Safety profile of autologous macrophage therapy for liver cirrhosis

Article metrics

Abstract

Therapies to reduce liver fibrosis and stimulate organ regeneration are urgently needed. We conducted a first-in-human, phase 1 dose-escalation trial of autologous macrophage therapy in nine adults with cirrhosis and a Model for End-Stage Liver Disease (MELD) score of 10–16 (ISRCTN 10368050). Groups of three participants received a single peripheral infusion of 107, 108 or up to 109 cells. Leukapheresis and macrophage infusion were well tolerated with no transfusion reactions, dose-limiting toxicities or macrophage activation syndrome. All participants were alive and transplant-free at one year, with only one clinical event recorded, the occurrence of minimal ascites. The primary outcomes of safety and feasibility were met. This study informs and provides a rationale for efficacy studies in cirrhosis and other fibrotic diseases.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Fig. 1: Trial profile.
Fig. 2: MELD score over time per cell dose group.
Fig. 3: Secondary outcomes.

Data availability

Data in the published article (and its Supplementary Information files) has been presented where possible in aggregated form. Any data presented to illustrate individual patient performance has been de-identified and only includes analysis of performance within the trial (such as MELD score). The datasets generated during and/or analyzed during the current study are available from the corresponding author (S.J.F.) upon reasonable request, although restrictions may apply due to patient privacy and the General Data Protection Regulation.

References

  1. 1.

    Asrani, S. K., Devarbhavi, H., Eaton, J. & Kamath, P. S. Burden of liver diseases in the world. J. Hepatol. 70, 151–171 (2019).

  2. 2.

    D’Amico, G., Garcia-Tsao, G. & Pagliaro, L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J. Hepatol. 44, 217–231 (2006).

  3. 3.

    Forbes, S. J., Gupta, S. & Dhawan, A. Cell therapy for liver disease: from liver transplantation to cell factory. J. Hepatol. 62, S157–S169 (2015).

  4. 4.

    Schuppan, D. & Kim, Y. O. Evolving therapies for liver fibrosis. J. Clin. Invest. 123, 1887–1901 (2013).

  5. 5.

    Duffield, J. S. et al. Selective depletion of macrophages reveals distinct, opposing roles during liver injury and repair. J. Clin. Invest. 115, 56–65 (2005).

  6. 6.

    Gouw, A. S., Clouston, A. D. & Theise, N. D. Ductular reactions in human liver: diversity at the interface. Hepatology 54, 1853–1863 (2011).

  7. 7.

    Boulter, L. et al. Macrophage-derived Wnt opposes Notch signaling to specify hepatic progenitor cell fate in chronic liver disease. Nat. Med 18, 572–579 (2012).

  8. 8.

    Ramachandran, P. et al. Differential Ly-6C expression identifies the recruited macrophage phenotype, which orchestrates the regression of murine liver fibrosis. Proc. Natl Acad. Sci. USA 109, E3186–E3195 (2012).

  9. 9.

    Fallowfield, J. A. et al. Scar-associated macrophages are a major source of hepatic matrix metalloproteinase-13 and facilitate the resolution of murine hepatic fibrosis. J. Immunol. 178, 5288–5295 (2007).

  10. 10.

    Bird, T. G. et al. Bone marrow injection stimulates hepatic ductular reactions in the absence of injury via macrophage-mediated TWEAK signaling. Proc. Natl Acad. Sci. USA 110, 6542–6547 (2013).

  11. 11.

    Fraser, A. R. et al. Development, functional characterization and validation of methodology for GMP-compliant manufacture of phagocytic macrophages: a novel cellular therapeutic for liver cirrhosis. Cytotherapy 19, 1113–1124 (2017).

  12. 12.

    Moore, J. K. et al. Phenotypic and functional characterization of macrophages with therapeutic potential generated from human cirrhotic monocytes in a cohort study. Cytotherapy 17, 1604–1616 (2015).

  13. 13.

    Foucher, J. et al. Diagnosis of cirrhosis by transient elastography (FibroScan): a prospective study. Gut 55, 403–408 (2006).

  14. 14.

    Hutchinson, J. A. et al. Cutting Edge: immunological consequences and trafficking of human regulatory macrophages administered to renal transplant recipients. J. Immunol. 187, 2072–2078 (2011).

  15. 15.

    Sharkey, J. et al. Functionalized superparamagnetic iron oxide nanoparticles provide highly efficient iron-labeling in macrophages for magnetic resonance-based detection in vivo. Cytotherapy 19, 555–569 (2017).

  16. 16.

    Thomas, J. A. et al. Macrophage therapy for murine liver fibrosis recruits host effector cells improving fibrosis, regeneration and function. Hepatology 53, 2003–2015 (2011).

  17. 17.

    Newsome, P. N. et al. Granulocyte colony-stimulating factor and autologous CD133-positive stem-cell therapy in liver cirrhosis (REALISTIC): an open-label, randomised, controlled phase 2 trial. Lancet Gastroenterol. Hepatol. 3, 25–36 (2018).

  18. 18.

    Younossi, Z. M. et al. Impact of liver transplantation on health-related quality of life. Liver Transpl. 6, 779–783 (2000).

  19. 19.

    Younossi, Z. M., Guyatt, G., Kiwi, M., Boparai, N. & King, D. Development of a disease specific questionnaire to measure health related quality of life in patients with chronic liver disease. Gut 45, 295–300 (1999).

  20. 20.

    Le Tourneau, C., Lee, J. J. & Siu, L. L. Dose escalation methods in phase I cancer clinical trials. J. Natl Cancer Inst. 101, 708–720 (2009).

  21. 21.

    Kullak-Ublick, G. A. et al. Drug-induced liver injury: recent advances in diagnosis and risk assessment. Gut 66, 1154–1164 (2017).

  22. 22.

    Mehta, R. L. et al. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit. Care 11, R31 (2007).

  23. 23.

    Henter, J. I. et al. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr. Blood Cancer 48, 124–131 (2007).

  24. 24.

    Tinegate, H. et al. Guideline on the investigation and management of acute transfusion reactions. Prepared by the BCSH Blood Transfusion Task Force. Br. J. Haematol. 159, 143–153 (2012).

  25. 25.

    Day, J., Patel, P., Parkes, J. & Rosenberg, W. Derivation and performance of standardized enhanced liver fibrosis (ELF) test thresholds for the detection and prognosis of liver fibrosis. J. Appl. Lab. Med. 3, 815–826 (2019).

  26. 26.

    Friedrich-Rust, M. et al. Comparison of ELF, FibroTest and FibroScan for the non-invasive assessment of liver fibrosis. BMC Gastroenterol. 10, 103 (2010).

  27. 27.

    Karsdal, M. A. et al. Extracellular matrix remodeling: the common denominator in connective tissue diseases. Possibilities for evaluation and current understanding of the matrix as more than a passive architecture, but a key player in tissue failure. Assay Drug Dev. Technol. 11, 70–92 (2013).

  28. 28.

    Nielsen, M. J. et al. The neo-epitope specific PRO-C3 ELISA measures true formation of type III collagen associated with liver and muscle parameters. Am. J. Transl. Res. 5, 303–315 (2013).

  29. 29.

    Veidal, S. S. et al. Matrix metalloproteinase-9-mediated type III collagen degradation as a novel serological biochemical marker for liver fibrogenesis. Liver Int. 30, 1293–1304 (2010).

  30. 30.

    Leeming, D. J. et al. Pro-C5, a marker of true type V collagen formation and fibrillation, correlates with portal hypertension in patients with alcoholic cirrhosis. Scand. J. Gastroenterol. 50, 584–592 (2015).

  31. 31.

    Karsdal, M. A. et al. Assessment of liver fibrosis progression and regression by a serological collagen turnover profile. Am. J. Physiol. Gastrointest. Liver Physiol. 316, G25–G31 (2019).

  32. 32.

    Huo, T. I. et al. Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child–Turcotte–Pugh score. J. Hepatol. 42, 826–832 (2005).

  33. 33.

    Barber, K. et al. Elective liver transplant list mortality: development of a United Kingdom end-stage liver disease score. Transplantation 92, 469–476 (2011).

  34. 34.

    Loria, A., Escheik, C., Gerber, N. L. & Younossi, Z. M. Quality of life in cirrhosis. Curr. Gastroenterol. Rep. 15, 301 (2013).

Download references

Acknowledgements

This work was supported by a Medical Research Council UK grant (Biomedical Catalyst Major Awards Committee; reference MR/M007588/1) to S.J. Forbes. We thank Z.M. Younossi (Center for Outcomes Research in Liver Diseases, Washington, DC, USA) for academic use of the CLDQ instrument and L.J. Fallowfield (Sussex Health Outcomes Research & Education in Cancer (SHORE-C), University of Sussex, UK) for advice about health-related quality of life assessment.

Author information

Conceptualization and design of the work were carried out by S.J.F., C.P., L.R., L.B., D.M., A.L., S.D., E.H., A.R.F., M.L.T., J.D.M.C., N.W.A.M., J.B., J.K.M., P.C.H. and J.A.F. The acquisition, analysis and interpretation of data were performed by S.J.F., J.A.F., F.M., B.D., C.G., D.J.L., M.J.N. and K.M. Trial delivery and administration were carried out by F.M. and A.G. The original draft of the manuscript was written by F.M. The draft was reviewed and edited by all the authors.

Correspondence to Stuart J. Forbes.

Ethics declarations

Competing interests

J.A.F. reports personal fees from Novartis, Ferring Pharmaceuticals, Galecto Biotech, Caldan Therapeutics, Gilde Healthcare, Arix Bioscience, Guidepoint and grants from GlaxoSmithKline, Novartis and Intercept Pharmaceuticals, outside the submitted work. S.J.F. has a grant from Syncona to develop macrophages as a therapy. D.J.L., K.M. and M.J.N. are full-time employees at Nordic Bioscience. D.J.L., M.K. and M.J.N. are among the original inventors and patent holders of C3M and PRO-C3. D.J.L. holds stock in Nordic Bioscience. P.C.H. is an advisor for AbbVie, BMS, Eisai Ltd, Falk, Ferring, Gilead, Gore, Janssen, Lundbeck, MSD, Norgine, Novartis, ONO Pharmaceuticals, Pfizer and Roche, outside the submitted work.

Additional information

Peer review information Jennifer Sargent was the primary editor on this article and managed its editorial process and peer review in collaboration with the rest of the editorial team.

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Extended data

Extended Data Fig. 1 Representative flow cytometry analysis from macrophage manufacturing process.

Samples analysed using a BD FACS Canto II flow cytometer. a) Leukapheresis start material from a patient enrolled in the trial before and after CliniMACS prodigy selection of CD14+ cells. Samples gated on live, singlet, CD45+ cells as described in Fraser et al. Cytotherapy 2017;19:1113-24. Pre-selection, leukapheresis material contains a population of CD14-high mononuclear cells, which is enriched to >95% after CliniMACS Prodigy Selection. b) Enriched macrophages at day 0 and after 7 days of culture in Macrophage-Colony Stimulating Factor (M-CSF). Fewer than 3% of CD14+ cells express the macrophage marker 25F9, which has risen to more than 86% after 7 days culture. Samples gated on live, singlet, CD45+ cells as described in Fraser et al. Cytotherapy 2017;19:1113-24. The product meets the specification of >80% live CD45+ / 25F9+ cells with a delta mean fluorescence change in 25F9 expression of >5x versus the start material as discussed in Fraser et al. Cytotherapy 2017;19:1113-24. (Actual delta 25F9 mean fluorescence is 6.85 in this case).

Extended Data Fig. 2 Dose-limiting toxicity, by dose of cells infused, expressed as change from baseline over time.

DLT = dose-limiting toxicity. a) Fold-change in serum alanine aminotransferase (ALT); DLT defined as >3-fold. b) Fold-change in serum total bilirubin; DLT defined as >3-fold. c) Fold-change in serum creatinine; DLT defined as ≥1.5-fold. d) Fold-change in haemoglobin; DLT defined as >−1.5-fold. One subject in 10^7 cell dose group developed anaemia at 360-day follow-up visit. This was confirmed, after the trial was completed, to be related to florid portal hypertensive gastropathy. e) Fold-change in platelets; DLT defined as >−2 fold. f) Total white cells count absolute numbers; DLT defined as <2.0 × 109/µL. Source data

Extended Data Fig. 3 Selected safety-related serum cytokine levels, by dose of cell infused, expressed as change from baseline over time.

All cytokine measurements are in pg/mL. a) Changes in IL8 levels from baseline. b) Changes in IL1α from baseline—two subjects in dose group 108 cells had undetectable IL1α levels. c) Changes in IL6 from baseline. d) Changes in TNFα from baseline. e) Changes in IFNγ from baseline. f) Changes in IL10 changes baseline. Source data

Extended Data Fig. 4 Change in MELD score from baseline over time and in the first month after cell infusion.

a) Individual participant data, classified by cell dose group (n = 3 per group), expressed as the delta-MELD from baseline (dotted black line) over time. Time-points indicate the time of macrophage infusion (black line; approximately 14 days from baseline) and study-specific follow-up visits in the trial. Primary and secondary outcomes were measured at day-90 post-infusion. b) Individual participant data by cell dose expressed over initial safety and follow-up visits up to 30 days after infusion of macrophages (indicating MELD changes closer to infusion time-point). Source data

Extended Data Fig. 5 Assessments of liver function, by dose of infused cells, expressed as changes from baseline over time.

a) Changes in United Kingdom End-Stage Liver Disease (UKELD) score from baseline (arbitrary units). b) Changes in serum albumin (g/dL) from baseline. Source data

Extended Data Fig. 6 Transient elastography (Fibroscan®) results (kPa), by dose of infused cells, expressed as changes from baseline over time.

One-dimensional transient elastography was performed in fasted subjects using FibroScan® (Echosens, Paris, France) by fully trained and certified operators, using either an M or XL probe to obtain ten valid readings, with a success rate of at least 60% and IQR < 30% of the median result. Three results did not meet the manufacturer’s recommended validity criteria and were therefore removed (baseline measure for participant 004 and participant 005 and 90 days measure for participant 008). Source data

Extended Data Fig. 7 Assessment of non-invasive serum liver fibrosis markers (individual Enhanced Liver Fibrosis (ELF) test components), by dose of infused cells, expressed as changes from baseline over time.

a) Changes in serum hyaluronic acid (ng/mL) from baseline. b) Changes in serum procollagen III amino terminal peptide (PIIINP; ng/mL) from baseline. c) Changes in serum tissue inhibitor of metalloproteinase 1 (TIMP-1; ng/mL) from baseline. Source data

Extended Data Fig. 8 Measurement of health-related quality of life scores using the Chronic Liver Disease Questionnaire (CLDQ) instrument, by dose of cells infused, expressed as change from baseline over time.

Measurement of health-related quality of life scores using the Chronic Liver Disease Questionnaire (CLDQ) instrument, by dose of cells infused, expressed as change from baseline over time. CLDQ domains are assessed using seven-point scales, ranging from the worst (1) to the best (7) possible function. a) Changes in ‘Emotional’ domain score from baseline. b) Changes in ‘Worry’ domain score from baseline. Each line in each of the graphs represents data from an individual participant. Source data

Supplementary information

Supplementary Information

Supplementary Table 1 and original study protocol for phase 1 MATCH study.

Reporting Summary

Source data

Source Data Fig. 1

Statistical source data

Source Data Fig. 2

Statistical source data

Source Data Extended Data Fig. 2

Statistical source data

Source Data Extended Data Fig. 3

Statistical source data

Source Data Extended Data Fig. 4

Statistical source data

Source Data Extended Data Fig. 5

Statistical source data

Source Data Extended Data Fig. 6

Statistical source data

Source Data Extended Data Fig. 7

Statistical source data

Source Data Extended Data Fig. 8

Statistical source data

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark