Background: Acute-on-chronic liver failure (ACLF) mostly occurs when there is an acute insult to the liver in patients with pre-existing liver disease, and it is characterized by a high mortality rate. Various therapeutic approaches have been used thus far, with orthotopic liver transplantation being the only definitive cure. Clinical trials and meta-analyses have investigated the use of granulocyte colony-stimulating factor (G-CSF) to mobilize bone marrow-derived stem cells. Some studies have suggested that G-CSF may have a significant role in the management and survival of patients with ACLF. However, the results are conflicting, and the efficacy of G-CSF still needs to be confirmed. Aim: The aim was to assess the efficacy of G-CSF in patients with ACLF.

Methods: Electronic databases were searched until May 2023 for randomized controlled trials investigating the use of G-CSF in adult patients with ACLF. Outcome measures were the effects of G-CSF on overall survival, changes in liver disease severity scores, complications of cirrhosis, other G-CSF-related adverse effects, and all-cause mortality. The study’s protocol has been registered with Prospero (CRD42023420273).

Results: Five double-blind randomized controlled trials involving a total of 421 participants met the inclusion criteria. The use of G-CSF demonstrated a significant effect on overall survival (HR 0.63, 95% CI 0.41 to 0.95, and I² 48%), leading to a decreased mortality (LogOR-0.97, 95% CI −1.57 to −0.37, and I² 37.6%) and improved Model for End-Stage Liver Disease (MELD) scores (SMD −0.87, 95% CI −1.62 to −0.13, and I² 87.3%). There was no correlation between the improvement of the Child–Pugh score and the use of G-CSF(SMD −2.47, 95% CI −5.78 to 0.83, and I² 98.1%). The incidence of complications of cirrhosis did not decrease significantly with G-CSF treatment (rate ratio 0.51, 95% CI 0.26 to 1.01, and I² 90%). A qualitative synthesis showed that the use of G-CSF is safe.

Conclusions: The administration of G-CSF has demonstrated a positive impact on overall survival, liver function, and the MELD score. The presence of heterogeneity in the included studies prohibits conclusive recommendations.