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

Abstract

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 regardto patient outcomes. In this retrospective study, we present our 'real-world experience' of GCSF use in a large group of DC. 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). Nine (16%, n= 56), 24 (43%, n= 56), and 36 (75%, n= 48) patients died at 3, 6, and 12-monthfollow-up after GCSF. The commonest cause of death was sepsis (53%) followed by progressive liver failure (33%). Ninepercent of patients developed hepatocellular carcinomaon 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 6and 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). Survival in DC was shorter than what was expected in the natural history of the disease after GCSF use.