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by severe hepatic dysfunction resulting from acute injury to an underlying chronic liver disease and a substantially high short-term mortality rate [1,2]. The hallmark of ACLF is the large-area necrosis of liver tissue and severe inflammation. However, current treatment for ACLF focuses on targeting the triggering insult and optimizing the clinical management of complications [3]. Currently, there is no specific treatment for ACLF, and liver transplantation is the definitive treatment for ACLF. However, many patients cannot benefit from liver transplantation because of limited organ availability, high cost, transplant-related complications, and lifetime immunity-related side effects [4,5]. Therefore, alternative treatment strategies for liver transplantation are being sought,such as an artificial liver support system[6], liver cell transplantation[7] and stem cell transplantations[8]. In particular, the great potential of stem cells to differentiate into multiple cell lineages raises the exciting hypothesis that these cells can be used in tissue repair and tissue-specific cell regeneration, when tissue-resided stem cells are not sufficient for the regeneration of a failing organ. During liver regeneration, bone marrow-derived hematopoietic stem cells (HSC) may mobilize to the liver and, together with hepatocytes and intrahepatic stem cells, contribute to the proliferation of liver cells[9].

GCSF is a 25 kDa secreted glycoprotein encoded by the CSF3 gene. The central physiological role played by GCSF is in the regulation of neutrophil production in health and particularly in emergency responses to infections and bone marrow aplasia. In healthy humans, the serum concentrations of GCSF are typically undetectable or detectable at deficient levels, which markedly increases in the presence of an infectious stimulus. Most of the tissues in the body secrete GCSF after stimulatory effects, such as induction of IL-1, lipopolysaccharide and TNF-a produced by the macrophages, endothelial cells, fibroblasts and related

mesenchymal cells. GCSF has been proposed  as a novel treatment modality in ACLF.It mobilizes hematopoietic stem cells and immune cells and represents an alternative for exogenous  stem cell infusions [[10,11]. It stimulates bone marrow  stem cell production, and it has immune regulation and regeneration capabilities.GCSF promotes injured liver viability and angiogenesis by directly affecting injured liver cells via the AKT and ERK signalling pathways [12].

                                               REVIEW OF LITERATURE

 Previous studies have reported encouraging results on the use of GCSF in animal models. GCSF is found to mobilize hematopoietic stem cells, induce liver regeneration, and improve survival. In human studies, a few small randomized clinical trials have demonstrated not only improvement in liver function with GCSF but also significant survival benefit compared with standard medical therapy for ACLF [13-15]. . Published in 2012, Garg et al. showed in a small single-center trial with in total of 47 patients that the administration of GCSF with a dose of 5 Âµg/kg s.c. and 12 injections over a period of 26 days improved the 60-day survival of patients with acute-on-chronic liver failure (ACLF) from about 30% to almost 70% [13]. The treatment success was attributed to an improved immune cell function, fewer infectious complications as well as higher numbers of CD34+stem cells in the liver potentially facilitating its recovery from injury. A comparable improvement in survival was shown when the efect of GCSF was investigated in further studies either in patients with acute alcoholic hepatitis [16,17] or with decompensated cirrhosis [18,19]. In severe acute alcoholic hepatitis, the 90-day mortality rate declined from more than 70% after standard of care to about 20% when patients were treated with GCSF (with a dose of 10 Âµg/kg/day) in two randomised single-center trials and in both studies GCSF therapy resulted in fewer severe infections [16,17].On the contrary, European clinical trials reported that the use of GCSF in ACLF patients did not result in survival benefits [20,21], which has caused widespread concern. The GRAFT study, a large multicentre trial, was originally initiated with the aim to confrm the efficacy of GCSF in ACLF. By using the identical study protocol as Garg et al. [13] this study failed to show improvement in the 90-day transplant-free survival, which was 34.1% and 37.5% in the GCSF and standard of care arm [20].

The conflicting results between Asian and European studies led to a high degree of overall heterogeneity in previous studies, and it is unclear whether this difference can be explained by ethnic differences or patient selection.There is unmet need of more RCTs and high quality literature to clarify the usefulness of G-CSF for ACLF treatment.

In this background,we decided to conduct this study to analyse the efficacy of GCSF in ACLF patients admitted at our department in SCB Medical college at Cuttack.Our’s is a tertiary care Govt. Hospital in Eastern Coastal region of India.So far this type of study has not been reported from this region.

AIMS AND OBJECTIVES

To assess the efficacy of Granulocyte colony stimulating factor (GCSF) in increasing survival in patients with Acute on chronic liver failure (ACLF) 

Primary objective

1.     To analyse the survival benefit at day 60 in ACLF patients treated with G-CSF.

Secondary objectives

1.     To investigate whether GCSF treatment results in any change in MELD and CTP score

2.     To investigate whether GCSF treatment results in prevention of new onset Hepatic encephalopathy and Hepatorenal syndrome.

3.     

MATERIALS AND METHODS

STUDY DESIGN- RANDOMIZED CONTROLLED OPEN LABEL TRIAL  FROM A TERTIARY CARE CENTRE IN ODISHA

STUDY AREA-DEPARTMENT OF HEPATOLOGY , SCB MEDICAL COLLEGE, CUTTACK.

STUDY DURATION- 1.0 YEARS

STUDY POPULATION-

During the study period all consecutive patient diagnosed as ACLF and fulfilling the inclusion and none of the exclusion criteria will be enrolled prospectively in the study.

INCLUSION CRITERIA:

During the study period  all consecutive patient diagnosed with  ACLF will be enrolled in the study.

EXCLUSION CRITERIA:

1.     Age younger than 12 years and older than 75 years

2.     Patients with HCC or portal vein thrombosis

3.     Patients in septic shock.

4.     Patients with TLC count >50,000/cc

5.     Patients with HIV seropositivity

6.     Patient with significant co morbidity like uncontrolled diabetes, CKD,CVA

7.      Pregnancy

8.     Patient with known hypersensitivity to GCSF

9.     Patients with mental illness and in alcohol withdrawal syndrome.

CONSENT: written informed consent will be taken from each prospective participant.All those patients consenting will be enrolled for the study.

BASELINE DATA: All baseline data of patient will be documented in a prescribed   format The variables   age, gender, presentation at the time of diagnosis.

·       Laboratory parameters:

Ø  Complete haemogram: haemoglobin (Hb), Mean Corpuscular Volume (MCV), platelet count and peripheral blood smear.

Ø  Liver function test: serum aminotransferase (alanine transferase(ALT) and aspartate transferase(AST)),Serum bilirubin(total/direct),total protein/ albumin, alkaline phosphatase(ALP) and GGT.

Ø  Liver indices- MELD Na, CTP, AARC  scores were calculated at baseline

SAMPLE SIZE: The sample size was determined as follows: Based on the hypothesis that GCSF therapy can improve survival rate by 10% in the treatment group compared to the control group, with a power of 95% and an alpha error of 5%, the number of patients should be 25 in each group.

RANDOMIZATION: Patients will be  randomized in a 1:1 ratio based on sequentially numbered envelops to either standard medical therapy (SMT) or standard medical therapy plus G CSF (SMT GCSF).

SMT GROUP: will receive standard medical treatment as per prevailing guidelines

 SMT+ GCSF GROUP: Patients randomized to the GCSF SMT group will be  receiving  GCSF at a dose of 5 µg/kg s.c. daily for 6 days along with SMT as per guidelines.

MONITORING: All patients will be  monitored daily for physical examination,every third day for WBC ,LFT ,RFT and Liver indices MELD Na, CTP, AARC  scores

FOLLOW UP :  During the 3-mo follow-up period, patients will be  monitored for the following parameters: the levels of serum bilirubin and albumin, prothrombin time and concentration, INR, the levels of ALT and aspartate aminotransferase, the levels of blood urea and serum creatinine, complete blood analysis, estimation of the degree of ascites, CTP score, MELD score, and hepatic encephalopathy. The survival rates will be  evaluated over a period of 3 mo.  

STATISTICAL ANALYSIS

Statistical analysis Data Will be  compiled using Excel XP and processed using Statistical Package for Science and Society (SPSS) version 12.0 (SPSS Inc., Chicago, IL). All quantitative variables will be presented as mean ± SD. All qualitative data will be described as frequency or percentage. Comparisons between groups for qualitative data will be  carried out using χ2 test, Fischer’s exact test, or McNemar test when ap propriate. Independent sample t test and paired sample t test will be used for quantitative variables with normal distribution, whereas non-parametric Mann-Whitney test and Wilcoxon signed-rank test will be  used for quantitative variables with non-normal distribution. In all tests, P less than 0.05 will be  considered as statistically significant

PROFORMA FOR STUDY

PROFORMA

1.     REGD. NO.-

2.     NAME OF THE HOSPITAL-

3.     PATIENT PARTICULARS: Name/Age/Sex/Caste/Religion/ Address-

4.     PRESENTING COMPLAINTS:

5.     PAST HISTORY: Past h/o any hospitalization/ BT/ Painful Episodes/ acute pain abdomen/umbilical venous catheterization/umbilical sepsis/dehydration in children.

6.     FAMILY HISTORY:  Relevant family history

7.     IMMUNISATION HISTORY.

8.     DIETARY HISTORY.

9.     GENERAL EXAMINATION.

General Findings-Pallor / Icterus / Cyanosis / Clubbing / Lymphoadenopathy / Edema.

10.  SYSTEMIC EXAMINATION.

Ø  Gastrointestinal System.

·       Abdomen- Soft/ Tense/ Normal/ Distended.

·       Skin- Normal/Venous Prominence.

·       Umbllicus- Normal/ Everted.

·       Liver-  __________ cm.

·       Spleen- _________ cm.

·       Fluid- Present/Absent.

Ø  Respiratory System.

Ø  Cardiovascular System.

Ø  Nervous System.

Ø  Skeletal System.

11.  INVESTIGATIONS.

Ø  Haematology.(Auto analyser method)

·       Biochemical

MELD Na:                                                             

CTP:

AARC :

SOFA SCORE:

Radiological investigation: USG Abdomen

                                               CXR

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