Correspondence to Dr Ping Wan; [email protected] ; Ludi Zhang; [email protected] ; Dr Qiang Xia; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
This study innovatively uses accelerated titration combined with traditional 3+3 design to minimise the number of patients receiving an unbeneficial therapeutic dosage.
Hepatic organoid transplantation with microencapsulated hydrogels will show its benefit in long-lasting durability and better functional support, as already evaluated in preclinical experiments.
This study includes a majority of diverse protopathy diseases as well as participants of different ages.
There may be limitations in providing powerful evidence regarding different ethnic groups due to the single-centre design.
Introduction
Based on the huge clinical demand for the treatment of liver failure, researchers of this project sought to achieve a breakthrough therapy for liver cell transplantation in the treatment of liver failure, using the cutting-edge technology of liver cell ex vivo expansion developed by Chinese researchers. A brief overview of this project is provided below.
Huge clinical need for liver failure treatment
Liver diseases have become one of the leading causes of death and illness worldwide. Major liver diseases, including acute hepatitis, cirrhosis and liver cancer, caused more than 2 million deaths worldwide in a single year, accounting for approximately 4% of all deaths.1 The liver is the largest metabolic detoxification organ in the body. Its structural unit is the hepatic lobule, which is composed of the hepatic plate formed by hepatic parenchymal cells, the bile ducts formed by bile duct epithelial cells and the vascular network formed by vascular endothelial cells. Hepatic parenchymal cells account for about 80% of the total number of cells in the liver2 and are the main performers of detoxification, metabolism and synthesis in liver tissues.
China has a high prevalence of liver diseases, with about 300 million patients suffering from various types of liver diseases, where the incidence of severe liver diseases is 1%–3%.3 More than half a million people die from end-stage liver disease every year in China.3 Liver failure is defined as severe impairment of liver functions caused by a variety of factors.4 Patients usually present with life-threatening clinical syndromes, including coagulation dysfunction, jaundice, hyperbilirubin, hepatic encephalopathy and ascites.5 Based on the pathological features and the course of the disease, liver failure is classified into four major groups: acute liver failure, subacute liver failure, acute-on-chronic liver failure (ACLF) and slow-onset liver failure. In situ liver transplantation is the most effective treatment for liver failure, but only a limited number of patients undergo liver transplantation due to the shortage of donors. Most patients die while waiting for a donor.6 Therefore, the treatment of liver failure is currently an urgent clinical challenge deserving further exploration.
Advantages and progress of hepatocyte transplantation
Hepatocyte transplantation technique
Hepatocyte transplantation technology is a promising method for treating various critical liver diseases, where hepatocytes are transplanted into the recipient to play the role of normal liver cells, providing additional liver function support and promoting the recovery of the patient’s own liver.7 Hepatocyte transplantation is safer and easier to promote in clinical practice than liver transplantation. Hepatocyte transplantation has already played an important role in the clinical treatment of hereditary metabolic liver diseases.8 9 Also, hepatocyte therapy can be used as a preoperative bridge to liver transplantation in patients with acute liver failure, CLF (chronic liver failure) and ACLF.10 Thus, hepatocyte transplantation can be used both as an aetiological treatment and as a bridge and complementary approach.11 Peritoneal transplantation is an important approach for hepatocyte transplantation. The large space of the abdominal cavity allows for a larger number of hepatocytes in a single course compared with other transplantation sites. The rich blood supply and high exchange efficiency of the peritoneum can effectively prolong the lifetime of patients with liver failure.12 However, due to the presence of many immune cells in the peritoneal cavity and the absence of a medium for cells to grow, the hepatocytes cannot survive for a long time after peritoneal transplantation, which affects the efficacy of hepatocyte transplantation.
Microencapsulated cell technology and application
To suppress immune rejection and promote cell survival, a microencapsulation immune isolation technique was established based on sodium alginate.13 Sodium alginate is a natural polymeric material, a cell wall component of seaweed consisting of mannuronic acid and guluronic acid. When sodium alginate comes in contact with a low concentration of calcium chloride solution, calcium ions and gullo-glyoxal non-covalently bond and microcapsules are formed. Cells are encapsulated in low-immunogenic microcapsules with a semipermeable membrane where material exchange works as normal, but immune rejection is well reduced or even eliminated.
Currently, sodium alginate microcapsule immune isolation technology is widely used in cell transplantation, including islet, neuron and hepatocyte, and it is also used in cardiac ischaemic rehabilitation, cerebral neurological rehabilitation, bone rehabilitation and meniscal rehabilitation (table 1). Between 1989 and 2015, research teams from countries such as Italy and Belgium carried out microencapsulated islet cell transplantation, which was observed in clinical trials for more than 3 years (up to 9.5 years in 1 patient), demonstrating the safety of microencapsulated cell peritoneal transplantation.14 15 The clinical trials on islet cell transplantation in type I diabetes, conducted by Living Cell Technologies, are currently in clinical phase II trials in New Zealand, Russia and Argentina, further demonstrating the safety of microencapsulated cell peritoneal transplantation. The safety of microencapsulated cell intraperitoneal transplantation was further demonstrated in phase II clinical trials of type I diabetes in New Zealand, Russia and Argentina.11 16
Table 1Clinical application progress of ultra-pure sodium alginate products
| Name | Category | Manufacturer | Country | Application | Development phase |
| Algisyl | Tissue repair | LoneStar Heart | America | Myocardial repair | Marketed |
| IK-5001 | Tissue repair | BioLineRx | Israel | Myocardial repair | FDA II |
| Emdogain | Tissue repair | Straumann | Switzerland | Enamel restoration | Marketed |
| Progenix DBM Putty | Tissue repair | Medtronic Sofamor Danek | America | Bone repair | Marketed |
| NTCELL | Cell transplantation | LCT | New Zealand | Parkinsonism | FDA IIb |
| DIABECELL | Cell transplantation | Diatranz Otsuka | Japan | Type I diabetes | FDA II |
FDA, Food and Drug Administration; LCT, Living Cell Technologies.
In the field of liver failure treatment, Prof. Anil Dhawan (clinical advisor of this project) from King’s College Hospital, London, UK, has conducted a clinical study of microencapsulated hepatocyte transplantation based on ultra-pure sodium alginate for the treatment of liver failure in children. All patients tolerated microencapsulated hepatocyte therapy at 1.5–3×107/kg without any adverse effects. Four of eight children achieved liver self-healing without liver transplantation, three were successfully bridged to liver transplantation and one achieved ideal liver function after treatment but died of a congenital heart defect.16
Despite the promising clinical applications of microencapsulated hepatocytes, the source of human primary hepatocytes is far from meeting the clinical demand due to the lack of donors. Therefore, the problem of seed hepatocyte source is becoming more and more prominent and has become a bottleneck limiting the widespread application of hepatocyte transplantation technology.9 Stem cell technology is a potential way to achieve both large-scale expansion and quality control under Good Manufacture Practice (GMP) conditions.
Progress in technology for obtaining human functional liver cells
Researchers have been able to induce directional differentiation of embryonic stem cells or induced pluripotent stem cells into liver parenchymal cells. However, hepatocyte-like cells directionally differentiated from pluripotent stem cells currently suffer from immature liver function and tumourigenicity.17 In vitro, expansion of human primary hepatocytes has been a challenge and a hot topic in the field.17 In 2013, researchers screened two compounds, FPH1 and FPH2, to promote human hepatocyte proliferation in vitro, but the expansion folds were only 10-fold.18 In 2018, Hans Clevers' laboratory reported that human fetal hepatocytes were successfully expanded in organoid culture, but the expansion of human primary hepatocytes was limited in this kind of culture condition and the integration efficiency was low after in vivo transplantation.19 Our team, directed by LH, has established a brand-new theory and culture system for the in vitro expansion of human hepatocytes and achieved a large-scale expansion of human primary hepatocytes in vitro, which can expand more than 10 000-fold in vitro.20 The products, proliferating human hepatocytes (ProliHHs), retain the function as mature hepatocytes, which can be maintained in vitro for more than 2 months after forming liver micro-organs in a three-dimensional culture system. Transplantation of ProliHHs into a mouse model of hepatic metabolic disease could repair the damaged liver, enhance its function and prolong animal survival time and survival rate, demonstrating that ProliHH transplantation could cure liver failure caused by metabolic disease. Compared with hepatocytes directly differentiated from stem cells, ProliHHs take advantage of greater similarity to mature hepatocytes, no introduction of an exogenous gene and no tumourigenicity. Compared with human primary hepatocytes, ProliHHs have the advantages of large-scale expansion, easy quality control and better clinical dissemination. Therefore, ProliHHs have a promising application in clinical hepatocyte transplantation therapy.
Study purpose
The main purpose of the study is to evaluate the safety of microencapsulated hepatocytes in patients with liver failure. The study was not controlled and, therefore, unable to evaluate the efficacy; however, we observed the clinical improvement rate, model for end-stage liver disease (MELD) and survival rate compared with historical controls to determine the effectiveness.
Methods and analysis
Study design
This study is a single-centre, unblinded, single-arm study comprising a dose escalation phase and a preliminary assessment of efficacy. Subjects who were diagnosed with liver failure (including CLF and ACLF) received 3 days of regular treatment with no beneficial effect and volunteered to participate in microencapsulated hepatocyte intraperitoneal transplantation therapy will be enrolled. Before the clinical research, the recruitment criteria and microencapsulated hepatocyte transplantation protocol will be confirmed. To minimise the number of patients receiving an unbeneficial therapeutic dosage, the accelerated titration design and ‘3+3’ design will be used jointly for the dosage escalation method. The accelerated titration design means that there will be only 1 patient in the initial dose group (0.15×109) during the acceleration phase. If no dose-limiting toxicity (DLT) is observed, the dose applied will increase to the 0.5×109 dose group, where two more patients will be enrolled. All patients with microencapsulated hepatocyte transplantation will be monitored on the 1st, 3rd, 7th, 14th, 28th, 60th and 90th days after the treatment for safety and primary efficacy analyses. The patients could still receive regular clinical treatment, including liver transplantation. The study started enrolment on 1 December 2023 and is expected to conclude by 31 December 2025.
Eligibility criteria
All inclusion and exclusion criteria will be reviewed by the investigator to ensure that the subject qualifies for the study during the screening period and 1 day before treatment.
Inclusion criteria
According to the Guidelines for the Diagnosis and Management of Liver Failure (2018, China) and Criteria and Consensus for Slow and Acute Liver Failure (2019, China), subjects diagnosed as CLF or ACLF will be recruited when they meet all the following criteria:
1. CLF group.
The progressive liver function decline or decompensation after liver cirrhosis.
Body weight >35 kg.
Aged between 18 and 75 years.
Serum total bilirubin (TBil) was higher than the normal range and lower than 10 times the upper limit of the normal value.
With or without significantly decreased serum albumin value, lower than 35.
With or without significantly decreased platelet (PLT) value, prothrombin activity (PTA) ≤40% (or international normalised ratio (INR) ≥1.5), other reasons excluded.
With or without refractory ascites or portal hypertension.
With or without stage I or II hepatic encephalopathy.
No obvious improvement after more than 3 days of regular clinical treatments.
2. ACLF group.
With known or unknown basic liver diseases, subjects undergoing acute liver failure syndrome (clinical manifestations indicated as an early stage of liver failure).
Body weight >35 kg.
Aged between 18 and 75 years.
With obvious fatigue, accompanied by other gastrointestinal symptoms, such as anorexia, vomiting and abdominal distension.
Complicated with ascites and/or hepatic encephalopathy within 4 weeks after diagnosis.
Progressive aggravation of jaundice, total serum bilirubin ≥85 µmol/L.
Coagulation disorders, INR>1.5 or PTA<40%.
No obvious improvement after more than 3 days of regular clinical treatments.
Exclusion criteria
Patients in any of the following situations cannot be selected as subjects.
With obvious brain oedema, cerebral hernia or indicated intracranial haemorrhage.
Diagnosed or suspected as primary or metastatic liver cancer.
With an uncorrectable oxygenation index (PaO2/FiO2) <200.
With disseminated intravascular coagulation.
Active haemorrhage.
Uncontrollable infection, including ascites infection, such as spontaneous bacterial peritonitis.
Uncorrectable decrease in PLT (<20×109/L).
HIV positive.
Drug abuse within 1 year.
Systemic haemodynamic instability.
Combined with pregnancy or lactation.
Other situations excluded by the clinician.
Participants and recruitment
The study will be advertised to the community through the Clinical Trial Centre, WeChat official accounts and hospital public platforms (Shanghai Ren Ji Hospital). Once participants contact the researcher, the study will be explained in more detail, including background, risks and benefits. The patient will be asked to sign the informed consent (online supplemental file 1) voluntarily for subsequent enrolment screening and clinical research. Participants could withdraw the informed consent form (ICF) at any time and be treated fairly. For participants who discontinue or deviate from intervention protocols, researchers should try to contact them by phone or letter as much as possible to collect the latest assessment data.
Description of intervention
Participants will receive a single course of microencapsulated hepatocyte intraperitoneal transplantation therapy. The hepatocytes encapsulated are consecutively amplified and cultured from primary human hepatocytes, and their function was maintained via a 3D culture system. Through ultra-purified sodium alginate encapsulation, microencapsulated hepatocytes were generated. Cell products will be tested through the established quality control standard. The GMP cell production centre at Shanghai Hexacell Biotech company is responsible for the amplification, preparation and storage of the microencapsulated hepatocytes. The cell products will be thawed before transplantation. The cannula (sizes: 16–20 G) will be placed in the abdominal cavity of the patient, under the guidance of ultrasound.
A single course will be divided into an ‘accelerated titration design’ phase and a ‘3+3 design’ phase to reduce the number of subjects exposed to potentially ineffective doses that may not provide treatment benefits (figure 1). The ‘accelerated titration design’ phase starts at the starting dose of 0.15×109, moving to the ‘3+3 design’ phase at the dose of 0.5×109. According to the semilogarithmic incremental (100.5-fold) approach, the treatment dosage was set into four groups at the dose of 0.15×109, 0.5×109, 1.5×109 and 4.5×109 (allowing for a ±20% difference between the actual dose and the planned dose, considering production specifics).
Enlarge this image.Figure 1. Diagrams of accelerated titration design and 3+3 design. The starting dose of 0.15×10 9 corresponds to the ‘accelerated titration design’ phase, while the dose of 0.5×10 9 initiates the transition to the ‘3+3 design’ phase. DLT, dose-limiting toxicity.
Accelerated titration design
The first patient is enrolled with a starting dose of 0.15×109. Then:
If no DLT is observed, the dose applied will increase to the 0.5×109 dose group and change to a ‘3+3 design’.
If DLT is observed in the first subject, the clinical study will be terminated. The researchers will analyse the preclinical and clinical data and redesign the clinical protocol.
According to the CTCAE (Common Terminology Criteria for Adverse Events) V.5.0, DLT is defined as a non-fatal adverse event (AE) related to microencapsulated hepatocyte transplantation that occurs within 28 days after the subject receives the cell therapy, including the following conditions: (1) grade 4 AE related to microencapsulated hepatocyte transplantation after treatment and (2) grade 3 AE related to microencapsulated hepatocyte transplantation after treatment without resolution to grade ≤2 within 7 days.
3+3 design
With the starting dose of 0.5×109, 3 subjects are randomised to each dose group in the ‘3+3 design’ for dose escalation. In each dose group:
If there are ≥2 DLT cases in these 3 cases, the dose cannot be adopted in the clinical trial. A lower dose should be applied to assess the dose toxicity.
If 1 DLT occurs in these 3 cases, 3 additional cases are needed to assess its dose toxicity. If there is ≥1 DLT in the additional 3 cases, the dose should not be adopted by the clinical trial. A lower dose should be applied to assess the dose toxicity.
If no DLT occurs in any of the 3 cases, the dose can increase to the higher group. If it has been raised to the highest dose, 3 more patients should be enrolled to assess the dose toxicity. If there is ≤1 DLT in the newly enrolled 3 cases, the dose can be judged as the maximum tolerated dose (MTD). MTD should be applied to at least 6 patients. Another patient should be enrolled if one subject does not complete the DLT observation period due to withdrawal for reasons other than DLT.
Concomitant and prohibited treatments
Concomitant treatments
All forms of concomitant drug or non-drug treatments, including vitamins, fluids and blood transfusions, except for physiological saline or glucose injections used as solvents having no therapeutic effect, must be recorded from the enrolment to the withdrawal of subjects or 2 months after the microencapsulated hepatocyte transplantation. All concomitant treatments, including permitted and prohibited concomitant treatments, during this period should be recorded in the original medical records and case report form (CRF). During the period from enrolment to 2 months after the microencapsulated hepatocyte transplantation, the following drugs and operating procedures are allowed: (1) liver-protecting and jaundice-reducing drugs (including glutathione, adenosine methionine succinate, ursodeoxycholic acid, etc); (2) albumin, immunoglobulin, blood products, prothrombin complexes, fibrinogen, vitamin K1 and other supportive therapies; (3) antibiotics; (4) ammonia-lowering drugs (including ornithine aspartate, lactulose, arginine, etc); (5) enteral or parenteral nutrition; (6) drugs for chronic diseases such as hypertension and diabetes; (7) non-biological artificial liver therapy and (8) liver transplantation.
Prohibited treatments
During the period from the enrolment to 2 months after the microencapsulated hepatocyte transplantation, the following treatments are prohibited: (1) in vivo cell transplantation therapy and (2) biological artificial liver therapy.
Primary outcome measures
Safety and tolerability will be evaluated on the 1st, 3rd, 7th, 14th, 28th, 60th and 90th days after cell transplantation therapy.
Adverse events
AEs refer to any adverse medical manifestations, including all abnormal findings, subjective and objective disease symptoms, complications and accidents that occur in subjects during treatment. AEs can occur due to the use of microencapsulated liver cell transplantation therapy or can be caused by accidental or intentional drug overdose, toxicity, abuse or withdrawal. Any worsening of existing conditions or diseases is considered an AE. Any AE that occurs during the research process should be classified according to the NCI CTCAE V.5.0 and recorded in the original form and CRF.
Serious AEs
SAEs refer to any experience that significantly harms the patient and/or contraindications that affect continuous treatments. In clinical practice, SAE includes the following events: (1) fatal; (2) life-threatening; (3) requiring unplanned hospitalisation or extended hospitalisation time; (4) causing permanent or significant disability/loss of function; (5) causing congenital malformations or birth defects and (6) medically significant or requiring clinical intervention to prevent the occurrence of any of the outcomes mentioned above.
Maximum tolerated dose
MTD is defined as the highest dose at which DLT occurs in no more than 1 out of 6 subjects. MTD should be applied to at least 6 patients. Another patient should be enrolled if one subject does not complete the DLT observation period due to withdrawal for reasons other than DLT.
Secondary outcome measures
Efficacy and immunogenicity will be evaluated on the 1st, 3rd, 7th, 14th, 28th, 60th and 90th days after cell transplantation. (1) Clinical improvement rate calculated referring to Chapter 2.6.2.2 of Guidelines for the Diagnosis and Management of Liver Failure (2018, China); (2) scores according to MELD and (3) serum antibodies against Human Leukocyte Antigen (HLA) Class I and II.
Evaluation criteria
Safety
The subject tolerates the treatment with absent or manageable AEs on the 1st, 3rd, 7th, 14th, 28th, 60th and 90th days after cell transplantation.
Relevance between AEs and hepatocyte transplantation
Researchers need to carefully observe any AE occurring in all subjects during the study, promptly record their clinical manifestations, severity, time of appearance, duration, treatment methods and prognosis and evaluate whether it is relevant to microencapsulated hepatocyte transplantation (table 2). The evaluation criteria for relevance are listed below. (1) The time of appearance of AEs coincides with the time of transplantation treatment; (2) AEs are associated with known adverse reactions in microencapsulated liver cell transplantation therapy; (3) AEs cannot be explained by other reasons; (4) AEs disappear after discontinuing microencapsulated hepatocyte transplantation treatment and (5) AEs recur after the treatment of microencapsulated hepatocyte transplantation. Criteria for evaluating the relevance between AEs and hepatocyte transplantation are as follows: (1) definitely relevant—simultaneously meeting the criteria of items 1, 2, 3, 4 and 5 mentioned above; (2) possibly relevant—simultaneously meeting the criteria of items 1, 2, 3 and 4 above; (3) unable to judge—simultaneously meeting the criteria of items 1 and 2 mentioned above; (4) possibly irrelevant—meeting the criteria of item 1 mentioned above and (5) definitely irrelevant—not meeting any of the 5 items mentioned above.
Table 2Evaluation criteria of AEs
| Judgement results | Evaluation criteria of AEs | ||||
| 1 | 2 | 3 | 4 | 5 | |
| Definitely relevant | + | + | + | + | + |
| Possibly relevant | + | + | + | + | − |
| Unable to judge | + | + | ± | ± | ± |
| Possibly irrelevant | + | ± | ± | ± | ± |
| Definitely irrelevant | − | − | − | − | − |
±, weakly positive; +, positive; -, negative; AE, adverse event.
Efficacy
Increased clinical improvement rate (refer to Chapter 2.6.2.2 of the Diagnosis and Treatment Guidelines for Liver Failure): (a) clinical symptoms such as fatigue, poor appetite, bloating and bleeding tendency have significantly improved, and hepatic encephalopathy has disappeared; (b) signs such as jaundice and ascites have significantly improved; (c) liver function indicators significantly improved (TBil drops below 5 times the normal, PTA>40% or INR<1.5). The formula for calculating the clinical improvement rate is: (clinical improvement cases/total number of clinical cases)×100%.
Improved MELD score is calculated using the formula: R=3.8 ln[bilirubin (mg/dL)]+112 ln(INR)+9.6 ln[creatinine (mg/dL)]+6.4 (aetiology: biliary or alcoholic=0, others=1).
Increased survival rates on the 28th, 60th and 90th days compared with the historical control group.
Immunogenicity
Serum antibodies against Class I and Class II HLA have not significantly increased compared with the level before treatment.
Record and management of AEs
The researchers need to obtain information related to AEs through specific questions and appropriate examinations at each follow-up and immediately record it in the source files (such as medical records) and the AEs section of electronic case report form (eCRF), including relevant symptoms, signs and abnormal diagnostic results, although the information can constitute another diagnosis.
Any AE occurring during the research needs to be recorded, and the clinical treatment process of each event should be tracked and recorded until the event is cured, managed, out of contact or explained with other reasons (related to the investigational drug) or followed up for 1 month (unrelated to the investigational drug).
SAEs occurring during the research need to be recorded in the SAE report form, signed and reported to the sponsors.
Researchers need to follow up and record the outcomes of all AEs and track patients dropping out due to AEs until they are completely cured. Researchers need to evaluate whether AEs are relevant to the transplantation and provide supportive evidence.
All clinically significant abnormal indicators in clinical or laboratory examinations should be recorded in an AE form and observed at least once a week until back to normal or baseline level.
Based on preclinical research data and drug composition, attention should be paid to observing changes in liver function, coagulation indicators and the digestive system of patients during the research.
Data collection and management
Study visits and assessments will be conducted in time according to the study schedule (online supplemental file 2). All participants’ data will be manually recorded on a paper-based CRF, and the data entry will be carried out independently by two data administrators. All the personal information, CRFs and other study data will be kept secure and provided only to the researchers. All the original files will be kept in locked cabinets, and electronic data will be password protected.
Study monitoring and quality control
A monitoring committee designated by the sponsors will supervise the study’s progress towards its interim and overall objectives at regular intervals. The monitor will inspect whether the study procedure is conducted according to protocol and confirm that all data recorded on the CRFs are correct, complete and consistent with the original information.
Patient enrolment will be immediately suspended on the occurrence of SAEs (including death, teratogenicity, disability, etc), pending comprehensive evaluation by both the monitoring committee and sponsors. All AEs will undergo rigorous causality assessment by the principal investigator within 24 hours of identification, using predefined safety evaluation criteria. In the event of meeting predefined stopping rules, the investigator is mandated to formally notify both the trial steering committee and sponsor within the stipulated 24-hour timeframe. Subsequently, the trial coordination team will initiate procedures, including immediate notification to all participating sites regarding enrolment suspension and convening an emergency monitoring committee meeting for a comprehensive safety review and subsequent recommendations.
Statistical analysis
All statistical analysis will be conducted using Statistical Analysis System V.9.4. All statistical tests will be two-sided tests. P value of a difference less than 0.05 will be considered statistically significant (unless specifically described). The CI will be 95%.
The baseline data will be analysed using the full analysis set. All efficacy indicators will be analysed using the preprotocol set and the compliance scheme set, and the safety analysis set will be used for the safety analysis.
The continuous data will be described as mean, SD, median, minimum value and maximum value. The category data will be described by the number and percentage of each category.
Subject characteristics
Enrolment and completion: summarise the number of enrolled and completed subjects and list the dropout subjects.
Baseline characteristics of general information: baseline is defined as the data obtained during the screening period. Describe the subject’s demographic characteristics, symptoms, physical signs, comorbidity, allergy history and medical history.
Safety analysis
Describe the number and frequency of various AEs. Analyse the severity, duration, drug-related effect and clinical outcomes of each AE case by case. Calculate the number and frequency of AEs and adverse reactions.
Analyse the abnormal changes in laboratory data before and after drug treatment. For laboratory safety data, highlight the abnormal values which exceed the normal range significantly and have clinical significance.
Efficacy analysis
The life table method was used to calculate the survival rate of patients, and the results will be further used for clinical improvement rate calculation. Efficacy endpoints will be summarised for each dose. TBil, coagulation time, albumin secretion, immunity, inflammation and other indicators were compared before and after treatment using the Wilcoxon matched-pairs signed-ranks test.
Patient and public involvement
Patients or the public will not be involved in the design, conduct, reporting or dissemination plans of this research.
Ethics and dissemination
Ethical approval has been obtained from Shanghai Jiao Tong University School of Medicine, Ren Ji Hospital Ethics Committee, with approval number KY2022-115-B. Results will be disseminated through publication in a peer-reviewed journal.
Discussion
This paper describes the protocol for a single-centre, unblinded, single-arm study to investigate the safety, tolerability and preliminary clinical efficacy of microencapsulated hepatocyte intraperitoneal transplantation therapy for adult patients with liver failure, recruiting in China. The study protocol uses the accelerated titration design and the 3+3 design to reduce the number of subjects exposed to potentially ineffective doses.
Strengths
To date, this clinical trial is the first approved microencapsulated hepatic organoid transplantation in the world. Even though multiple clinical trials related to hepatocyte transplantation or stem cell transplantation have shown their efficacy in patients with liver failure, hepatic organoid transplantation with microencapsulated hydrogels will show its benefit in long-lasting durability and better functional support, as already evaluated in preclinical experiments.
When completed, this clinical trial will overcome the resources of transplanted hepatocytes. Based on our established protocols and Standard Operating Procedure certificated by GMP, we have successfully expanded billions of cells from only a few donors. Rather than isolating and culturing the cells more than 20 days in advance, we expect that in the future, we will be able to provide timely universal human hepatocytes to multiple urgent patients with liver failure.
Limitations
Since we plan to conduct this clinical trial in a single centre, we may restrict our ability to provide powerful evidence regarding different ethnic groups. However, we have included the majority of diverse protopathy diseases as well as participants of different ages. The conclusion should be robust related to liver failure indication. There is also concern about the effective duration of transplanted encapsulated ProliHHs liver organoids (eLO) and eLO’s degradation period. A preclinical study has approved that eLO could be effective for at least 1–2 weeks. We did not observe any eLO left 6 months later in animal experiments. Since invasive procedures, such as peritoneal punctures, may pose potential risks to patients, we did not directly evaluate the survival time of microencapsulated liver cells in the human body, but we plan to develop methodologies to evaluate it in future investigations.
In conclusion, we believe our current clinical trial will guide evidence to properly perform a novel cell transplantation therapy for patients with liver failure. The conclusion will provide the first-in-class hepatic organoid transplantation guideline and standard procedure to prepare universal human hepatocytes.
Ethics statements
Patient consent for publication
Not applicable.
TY, XZ and ML contributed equally.
Contributors All authors contributed to the design and protocol development. All authors have read and approved the final manuscript for publication. PW is the guarantor.
Funding This work has received funding from the National Natural Science Foundation of China (Grant No. 82100694), the Shanghai Central Guidance for Local Science and Technology Development Fund (No. YDZX20243100002002), the Shanghai Science and Technology Innovation Action Plan - Special Program for Medical Innovation Research (No. 22Y21900400), the National Center of Technology Innovation for Biopharmaceuticals (NCTIB2023XB01019) and the Youth Innovation Promotion Association CAS.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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; Hui, Lijian 2 ; Yuan, Xiang 2 ; Sun, Zhen 2 ; Zhang, Ludi 2 ; Xia, Qiang 1 ; Wan, Ping 1 1 Department of liver surgery, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, Shanghai, China
2 State Key Laboratory of Cell Biology, CAS Center for Excellence in Molecular Cell Science, Shanghai Institute of Biochemistry and Cell Biology, Shanghai, Shanghai, China