Review Article

Dig Dis 2006;24:174183

DOI: 10.1159/000090320

Emerging Therapies for Liver Fibrosis

Andrew J. Fowell a John P. Iredale b
a

Liver Research Group, Division of Infection, Inflammation and Repair, University of Southampton,
Southampton General Hospital, Southampton, and
b
MRC/University of Edinburgh Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK

Key Words
Cirrhosis
Antifibrotic therapy
Hepatic stellate cell

Matrix degradation
Apoptosis

Abstract
Liver fibrosis occurs as a result of a wide range of injurious processes and in its end-stage results in cirrhosis.
This gross disruption of liver architecture is associated
with impaired hepatic function, portal hypertension and
significant resultant morbidity and mortality. Indeed, liver fibrosis and cirrhosis represent a major worldwide
healthcare burden. Recent progress in liver transplantation, the management of portal hypertension and the
treatment of chronic viral hepatitis have had an important impact. However, these approaches are not without
their limitations in particular, issues regarding organ
availability for transplantation and serve to highlight
the urgent requirement to influence pharmacologically
the underlying fibrotic process in many patients. Liver
fibrosis has been shown to be a bidirectional process
and increasing data from laboratory and clinical studies
reveal that even advanced fibrosis and cirrhosis are potentially reversible. Exploration of the molecular mechanisms underlying this bi-directionality will lead to characterisation of the essential attributes of an antifibrotic
therapy. In this review, these mechanisms are highlighted and the growing number of emerging antifibrotic
agents discussed.
Copyright 2006 S. Karger AG, Basel

2006 S. Karger AG, Basel

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Introduction

Liver brosis represents the generic wound healing response to a wide range of underlying injurious processes,
including excessive alcohol consumption, chronic viral
hepatitis, non-alcoholic steatohepatitis (NASH), haemochromatosis and immune-mediated liver injury. With
progressive brosis, cirrhosis develops, representing the
end-stage manifestation of these disease processes. Cirrhosis is characterised by the presence of bands of brosis,
parenchymal nodules and vascular distortion, which lead
to hepatic dysfunction and the major life-threatening
complications that are a feature of the condition. Liver
brosis and cirrhosis represent a major worldwide health
problem, with alcohol excess and chronic viral hepatitis
B and C being the signicant causes. The World Health
Organisation estimates that 3% (170 million) of the global population are infected with hepatitis C alone. In the
UK, the death rates from cirrhosis have risen steeply,
with over 4,000 people (two-thirds of them under the age
of 65 years) dying from the disease in 1999 [1]. Furthermore, rising rates of obesity and changing patterns of alcohol consumption in the West predict that the burden
of liver disease related to alcohol and NASH are set to
increase.
Although removal of the injurious process may halt the
progression of liver brosis, any natural resolution of
scarring is very slow and for individuals with advanced
cirrhosis, currently the only curative treatment is liver
transplantation. The advent of new immunosuppressive
regimes has improved the success of this approach, with

Prof. J.P. Iredale

MRC/University of Edinburgh Centre for Inammation Research
University of Edinburgh
Edinburgh, ED16 4TJ (UK)
Tel. +44 131 242 6559, E-Mail [email protected]

Fig. 1. Pathogenesis of liver brosis.

5-year survival following liver transplantation in the region of 75%. However, issues regarding donor organ
availability, compatibility and recipient co-morbidity, restrict the clinical applicability of liver transplantation in
many cases.
Liver brosis and cirrhosis have historically been considered irreversible, but a wealth of clinical and experimental data now suggest that even advanced disease is at
least partially reversible following either specic treatment or removal of the underlying injurious process. Major advances in our understanding of the mechanisms
underlying the progression of and recovery from liver brosis have led to the emergence of a number of exciting
potential therapeutic targets.

Pathophysiology of Liver Fibrosis

Research in a number of centres has led to the identication of the hepatic stellate cell (HSC) as a key effector
in the pathogenesis of liver brosis (g. 1). Located in the
subendothelial space of Disse, these cells store retinoids
in the normal liver. However, during liver injury, HSC
undergo a process of transdifferentiation to an activated,
alpha-smooth muscle actin (
SMA)-positive, myobroblast-like phenotype. These activated HSC proliferate,
develop contractile proteins and express the brillar collagens (chiey types I and III) that characterise hepatic
brosis, as well as a range of cytokines, matrix metalloproteinases (MMPs) and their specic inhibitors, the tissue inhibitors of metalloproteinases (TIMPs). The HSC
plays a pivotal role in the development of liver brosis
and unsurprisingly, offers multiple potential opportunities for therapeutic manipulation. Other cell types also
contribute to the activated myobroblast population, including stem cells and portal myobroblasts.

Investigation of the pathophysiology of liver brosis

has been greatly assisted by the development of reproducible rodent models of liver injury that utilise, for instance,
carbon tetrachloride (CCl4) or bile duct ligation (BDL).
These models have allowed detailed analysis of the extent, chronology and cell dynamics of brotic liver injury
from its onset and importantly, during its subsequent recovery. Furthermore, they have allowed researchers to
characterize the critical attributes of an effective antibrotic therapy.

Hepatic Stellate Cell Activation and Fibrogenesis

Injury to the liver results in the release of various bioactive mediators by resident liver cells and inltrating
leucocytes. Acting in a paracrine fashion, these mediators
are chiey responsible for the initiation of HSC activation. For example, hepatocytes and Kupffer cells (KC)
promote activation of HSC both by the generation of lipid peroxides (and induction of oxidative stress) and by
the release of various cytokines including TGF-, plate-

Liver Fibrosis Therapy

Dig Dis 2006;24:174183

175

let-derived growth factor (PDGF) and endothelin-1

(ET-1) [3]. Acting via intracellular signalling pathways
that are regulated by transcription factors such as NF-B,
c-jun, AP-1, c-myb and Sp1, these cytokines play an important role in HSC activation.
Following activation, HSC proliferate in response to
various mitogens including PDGF, thrombin and angiotensin-II and migrate to sites of injury in response to
growth factors, chemokines and vasoactive mediators
(e.g. PDGF, monocyte chemotactic protein-1 (MCP-1)
and ET-1). Perpetuation of the activated HSC brogenic
phenotype is controlled by a number of autocrine and
paracrine factors such as a cytokines and extracellular
matrix (ECM) components, acting via positive and negative feedback loops. Activated HSC express a range of
ECM components that result in the characteristic quantitative and qualitative changes to the normal hepatic
ECM. The leading brogenic cytokine is TGF-1 [3], produced primarily by HSC, but also by KC and incoming/
recruited macrophages and platelets. HSC are also a major source of the MMPs that degrade normal and brotic
liver ECM. Early in activation HSC exhibit a predominantly matrix-degrading phenotype with activity against
the normal basement membrane-like matrix, through expression of stromelysin and MMP-1/13 and relatively
weak expression of TIMPs. In the later stages of injury,
expression of MMP-2 and -14 predominates, but there is
net inhibition of collagen degradation through increased
secretion of TIMP-1 and -2 [4]. Macrophages and KC are
also potent sources of MMPs; again their activity may be
inhibited by TIMPs.
Matrix-HSC Interaction
As well as acting as a mechanical scaffold, the ECM
itself plays an important function in the control of matrix
synthesis and degradation [5]. Two main processes facilitate this role. Firstly, HSC may receive signals from
certain ECM components that contain ligands recognised
by specic transmembrane receptors known as integrins.
HSC express a number of integrins, the activation of
which results in regulation of various downstream effector functions, including proliferation, migration, contraction and collagen synthesis. Secondly, the ECM acts a
reservoir for matrix-bound MMPs, cytokines and growth
factors, which on matrix degradation are released to modulate HSC function.
Stellate Cell Contractility
Contraction and relaxation of activated HSC may be
a signicant determinant of the increased intrahepatic

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resistance and portal hypertension that accompanies advanced liver brosis [6]. A number of factors have been
shown to induce HSC contraction (e.g. ET-1, angiotensin
II, thrombin, vasopressin) and relaxation (e.g. nitric oxide (NO), carbon monoxide, prostaglandin E1). In cirrhosis, ET-1 and NO are overexpressed and suppressed, respectively. Moreover, ET-1 appears capable of exerting
different effects on HSC whilst brosis progresses. With
early brosis there is enhanced expression of the ETA receptor isoform, as seen in brogenesis in the kidney and
lung. However, as brosis becomes more advanced, there
is over expression of the ETB receptor, which conversely
may limit HSC proliferation and brogenesis.

Reversibility of Liver Fibrosis

Reversal of liver brosis has been demonstrated in a

number of experimental models and paired biopsies
from humans with liver disease. Earlier reports of reversibility have been justiably criticised for being largely
anecdotal and involving relatively small patient numbers. However, recent large scale trials of therapy for
chronic hepatitis C using pre- and post-treatment liver
biopsy have provided robust and compelling data. An
important study by Poynard et al. [7], which analysed
the results of several such randomised controlled trials
using either interferon (IFN) or pegylated-IFN with or
without ribavirin, demonstrated that there was a signicant benecial effect of antiviral treatment on liver brosis, especially in those given combination therapy. The
benets were not restricted solely to those with comparatively early brosis, in that reversal of brotic extent
was demonstrated in 49% (n = 153) of those deemed cirrhotic at baseline.
Rodent models have provided an excellent means to
determine the mechanisms underlying resolution of liver
brosis. Detailed analysis of two such (mechanistically
distinct) models (CCl4 and BDL) has shown that recovery
from even comparatively severe brosis and cirrhosis is
possible, but that in advanced cirrhosis this recovery is
incomplete [8]. The exact mechanisms underlying such
recovery are yet to be determined, but increased hepatic
collagenolytic activity and loss of activated HSC through
apoptosis appear to be central to resolution. In the CCl4
model of liver injury there was a marked increase in HSC
apoptosis on withdrawal of injury. This was associated
with a 50% reduction in activated HSC numbers within
the rst three days of recovery and an upregulation of
liver collagenase activity that coincided temporally with

Fowell/Iredale

a decrease in hepatic TIMP levels and degradation of brotic matrix [9].

Matrix degradation in the liver occurs primarily due
to the action of MMPs. A key initial step in recovery from
liver brosis appears to be the initiation of matrix degradation, launching a cascade of events resulting in loss of
brillar collagens and apoptosis of HSC. The nature and
origin of the major MMPs involved in matrix degradation and restitution of normal or near normal liver architecture remains unclear. The interstitial collagenases
(predominantly MMP-1 in humans and MMP-13 in rodents) appear to play an important role by cleaving the
collagen-1 molecule between Gly775 and Ile776 in the

-1 chain and a corresponding Gly/Leu in the
-2 chain.
This cleavage results in unwinding of the collagen-1 molecule, rendering it more susceptible to degradation by
gelatinases and other more promiscuous MMPs [10]. Recent evidence suggests that MMP-2 (gelatinase A) and
MMP-14 (MT1-MMP), both of which are expressed in
brotic liver, may also have collagenolytic properties. As
described earlier, progressive brosis is characterised by
increased expression of TIMPs. In rodent models of spontaneous recovery from liver brosis, withdrawal of the
injurious agent resulted in a rapid downregulation of
TIMP-1 activity. However, in advanced cirrhosis, TIMP1 expression is maintained longer into the recovery period [8]. Since net collagenase activity is dependent on
the relative levels of MMP and TIMP activity, sustained
TIMP-1 may represent a major determinant of failure to
degrade accumulated scar, leading to limited and incomplete spontaneous resolution.
Cells that die by apoptosis (programmed cell death) do
not usually elicit the inammatory responses that are associated with necrosis. Apoptosis of HSC appears to serve
the function of removing the cells responsible both for
both matrix secretion and concomitant expression of
TIMPs that inhibit matrix degradation. Therefore, the
effect of HSC loss is net matrix degradation. In support
of this hypothesis, it has recently been shown that by inducing HSC apoptosis, recovery from liver brosis in rodents can be accelerated [11]. As discussed earlier, there
is strong evidence for recovery from brosis in humans
following treatment of various liver diseases. Although
HSC apoptosis was not directly evaluated in these studies, there was histological evidence of a reduction in HSC
numbers. Hence, apoptosis of HSCs has emerged as a
pivotal step in the resolution of liver brosis and an important potential therapeutic target.

Liver Fibrosis Therapy

Potential Therapeutic Approaches for

Liver Fibrosis

General Principles
There are currently no approved antibrotic agents in
humans. The rational design of a successful antibrotic
will need to consider a number of general principles. Any
treatment will need to be well tolerated by the recipient,
possibly in multiple doses over a long period of time. In
order to minimise adverse systemic side effects, specic
targeting of the liver is likely to be an important design
requisite. It is possible that combination therapy will be
required with agents that selectively tackle, for instance,
the inammatory, brotic and vascular contractile mechanisms that underpin the clinical manifestations of liver
brosis and cirrhosis.
Although safety and proof of concept may be assessed
in animal models, controlled trials in humans may need
a prolonged period of treatment before any benet is
demonstrated. These trials will by necessity be relatively
costly; however, these nancial implications may be offset from a commercial point of view by the conceivable
requirement for chronic treatment with any successful
agent. Furthermore, a non-invasive method of assessing
response is required as an alternative to serial liver biopsy; an invasive technique, associated with a small, but
well-recognised morbidity and mortality and one prone
to sampling error [12]. Progress in this area has been
made with the recent development of serum brosis
markers. Various panels of these (mainly biochemical)
indices are able to predict the degree of brosis with variable success [13, 14]. It is hoped that with further renement, they will become a valuable tool, both clinically and
in the development of effective antibrotic agents.
Emerging potential therapies for liver brosis may be
sub-divided according to their potential site or mechanism of action as described in detail below and in table
1. However, this classication is in some respects arbitrary and articial in that some agents act through more
than one mechanism (e.g. TGF).
Treatment of the Primary Disease
Treatment of the underlying disease remains the most
effective therapy for liver brosis currently available. Removal of the underlying injurious process produces clinical improvement in chronic liver disease of various aetiologies. Moreover, histological evidence for reversibility of cirrhosis has been reported following abstinence in
alcoholic liver disease, anti-viral therapy in chronic viral
hepatitis B and C, immunosuppression in autoimmune

Dig Dis 2006;24:174183

177

Table 1. Potential therapy for liver brosis

Mechanistic target

Examples

Cure primary disease

remove injurious agent (e.g. alcohol)

anti-viral therapy for hepatitis B/C

Suppress hepatic
inammation

corticosteroids
TNF-
antagonists (e.g. iniximab,
thalidomide)
IL-1 antagonists
IL-10

Inhibit HSC activation

anti-oxidants (e.g. vitamin E,

phosphatidylcholine)
IFN-
glitazones
trichostatin A

Inhibit HSC proliferation

PDGF antagonists
fumigillin analogue

Downregulate HSC
brogenesis

TGF- antagonists
ACE-inhibitors
AT1 receptor antagonists

Enhance matrix
degradation

MMPs
TIMP antagonists
uPA

Promote HSC apoptosis

Fas ligand
NGF
benzodiazepines
gliotoxin
sulphasalazine

liver disease, venesection in haemachromatosis, copper

chelation in Wilsons disease, drug withdrawal in iatrogenesis and decompressive surgery for secondary biliary
cirrhosis [15]. If treatment is instigated early, a near-normal restitution of liver histology has been reported; however, complete resolution of established cirrhosis seems
unlikely, especially given the evidence from animal models [8].
Suppression of Hepatic Inammation
Inammation in the liver invariably precedes brosis
and persistent inammation from a sustained hepatic injury perpetuates the brogenic HSC phenotype. Consequently a number of anti-inammatory agents have been
evaluated both in vitro and in vivo.
Colchicine is a well-known anti-inammatory that has
been used as an antibrotic on the basis of an early study
that suggested improved survival in cirrhotic patients

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[16]. However, a subsequent Cochrane review of 14 randomised controlled trials demonstrated no clinical, biochemical or histological benet and a signicant risk of
adverse events in both alcoholic and non-alcoholic cirrhosis [17]. Malotilate is an immunomodulatory and
anti-inammatory agent with potential for benet in
chronic liver disease. However, although a reduction in
liver damage and collagen deposition was demonstrated
with its use in animal models of liver brosis, large-scale
randomised trials in PBC and ALD were disappointing
[18, 19].
Glucocorticoids have broad-reaching anti-inammatory effects and have been used for many years to successfully treat autoimmune hepatitis. Progression of brosis
and development of cirrhosis are delayed in those that are
steroid responsive, and steroid-sparing agents such as
azathioprine are utilised to limit the long-term side effects
of treatment. Corticosteroids have also been shown to
improve survival and reduce progression to cirrhosis in
selected patients with severe alcoholic hepatitis [20].
However, no benet has been shown in the treatment of
PBC or primary sclerosing cholangitis (PSC) [21].
Antagonism of pro-inammatory cytokines is an attractive mechanism by which hepatic inammation and
brosis might be reduced. TNF
plays an important role
in the development of hepatic inammation, especially
in the pathogenesis of alcoholic hepatitis. A soluble TNF

receptor has shown potential for reducing liver injury
[22]. The humanised monoclonal anti-TNF
antibody
iniximab, which has been used with an acceptable safety prole in the treatment of rheumatoid arthritis and
Crohns disease, showed early promise versus historical
controls in the treatment of acute alcoholic hepatitis [23].
However, a subsequent randomised controlled trial was
stopped early, due to an excess of deaths through sepsis
in the treatment group. Thalidomide also behaves as a
TNF
antagonist and has been shown to be benecial in
experimental models of liver injury [24]. Blockade of IL1, another important pro-inammatory cytokine, using
IL-1 receptor antagonist gene delivery reduced liver damage and pro-inammatory cytokine levels, whilst improving survival in a rodent model of ischaemia-reperfusion
injury [25].
The cytokine IL-10 is known to have potent anti-inammatory and antibrotic effects. IL-10 knock-out mice
exhibit a more brotic phenotype than wild-type controls
in response to liver injury and IL-10 is produced by HSC
during the course of activation in vitro [26, 27]. Recombinant IL-10 was well tolerated and reduced inammation and brosis in patients with chronic hepatitis C who

Fowell/Iredale

were non-responsive to treatment with IFN. However,

treatment led to an increased HCV viral burden via alterations in immunological viral surveillance [28]. Onsite expression of another anti-inammatory cytokine,
IFN
, using an inducible adenovirus vector achieved signicant hepatic retention of IFN
and improved liver
brosis in a dimethylnitrosamine-induced model of cirrhosis [29]. Finally, the benecial effects of ursodeoxycholic acid in the treatment of PBC are thought to be in
part via anti-inammatory mechanisms.
Inhibition of HSC Activation and Effector Function
As discussed earlier, HSC activation, proliferation and
brogenesis are pivotal steps in the development of liver
brosis, and the potent mechanisms that mediate these
processes make attractive targets for therapeutic intervention.
Several therapeutic agents have been applied experimentally in an attempt to prevent the activation of HSC.
A number of anti-oxidants have been investigated, including Vitamin E, which was shown to inhibit HSC activation and suppress brogenesis in experimental models of liver injury [30]. Furthermore, Vitamin E was
shown to reduce HSC activation in a pilot study of humans with chronic hepatitis C infection [31]. Silybum
marianum (milk thistle) is a popular complementary
therapy whose active ingredient, silymarin, is a avinoid
antioxidant. However, a recent randomised controlled
trial of silymarin in ALD showed no benet [32]. Other
potential antioxidants include phosphatidylcholine, an
extract from soya beans, which is being evaluated in ALD,
and S-adenosyl-L-methionine which showed some benet in ALD, although not in those with advanced disease
[33]. IFN- inhibits HSC activation and mice lacking this
cytokine are more prone to develop brosis on liver injury [34]. A large trial of IFN- is under way in humans
with established cirrhosis secondary to HCV.
Histone deacetylation is a major gene regulatory process that operates during HSC activation and trichostatin
A, a deacetylase inhibitor, reduced HSC activation in vitro and CCl4-induced liver disease in vivo [35]. Furthermore, there are a number of other agents, including glycyrrhizin [36], retinyl palmitate [37] and resveratrol [38],
that have not been trialed in humans, but have demonstrated antioxidant and/or protective effects in experimental studies.
Numerous mitogens, including epidermal growth factor, broblast growth factor, insulin-like growth factor
and, especially PDGF, are markedly increased following
acute and chronic liver injury and promote HSC prolif-

eration via tyrosine kinase receptor signalling. PDGF-related HSC mitogenesis is inhibited by both the phosphodiesterase inhibitor pentoxifylline and cariporide [39,
40]. The PDGF intracellular signalling pathway is mediated in part by h-ras, and the ras inhibitor S-farnesylthiosalicylate reduces HSC proliferation and migration and
attenuates thioacetamide-induced liver brosis in rats
[41]. HSC proliferation and progression of experimental
liver brosis are also reduced by TNP-470, a semi-synthetic analogue of fumagillin originally developed as a
chemotherapeutic agent with anti-angiogenic properties
[42]. Recently developed small-molecule tyrosine kinase
receptor inhibitors are being used successfully in the
treatment of gastrointestinal stromal tumours [43], and
it is hoped that this technology might be applicable (with
modication) to the treatment of liver brosis.
TGF- is a key mediator of hepatic brogenesis. With
hepatic injury, latent TGF- is released from the local
ECM in response to inammatory cell activity, yielding
bioactive TGF- that binds to the increased number of
HSC TGF- receptors that accompany activation. Signalling via the SMAD pathway then leads to increased collagen synthesis, upregulation of TIMPs and decreased
MMP expression. Several inhibitors of the TGF- pathway have been effective in experimental models of liver
brosis. These include camostat, a serine protease inhibitor that prevents release of latent TGF- [44], soluble
TGF- type II receptor [45], a dominant negative type II
TGF- receptor [46], adenoviral expression of TGF-1
antisense mRNA [47], and gene transfer of smad7 (which
blocks TGF- intracellular signalling) [48]. To date, no
anti-TGF- strategy has been studied in humans. As with
hepatocyte growth factor, which inhibits HSC proliferation and brogenesis as well as the progression of experimental brosis [49], regulation of TGF- signalling may
potentially prove oncogenic with respect to hepatocytes.
Peroxisome proliferator activator receptor gamma
(PPAR)- is a member of a family of receptors that control cell growth and differentiation. Ligands of PPAR-
such as the thiazolidinediones, inhibit the pro-inammatory and pro-brotic activity of HSC and have been shown
to promote brolysis in experimental models [50]. Such
glitazones have been used in the treatment of diabetes
mellitus for some time and are currently being subjected
to controlled trials in patients with NASH. There are further examples of agents with established roles and safety
records in other areas of human disease, but with potential ability to ameliorate liver brosis. Stimulation of the
renin-angiotensin system via mineralocorticoid receptor
activation, promotes collagen synthesis in the heart and

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Dig Dis 2006;24:174183

179

kidney [51, 52] and captopril and candesartan (angiotensin-converting enzyme (ACE) inhibitor and angiotensin II type 1 (AT1) receptor antagonist, respectively) have
been shown to attenuate liver brosis in animal models
[53, 54].
As discussed earlier, contraction of activated HSC is
thought to be a major determinant of portal hypertension.
The ETA/ETB receptor antagonist, bosentan, has been
shown to reduce portal pressure when perfused into cirrhotic rat liver [55]. Similar effects have been demonstrated using adenoviral expression of neuronal NO synthetase [56]. Furthermore, bosentan has been shown to
inhibit HSC activation in vitro and reduce hepatic brogenesis in animal models [57].
Promotion of Matrix Degradation
Liver brosis is usually advanced at the point of clinical
presentation and this fact coupled with current animal evidence suggesting incomplete reversibility [8], indicates
that degradation of the existing scar will be a critical requirement of any antibrotic therapy. Degradation of the
brotic neomatrix might be achieved by modulation of the
MMP/TIMP interface or by upregulating MMP activation
via urokinase plasminogen activator (uPA) activity, for
example. However, this would need to be relatively liver
specic in order to avoid side effects related to alterations
in systemic basal ECM turnover. Studies in animal models
of liver brosis have demonstrated proof of concept for a
number of agents. For example, direct administration of
MMP-1 mRNA via an adenoviral vector attenuated established liver brosis in thioacetamide treated rats and administration of an anti-TIMP-1 antibody decreased HSC
activation and attenuated brosis in a CCl4 rat model [58,
59]. Downregulation of TIMPs by the reproductive hormone relaxin has also been shown to inhibit liver brosis
in vivo [60]. Furthermore, adenoviral delivery of uPA,
which initiates the matrix proteolysis cascade and upregulates HGF, results in enhanced collagenase activity,
reversal of brosis and hepatocyte regeneration [61]. Dietary supplementation with zinc, an essential co-factor
for MMP activity, has also been shown to promote collagen degradation in CCl4-injured rats [62].
Stimulation of HSC Apoptosis
Apoptosis of HSC is a key event in the spontaneous
recovery from liver brosis [9]. Apoptosis (or programmed cell death) is a ubiquitous phenomenon occurring during normal tissue development and in the selective killing of damaged or virally infected cells. There are
two general mechanisms by which apoptosis may be in-

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Dig Dis 2006;24:174183

duced. Firstly, stimulation of specic cell surface death

receptors may trigger an intracellular cascade of proteolytic enzymes known as caspases, with ensuing cellular
apoptosis. This so-called extrinsic pathway is in contrast
to the intrinsic pathway, which operates at the level of
the mitochondria. The mitochondrial membrane contains a balance of pro-and anti-apoptotic proteins of the
Bcl-2 family. Certain stimuli (e.g. toxins, UV radiation,
reactive oxygen species) cause a predominance of proapoptotic factors in the mitochondrial membrane, resulting in leakage of cytochrome C into the cytosol, subsequent caspase activation and apoptosis.
HSC express a number of cell-surface death receptors,
including Fas (CD95), TNF-
receptor, and low-afnity
nerve growth factor (NGF) receptor (p75). Activation of
such death receptors following exposure to Fas ligand
[63], NGF [64], or benzodiazepines acting via the peripheral benzodiazepine receptor [65] has been shown to increase HSC apoptosis in vitro. HSC apoptosis is also induced by cyclopentenone prostaglandins acting via a
mechanism thought to involve oxidative stress [66] and
by GRGDS peptide through disruption of integrin-mediated cell adhesion [67]. An alternative strategy might be
to induce HSC apoptosis by adenoviral delivery of proapoptotic proteins. Abriss et al. [68], who demonstrated
that transduction of p53 or retinoblastoma protein induced apoptosis of activated HSC in vitro, explored this
concept recently.
Suppression of I-B by the transcriptional repressor C
promoter binding factor (CBF)-1 results in persistently
raised activity of the transcription factor NF-B in activated HSC [69]. NF-B protects HSC from apoptosis and
NF-B inhibition with gliotoxin has been shown to promote HSC apoptosis in rat and human HSC. Moreover,
gliotoxin accelerated recovery from CCl4 and thioacetamide-induced liver brosis in rats [11]. These experiments demonstrated proof-of-concept that HSC proapoptotic agents could abrogate liver brosis, however,
gliotoxin also induces apoptosis in other tissues (e.g. thymus). A safer alternative may be sulphasalazine, which
has been used extensively in the treatment of rheumatoid
arthritis and inammatory bowel disease. Sulphasalazine
is a potent inhibitor of NF-B and was found to increase
HSC apoptosis in vitro and in vivo and (following a single
administration) dramatically accelerate recovery from brosis in a rat CCl4 model [70].
Targeting Antibrotic Therapy
Liver-specic targeting is likely to be an important
consideration in order to minimise potential deleterious

Fowell/Iredale

effects in other tissues, especially since wound healing is

an important universal process. To some extent the liver
is an attractive proposition for directed therapy with orally administered drugs, given the extensive rst pass metabolism that may occur. However, hepatic delivery may
need to be optimised via cell-specic targeting to, for example, hepatocytes, KC or HSC. Two methods that have
shown promise rely on the unique expression of the mannose-6-phosphate receptor and type VI collagen receptor
by activated HSC [71, 72]. Both receptors have been
shown to allow HSC-specic drug targeting, clearly generating optimism that such methods might be translatable
to human clinical studies.
Gene transfer is an alternative mechanism of drug delivery. Plasmid-based transfection is inefcient when applied to HSC and adenoviral gene transfer has been a
more popular investigational tool as illustrated in several
examples above. Other potential viral vectors include
baculovirus and herpes virus saimiri (HVS). Clearly,
there remain concerns regarding the safety of gene therapy systems in terms of cytotoxicity and effects on the immune system. However, with improving delivery techniques and the prospect of conditional expression systems, it may become feasible to initiate antibrotic trials
in humans.

Conclusion

A rapid increase in our understanding of the reversibility of liver brosis and, in particular, the behaviour of
activated hepatic myobroblasts, has made therapy for
liver brosis an emerging and realistic prospect. A number of key questions remain unanswered. For instance,
does brosis reach a critical point at which, perhaps due
to complex collagen cross-linking, the presence of elastin,
or development of a critical mass of matrix components,
it becomes truly irreversible? Several agents have demonstrated efcacy in vitro and in animals. Clinical trials are
currently in progress in an effort to translate these ndings into successful therapy for human liver disease and
it is likely that a multiple agent strategy will eventually be
adopted, whereby different mechanistic levels are simultaneously targeted. Advances in non-invasive, quantiable means of staging liver brosis will greatly assist the
assessment of such agents in human trials. Furthermore,
demonstration of palpable long-term benet from antibrotic therapy will become an increasing requirement.

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