BACKGROUND:Non-alcoholic steatohepatitis (NASH) is characterised by hepatic steatosis, inflammation, and injury, and is associated with an increased risk of liver transplantation and death. NASH affects more than 16 million people in the USA, and there is no approved therapy. The aim of this study was to evaluate the safety and efficacy of aldafermin, an engineered analogue of the gut hormone fibroblast growth factor 19 (FGF19). METHODS:In this randomised, double-blind, placebo-controlled, phase 2b study (ALPINE 2/3) in patients with biopsy-confirmed NASH and stage 2 or 3 fibrosis, we randomly assigned patients stratified by fibrosis stage in a 1:1:1:1 ratio to receive placebo, aldafermin 0·3 mg, 1·0 mg, or 3·0 mg once daily for 24 weeks at 30 study sites in the USA. Patients, investigators, the funder, and all other staff, were masked to treatment assignment throughout the study. The primary endpoint was an improvement in liver fibrosis of at least one stage with no worsening of NASH at week 24. Analyses were done by intention-to-treat. This trial is registered with ClinicalTrials.gov, number NCT03912532, and has been completed. FINDINGS:Between May 16, 2019, and Sept 4, 2020, 786 patients were screened, of whom 171 were randomly assigned to a treatment group and included in the intention-to-treat population: 43 in the 0·3 mg aldafermin group, 42 in the 1·0 mg group, 43 in the 3·0 mg group, and 43 in the placebo group. In total, 145 (85%) of patients completed treatment. At week 24, among patients with biopsies at both baseline and week 24, was seven (19%) of 36 patients in the placebo group, 11 (31%) of 36 in the 0·3 mg aldafermin group (difference 90% CI 12% [-9 to 33]; p=0·11), five (15%) of 34 patients in the 1·0 mg group (difference -5% [-24 to 13]; p=0·80), and 11 (30%) of 37 patients in the 3·0 mg group (difference 10% [-9 to 30]; p=0·12) had an improvement in liver fibrosis of at least one stage with no worsening of NASH, without meeting the prespecified significance for dose response (p=0·55). Adverse events were mostly mild or moderate in severity. Diarrhoea occurred in six (14%) of 43 patients in the placebo group, three (7%) of 43 patients in the 0·3 mg aldafermin group, five (12%) of 41 patients in the 1·0 mg group, and ten (23%) of 43 patients in the 3·0 mg group. Incidences of serious adverse events and discontinuations owing to adverse events were similar between groups. INTERPRETATION:Aldafermin was generally well tolerated but did not produce a significant dose response on fibrosis improvement of at least one stage with no worsening of NASH, despite positive effects on a number of secondary endpoints. The findings of this trial may have implications for the design of future NASH trials. FUNDING:NGM Biopharmaceuticals.

BACKGROUND & AIMS: Aldafermin, an engineered analog of fibroblast growth factor 19, inhibits bile acid synthesis and regulates metabolic homeostasis. We report results from a 24-week, phase 2 study, with serial liver biopsies, of patients with nonalcoholic steatohepatitis (NASH). METHODS: We performed a double-blind study of 78 patients with NASH at 9 centers in the United States. Key inclusion criteria were biopsy-proven NASH with Nonalcoholic Fatty Liver Disease Activity Score >= 4, stage 2 or 3 fibrosis by NASH Clinical Research Network classification, and absolute liver fat content >= 8%, measured by magnetic resonance imaging-proton density fat fraction. Patients were randomly assigned (1:2) to groups given subcutaneous placebo (n = 25) or aldafermin 1 mg (n = 53) daily for 24 weeks. The primary outcome was change in absolute liver fat content from baseline at week 24. Secondary outcomes included serum markers and histologic measures of fibrosis improvement and NASH resolution. RESULTS: At week 24, the aldafermin group had a significant reduction in absolute liver fat content (reduction of 7.7%) compared with placebo (reduction of 2.7%; difference, reduction of 5.0%; 95% confidence interval, reduction of 8.0%-1.9%; P = .002). Aldafermin produced significantly greater decreases in levels of 7 alpha-hydroxy-4-cholesten-3-one, bile acids, alanine and aspartate aminotransferases, and neoepitope-specific N-terminal propeptide of type III collagen (Pro-C3) than placebo. Fibrosis improvement (>= 1 stage) with no worsening of NASH was achieved in 38% of patients receiving aldafermin vs 18% of patients receiving placebo (P = .10). NASH resolution with no worsening of fibrosis was observed in 24% of patients given aldafermin vs 9% of patients given placebo (P = .20). Discontinuations due to adverse events occurred in no patients in the aldafermin group and 4% of patients in the placebo group. CONCLUSIONS: In a phase 2 trial of patients with NASH, aldafermin reduced liver fat and produced a trend toward fibrosis improvement.

Background and Aims: Recent studies suggest the involvement of other cell types in liver regeneration upon impaired hepatocyte cell division.However, more investigation is needed on the source of these cells.We previously showed that deletion of Cdk1, a critical component of cell cycle, in hepatocytes (Cdk1 liv-/-) does not affect the development and the regeneration of the liver.However, excessive inflammation and fibrosis were observed during postnatal liver development.We detected hypertrophied hepatocytes accompanied by the emergence of normal sized hepatocytes (NSHs) that express CDK1, despite Cdk1 being completely deleted at 2 weeks postpartum.This indicates a contribution of non-parenchymal cells to liver regeneration and development.Thus, our aim is to identify other cell types contributing to the regeneration of the liver in the absence of hepatocyte cell division.Method: Liver samples were collected at three-day intervals from postnatal mice to identify important time points for the emergence of NSHs.AAV8-TBG-GFP tail-vein injection was used to label and track the fate of hepatocytes to show that NSHs are not emerging from preexisting ones.Samples were analyzed via IHC, IF, qPCR, and WB.Hepatocyte isolation and FACS analysis were used for GFP labelled hepatocytes to identify and analyze bi-phenotypic hepatocytes.Results: P37 and P48 Cdk1 liv-/-liver displayed substantial amount of NSH populations near hypertrophied hepatocytes and they were localized around zone 1.We labelled both Cdk1 liv-/-and WT mice with AAV8-TBG-GFP, which specifically infects hepatocytes and causes GFP expression.Samples were injected at P28 and harvested at P42. IHC and IF analysis revealed that in WT samples, all the hepatocytes retained GFP labelling as there is nearly no cell division after P28.However, in Cdk1 liv-/-samples, only hypertrophied hepatocytes retained GFP labelling, while all the NSH populations were GFP negative.Additionally, IHC staining and WB analysis revealed that some of these NSHs were able to express CDK1.We identified a small number of normal sized HNF4-alpha + hepatocytes that express a newly identified cholangiocyte specific marker (CSM) that also labels hepatic progenitor cells (HPCs).To analyze these biphenotypic hepatocytes, we labelled Cdk1 liv-/-and WT mice with GFP and isolated hepatocytes three days later.FACS analysis of CSM and GFP revealed that 3.1% of the Cdk1 liv-/-hepatocyte population display bi-phenotypic expression. Conclusion:We demonstrated that compromised hepatocyte cell division activates HPCs during postnatal liver development.A small population of bi-phenotypic hepatocytes were identified, and further investigation is needed to elucidate the differentiation process and underlying signals that activate these bi-phenotypic cells.