CD4+ T cells promote fibrosis during metabolic dysfunction–associated steatohepatitis

BACKGROUND AND AIMS: Unresolved inflammation and fibrosis are defining features of metabolic dysfunction-associated steatohepatitis (MASH), a progressive form of steatotic liver disease that can advance to cirrhosis and hepatocellular carcinoma. While innate immune mechanisms in MASH have been extensively characterized, the role of CD4+ T cells remains poorly understood despite their central function in orchestrating immune responses through effector and regulatory mechanisms. APPROACH AND RESULTS: Integrated single-cell proteomic, transcriptomic, and functional analyses were used to investigate the CD4+ T-cell landscape in murine and human MASH. We delineated a profound shift in the differentiation of intrahepatic and peripheral CD4+ T cells toward Th1, regulatory, and cytotoxic phenotypes in murine and human MASH. Notably, hepatic CD4+ T cells exhibited heightened effector activity and elevated secretion of proinflammatory cytokines, thus amplifying inflammatory signaling cascades. The CD4+ T-cell reprogramming in MASH also included the induction of the co-stimulatory receptor OX40. In parallel, OX40 ligand (OX40L)-expressing monocyte-derived macrophages and dendritic cells accumulated in MASH livers, establishing a feed-forward CD4+ T cell-myeloid activation loop. Therapeutic blockade of the OX40-OX40L axis, in turn, reversed liver pathology in mice with established MASH and reduced disease markers in an ex vivo human liver model. Furthermore, genetic depletion or functional inhibition of CD4+ T cells attenuated fibrosis, accompanied by decreased infiltration of monocyte-derived macrophages. CONCLUSIONS: These studies provide a comprehensive single-cell proteogenomic atlas of CD4+ T cells in MASH and identify an OX40-dependent CD4+ T cell-macrophage axis as a promising therapeutic target for the treatment of MASH and liver fibrosis.