Dual therapy for amanita phalloides-induced acute liver failure in mice: A combination of etanercept and alpha-1 antitrypsin

Background The toxin α-amanitin from Amanita phalloides induces hepatocyte death and disrupts local and systemic immune responses, key drivers of acute liver failure (ALF). Although TNF-α plays a central role in ALF, TNF-α-targeted therapies alone have shown limited efficacy. Methods Serum alpha1-globulin levels were measured retrospectively in a cohort of patients with amanita-induced ALF. Additionally, a murine interventional study was conducted, incorporating flow cytometry (FACS)-based immunophenotyping to analyze immune cell populations in the liver and lung to assess systemic versus liver-specific immune effects. Results We observed a correlation between lower serum alpha1-globulin levels—primarily comprising α1-antitrypsin (AAT)—and increased disease severity in patients with amanita-induced ALF. In a murine interventional study aiming to evaluate the therapeutic potential of alpha1-antitrypsin and TNF-α inhibition—alone and in combination—, the combined administration of etanercept (Enbrel®), a TNF-α scavenger, and recombinant AAT (recAAT) produced in CHO cells significantly improved survival rates in mice with amanita-induced ALF. Reduced liver damage markers, including lower cleaved caspase-3 levels, and decreased activation of liver CD4+ T cells and natural killer (NK) cells, accompanied this protective effect. Additionally, there was an increase in liver dendritic cells and IL-6+ TNF-α + macrophages, suggesting their potential role in mitigating liver injury. Immune changes in the lung were less pronounced and showed only modest reductions in CD4+ and NK1.1+ cells, with no significant shifts in innate immune populations. Conclusions Our findings from the mouse model suggest a promising approach for treating ALF caused by α-amanitin from Amanita phalloides: the combined use of AAT (broad-spectrum protease inhibitor) and a TNF-α inhibitor. This dual therapy offers a novel and potentially effective treatment strategy for ALF patients.