Liver Histology: Diagnostic and Prognostic Features

Therapeutic potential of oleanolic acid in liver diseases

Liver-associated diseases affect millions of individuals worldwide. In developed countries, the incidence of viral hepatitis is reducing due to advancements in disease prevention, diagnosis, and treatment. However, with improvements in living standards, the prevalence of metabolic liver diseases, such as non-alcoholic fatty liver disease and alcohol-related liver disease, is expected to increase; notably, this rise in the prevalence of metabolic liver disease can lead to the development of more severe liver diseases, including liver failure, cirrhosis, and liver cancer. The growing demand for natural alternative therapies for chronic diseases has highlighted the importance of studying the pharmacology of bioactive compounds in plants. One such compound is oleanolic acid (OA), a pentacyclic triterpenoid known for its antioxidant, anti-inflammatory, anti-ulcer, antibacterial, antiviral, antihypertensive, anti-obesity, anticancer, anti-diabetic, cardioprotective, hepatoprotective, and anti-neurodegenerative properties. Recent studies have demonstrated that OA treatment can reduce the risk of pathological liver damage, ultimately alleviating liver dysregulation and restoring overall liver function. This review aims to explore the latest research on the biological effects of OA and its derivatives. Notably, it explores the mechanisms of action of these compounds in both in vitro and in vivo research models and, ultimately, highlights OA as a promising candidate for alternative therapies in the treatment and management of chronic liver disease.

Bioinspired Bioinks for the Fabrication of Chemomechanically Relevant Standalone Disease Models of Hepatic Steatosis

Hepatotoxicity-related issues are poorly predicted during preclinical experimentation, as its relevance is limited by the inadequacy to screen all the non-physiological subclasses of the population. These pitfalls can be solved by implementing complex in vitro models of hepatic physiology and pathologies in the preclinical phase. To produce these platforms, extrusion-based bioprinting is focused on, since it allows to manufacture tridimensional cell-laden constructs with controlled geometries, in a high-throughput manner. Different bioinks, whose formulation is tailored to mimic the chemomechanical environment of hepatic steatosis, the most prevalent hepatic disorder worldwide, are proposed. Internally crosslinked alginate hydrogels are chosen as structural components of the inks. Their viscoelastic properties (G' = 512-730 Pa and G″ = 94-276 Pa, depending on frequency) are tuned to mimic those of steatotic liver tissue. Porcine hepatic ECM is introduced as a relevant biochemical cue. Sodium oleate is added to recall the accumulation of lipids in the tissue. Downstream analyses on 14-layered bioprinted structures cultured for 10 days reveal the establishment of steatotic-like features (intracellular lipid vesicles, viability decrease up to ≈50%) without needing external conditionings. The presented bioinks are thus suitable to fabricate complex models of hepatic steatosis to be implemented in a high-throughput experimental frame.

Advanced three-dimensional in vitro liver models to study the activity of anticancer drugs

The liver is one of the most important organs in the human body. It performs many important functions, including being responsible for the metabolism of most drugs, which is often associated with its drug-induced damage. Currently, there are no ideal pharmacological models that would allow the evaluation of the effect of newly tested drugs on the liver in preclinical studies. Moreover, the influence of hepatic metabolism on the effectiveness of the tested drugs is rarely evaluated. Therefore, in this work we present an advanced model of the liver, which reflects most of the morphologically and metabolically important features of the liver in vivo, namely: three-dimensionality, cellular composition, presence of extracellular matrix, distribution of individual cell types in the structure of the liver model, high urea and albumin synthesis efficiency, high cytochrome p450 activity. In addition, the work, based on the example of commonly used anticancer drugs, shows how important it is to take into account hepatic metabolism in the effective assessment of their impact on the target organ, in this case cancer. In our research, we have shown that the most similar to liver in vivo are 3D cellular aggregates composed of three important liver cells, namely hepatocytes (HepG2), hepatic stellate cells (HSCs), and hepatic sinusoidal endothelial cells (HSECs). Moreover, we showed that the cells in 3D aggregate structure need time (cell-cell interactions) to improve proper liver characteristic. The triculture model additionally showed the greatest ability to metabolize selected anticancer drugs.

Hydroxytyrosol ameliorates stress-induced liver injury through activating autophagy via HDAC1/2 inhibition

Hydroxytyrosol (HT), a phenolic extra-virgin olive oil compound used as a food supplement, has been recognized to protect liver function and alleviate stress-induced depressive-like behaviors. However, its protective effects against stress-induced liver injury (SLI) remain unknown. Here, the anti-SLI effect of HT was evaluated in mice with chronic unpredictable mild stress-induced SLI. Network pharmacology combined with molecular docking was used to clarify the underlying mechanism of action of HT against SLI, followed by experimental verification. The results showed that accompanying with the alleviation of HT on stress-induced depressive-like behaviors, HT was confirmed to exert the protective effects against SLI, as represented by reduced serum corticosterone (CORT), aspartate aminotransferase and alanine aminotransferase activities, as well as repair of liver structure, inhibition of oxidative homeostasis collapse, and inflammation reaction in the liver. Furthermore, core genes including histone deacetylase 1 and 2 (HDAC1/2), were identified as potential targets of HT in SLI based on bioinformatic screening and simulation. Consistently, HT significantly inhibited HDAC1/2 expression to maintain mitochondrial dysfunction in an autophagy-dependent manner, which was confirmed in a CORT-induced AML-12 cell injury and SLI mice models combined with small molecule inhibitors. We provide the first evidence that HT inhibits HDAC1/2 to induce autophagy in hepatocytes for maintaining mitochondrial dysfunction, thus preventing inflammation and oxidative stress for exerting an anti-SLI effect. This constitutes a novel therapeutic modality to synchronously prevent stress-induced depression-like behaviors and liver injury, supporting the advantaged therapeutic potential of HT.

The Value of Liver Biopsy and Histology in Liver Disease Diagnosis and Patient Care-a Pragmatic Prospective Clinical Practice Study

GOALS

We aimed to examine the correlation of pre-biopsy clinical diagnosis with hepatic histopathology.

BACKGROUND

Liver biopsy provides histologic information and informs physicians about the underlying clinical disease. We hypothesized that expert physicians' pre-biopsy clinical diagnoses may obviate the need for histopathological diagnosis.

STUDY METHODS

Patients undergoing liver biopsy to investigate a liver diagnosis were prospectively identified. In the 80 patients included, an anonymous validated questionnaire inquiring about the most likely clinical diagnosis and liver disease stage was completed prospectively by hepatologists before biopsy performance.

RESULTS

The most common pre-biopsy diagnoses were alcoholic liver disease (19 diagnoses), followed by non-alcoholic steatohepatitis and autoimmune hepatitis (18 each). Overall, the predicted histologic diagnosis was the same as the histologic diagnosis in 51/80 patients (64%), and thus a new liver disease diagnosis was made in 36% of patients. The diagnosis with the greatest pre-biopsy and post-biopsy diagnosis discrepancy was autoimmune hepatitis, with the correct diagnosis being predicted in 6/18 (33%) of patients (other diagnoses included the following: non-alcoholic steatohepatitis/non-alcoholic fatty liver disease (4), alcoholic liver disease (3), drug-induced liver injury (3), others (2)). For fibrosis staging, when grouped as no fibrosis (F0), fibrosis (F1-F3), or cirrhosis (F4), the fibrosis stage was correctly predicted in 68% of patients (54/80). Notably, 7 patients (9%) who were initially thought to have no or early-stage fibrosis had F4 fibrosis, and 6/80 (8%) patients who were considered to have a liver disease diagnosis before their biopsy had normal histology.

CONCLUSIONS

Although hepatology experts often predict the correct underlying liver disease diagnosis, histopathological diagnoses different from expected are common.

Application of multiple-finding segmentation utilizing Mask R-CNN-based deep learning in a rat model of drug-induced liver injury

Drug-induced liver injury (DILI) presents significant diagnostic challenges, and recently artificial intelligence-based deep learning technology has been used to predict various hepatic findings. In this study, we trained a set of Mask R-CNN-based deep algorithms to learn and quantify typical toxicant induced-histopathological lesions, portal area, and connective tissue in Sprague Dawley rats. We compared a set of single-finding models (SFMs) and a combined multiple-finding model (MFM) for their ability to simultaneously detect, classify, and quantify multiple hepatic findings on rat liver slide images. All of the SFMs yielded mean average precision (mAP) values above 85%, suggesting that the models had been successfully established. The MFM showed better performance than the SFMs, with a total mAP value of 92.46%. We compared the model predictions for slide images with ground-truth annotations generated by an accredited pathologist. For the MFM, the overall and individual finding predictions were highly correlated with the annotated areas, with R-squared values of 0.852, 0.952, 0.999, 0.990, and 0.958 being obtained for portal area, infiltration, necrosis, vacuolation, and connective tissue (including fibrosis), respectively. Our results indicate that the proposed MFM could be a useful tool for detecting and predicting multiple hepatic findings in basic non-clinical study settings.

Assessing the Acute Toxicological Effects of Annona muricata Leaf Ethanol Extract on Rats: Biochemical, Histopathological, and Metabolomics Analyses

Annona muricata is a common plant used in Africa and South America to manage various types of disease. However, there is insufficient toxicological information or published standard available regarding repeated dose animal toxicity data. As part of the safety assessment, we exposed Sprague Dawley rats to an acute oral toxicity of A. muricata. The intent of the current study was to use advanced proton nuclear magnetic resonance (1H NMR) in serum and urinary metabolomics evaluation techniques to provide the in vivo acute toxicological profile of A. muricata leaf ethanol extract in accordance with the Organization for Economic Co-operation and Development's (OECD) 423 guidelines. A single 2000 mg/kg dose of A. muricata leaf ethanol extract was administered to Sprague Dawley rats over an observational period of 14 days. The toxicity evaluation (physical and behavior observation, body weight, renal function test, liver function test and 1H NMR analysis) showed no abnormal toxicity. Histopathological analysis manifested mild changes, i.e., the treated kidney manifested mild hypercellularity of mesangial cells and mild red blood cell congestion. In addition, there was mild hemorrhage into tissue with scattered inflammatory cells and mild dilated central vein with fibrosis in the liver. However, the changes were very mild and not significant which correlate with other analyses conducted in this study (biochemical test and 1H NMR metabolomic analysis). On the other hand, urinary 1H NMR analysis collected on day 15 revealed high similarity on the metabolite variations for both untreated and treated groups. Importantly, the outcomes suggest that A. muricata leaf ethanol extract can be safely consumed at a dose of 2000 mg/kg and the LD50 must be more than 2000 mg/kg.

Insights into the pharmacological and therapeutic effects of apigenin in liver injuries and diseases

Background

Liver diseases are a spectrum of diseases that include hepatic steatosis, nonalcoholic fatty liver disease, hepatitis, liver fibrosis, cirrhosis, and hepatic cancer. These diseases not only severely decrease the quality of life for patients, but also cause financial burden. Although apigenin (APG) has recently become the primary treatment for liver injuries and diseases (LIADs), there has been no systematic review of its use.

Purpose

To review the existing literature and put forward novel strategies for future APG research on LIADs.

Methods

A search was conducted in PubMed, Science Direct, Research Gate, Web of Science, VIP, Wanfang, and CNKI, and 809 articles were obtained. After applying inclusion and exclusion criteria, 135 articles were included.

Results

APG is promising in treating LIADs via various mechanisms arising from its anti-inflammation, anti-proliferation, anti-infection, anti-oxidation, and anti-cancer properties.

Conclusion

This review summarizes the evidence supporting the use of APG as a treatment for LIADs and provides an insight into the intestinal microbiota, which may have important implications in its future clinical use.

Development of a Novel Ex Vivo Porcine Hepatic Segmental Perfusion Proof-of-Concept Model Towards More Ethical Translational Research

Introduction Ex vivo machine perfusion describes the technique where organs are continuously perfused and oxygenated extracorporeally (at physiological conditions) to maintain the organs' viability. To our knowledge, there are currently no reported studies describing ex vivo perfusion of a single hepatic segment. Here, we describe the development of a porcine ex vivo hepatic segmental perfusion model to demonstrate proof of concept and support further research into the ex vivo perfusion of the human liver using discarded tissue.  Methods Whole livers were retrieved from abattoir-derived pigs and connected to a normothermic extracorporeal perfusion circuit. Constant segmental perfusion via the common or segmental hepatic artery and portal vein with heparinised autologous blood was established. The viability of the perfused organ was assessed by monitoring perfusion pressures, flow rates and histology samples. Results Following perfusion and optimisation of the model for three hepatic segments, the third perfusion demonstrated viable hepatocytes centrally after 4 h of segmental perfusion. Conclusion Ex vivo hepatic segmental perfusion is technically challenging but its success in a porcine model and the principles learned should facilitate the development of an analogous human model using discarded tissue following formal liver resections. The model would use a healthy liver segment following a major formal resection such as a hemi-hepatectomy and ex vivo perfusion performed via a segmental hepatic artery and portal vein. If successful this model would represent a significant development and enable ethical translation research to assess the response of human livers to a variety of stressors, including toxicity and infection.

NRF2 and FXR dual signaling pathways cooperatively regulate the effects of oleanolic acid on cholestatic liver injury

BACKGROUND

Previous studies have shown that the anti-cholestatic effect of oleanolic acid (OA) is associated with FXR and NRF2. However, how the two signaling pathways cooperate to regulate the anti-cholestatic effect of OA remains unclear.

PURPOSE

This study aimed to further demonstrate the effect of OA on alpha-naphthyl isothiocyanate (ANIT)-induced cholestatic liver injury and the interaction mechanism between NRF2 and FXR signaling pathways in maintaining bile acid homeostasis.

METHODS

Gene knockout animals and cell models, metabolomics analysis, and co-immunoprecipitation were used to investigate the mechanism of OA against cholestatic liver injury.

RESULTS

The effect of OA against ANIT-induced liver injury in rats was dramatically reduced after Nrf2 gene knockdown. With the silencing of Fxr, the hepatoprotective effect of OA was weakened, but it still effectively alleviated cholestatic liver injury in rats. In L02 cells, OA can up-regulate the levels of NRF2, FXR, BSEP and UGT1A1, and reduce the expression of CYP7A1. Silencing of NRF2 or FXR significantly attenuated the protective effect of OA on ANIT-induced L02 cell injury and its regulation on downstream target genes, and the influence of NRF2 gene silencing on OA appeared to be greater. The NRF2 activator sulforaphane, and the FXR activator GW4064 both remarkably promoted NRF2 binding to P300 and FXR to RXRα, but reduced β-catenin binding to P300 and β-catenin binding to FXR.

CONCLUSION

The effect of OA on cholestatic liver injury is closely related to the simultaneous activation of NRF2 and FXR dual signaling pathways, in which NRF2 signaling pathway plays a more important role. The dual signaling pathways of NRF2 and FXR cooperatively regulate bile acid metabolic homeostasis through the interaction mechanism with β-catenin/P300.

Nucleic acids and proteins carried by exosomes from various sources: Potential role in liver diseases

Exosomes are extracellular membrane-encapsulated vesicles that are released into the extracellular space or biological fluids by many cell types through exocytosis. As a newly identified form of intercellular signal communication, exosomes mediate various pathological and physiological processes by exchanging various active substances between cells. The incidence and mortality of liver diseases is increasing worldwide. Therefore, we reviewed recent studies evaluating the role of exosomes from various sources in the diagnosis and treatment of liver diseases.

Identification of MRI features associated with injury type, severity, and prognosis in drug-induced liver injury

OBJECTIVES

To identify magnetic resonance imaging (MRI) features associated with injury type, severity, and liver transplantation (LT)/liver-related death (LRD) in drug-induced liver injury (DILI).

METHODS

The eligible DILI patients (2016 to 2020) who underwent contrast abdominal MRI within 3 months of onset were retrospectively analysed at Beijing Friendship Hospital, Capital Medical University. The MRI features independently associated with severity and prognosis were identified by backwards logistic regression. Unadjusted odds ratios (ORs) and 95% confidence intervals (CIs) are given.

RESULTS

The median age of 180 patients was 55.5 years, with 126 (70.0%) women. The injury types included hepatocellular (135 cases, 75.0%), mixed (23, 12.8%), and cholestatic (22, 12.2%). The proportion of periportal oedema in patients with hepatocellular and mixed injury was significantly higher than that in cholestatic injury (62.2%, 47.8% vs. 18.2%, p < 0.001). For severity, 157 (87.2%) patients had mild to moderate injury, and 23 (12.8%) had severe to fatal/LT. Irregularity of the liver surface (6.56 (95% CI, 1.27-22.84)), transient hepatic attenuation difference (THAD) (3.27 (95% CI, 1.14-9.36)), and splenomegaly (5.86 (95% CI, 1.96-17.53)) were independently associated with severity. Eight (4.4%) patients died/underwent LT. THAD (8.89 (95% CI, 1.35-58.43)), and ascites (64.63 (95% CI, 6.93-602.40)) were independently associated with LT/LRD. The prediction of the new model employing THAD and ascites for LT/LRD within 1 year was 0.959 (95% CI, 0.917-1.000).

CONCLUSIONS

Periportal oedema was associated with the type of injury. Irregularity of the liver surface, THAD, and splenomegaly were associated with severity. THAD and ascites may have potential clinical utility in predicting LT/LRD outcomes within 1 year.

KEY POINTS

• Contrast abdominal magnetic resonance imaging features can help clinicians evaluate the type of injury, severity, and poor prognosis of drug-induced liver injury. • Transient hepatic attenuation difference and ascites have potential clinical utility in the prediction of the poor prognosis of liver transplantation/liver-related death. • The new model predicting poor prognosis has a relatively high sensitivity of 0.875 and a high specificity of 0.919.

Highlights of the drug-induced liver injury literature for 2021

INTRODUCTION

In 2021, over 3,000 articles on Drug-Induced Liver Injury (DILI) were published, nearly doubling the annual number compared to 2011. This review selected DILI articles from 2021 we felt held the greatest interest and clinical relevance.

AREAS COVERED

A literature search was conducted using PubMed between 1 March 2021 and 28 February 2022. 86 articles were included. This review discusses new and established cases of hepatotoxins, including new FDA approvals and COVID-19 therapeutics. Developments in biomarkers and causality assessment methods are discussed. Updates from registries are also explored.

EXPERT OPINION

DILI diagnosis and prognostication remain challenging. Roussel Uclaf Causality Assessment Method (RUCAM) is the best option for determining causality and has been increasingly accepted by clinicians. Revised Electronic Causality Assessment Method (RECAM) may be more user-friendly and accurate but requires further validation. Quantitative systems pharmacology methods, such as DILIsym, are increasingly used to predict hepatotoxicity. Oncotherapeutic agents represent many newly approved and described causes of DILI. Such hepatotoxicity is deemed acceptable relative to the benefit these drugs offer. Drugs developed for non-life-threatening disorders may not show a favorable benefit-to-risk ratio and will be more difficult to approve. As the COVID-19 landscape evolves, its effect on DILI deserves further investigation.

Long-term oral administration of Epimedii Folium induced cholestasis in mice by interfering with bile acid transport

ETHNOPHARMACOLOGICAL RELEVANCE

Epimedii Folium (EF) is a common traditional Chinese medicine that functions as a tonifying kidney yang to strengthen bones and muscles and dispel wind dampness (limb pain, lethargy, nausea, anorexia, and loose stools). Several studies have reported the potential risk of cholestatic liver damage from EF use; however, there have been few investigations of EF-induced cholestasis, particularly the underlying mechanisms.

AIMS OF THE STUDY

The purpose of this study was to evaluate the risk of EF-induced cholestasis in vivo and to explore the mechanisms of action.

MATERIALS AND METHODS

ICR mice were orally administered a water extract of EF (WEF) in doses of 6.5 and 19.5 g/kg/day for 14 weeks. Liver-to-body weight ratios, body weight, histopathological examination, and biochemical analyses were performed to assess WEF-induced cholestasis in the mice. Genes associated with bile acid (BA) metabolism and transport, including sodium taurocholate cotransporting polypeptide (NTCP), cytochrome P450 8B1 (CYP8B1), bile-salt export pump (BSEP), multidrug resistance P-glycoproteins 1 (MDR1), and farnesoid X receptor (FXR), were measured at the transcript and protein levels to investigate the potential mechanisms through which cholestasis is aroused by EF.

RESULTS

After administration of WEF for 14 weeks, mice in the high-dose WEF group showed poor health with an increased liver-to-body weight ratio as well as higher serum aminotransferase, alkaline phosphatase, direct bilirubin, and total BA levels. Compared with the control group, mRNA expression of NTCP and cholesterol 7a-hydroxylase (CYP7A1) increased, and levels of BSEP, MDR1, multidrug resistance-associated protein 2, and multidrug resistance-associated protein 3 decreased in the WEF-treated group. NTCP, BSEP, MDR1, and CYP8B1 showed similar mRNA and protein expression trends.

CONCLUSION

We demonstrated that the long-term oral administration of WEF causes cholestatic liver injury in mice, which is consistent with reported clinical cases. Furthermore, we found that the destruction of BA metabolism and transport is involved in WEF-induced cholestasis. The fine-scale molecular mechanisms of WEF-induced cholestasis and the active compounds of EF need further study.

Prognostic Role of Liver Biopsy in Patients With Severe Indeterminate Acute Hepatitis

BACKGROUND AND AIMS

Severe indeterminate acute hepatitis (sIAH) is a poorly understood rare disease with no specific therapy. This study aims to define the clinicopathological characteristics of sIAH and the role of liver biopsy in determining prognosis.

METHODS

Patients with sIAH admitted to a single center between 2010 and 2019 were included. Histopathological patterns of liver biopsies were reviewed by 2 histopathologists, and key findings further were specified by multiplex immunofluorescence. Patients that died or underwent liver transplantation were analyzed as nonsurvivors.

RESULTS

Of 294 patients with acute hepatitis, 43 with sIAH were included. Seventeen (39.5%) underwent liver transplantation and 7 (16.2%) died within 3 months. Multilobular necrosis was the predominant histopathological feature, being significantly more frequent in nonsurvivors (62.5% vs 21.1%; P = .016). Necrotic areas showed low HNF4α and Ki67 expression but high expression of CK19 and cell death markers identifying areas of severe tissue injury and inadequate regenerative response. Patients with multilobular necrosis had higher international normalized ratio, Model for End-Stage Liver Disease, and Model for End-Stage Liver Disease-Sodium scores compared with those without (P values for all markers <.05). Multivariate Cox analysis revealed that multilobular necrosis (hazard ratio, 3.675; 95% confidence interval, 1.322-10.211) and lower body mass index (hazard ratio, 0.916; 95% confidence interval, 0.848-0.991) independently predicted death or transplantation.

CONCLUSIONS

The results of this study provide novel insights into the important role of liver biopsy in sIAH patients, suggesting that the presence of multilobular necrosis is an early indicator of poor prognosis.

Long-term sequelae of drug-induced liver injury

Drug-induced liver injury (DILI) has a very variable clinical and biochemical phenotype and differs widely in severity, from mild injury to life-threatening liver failure. Chronic injury has also been reported to occur at a variable frequency, ranging from 3.4% to 39%, 6-12 months after discontinuing the implicated agent. This wide range is probably related to various definitions of chronic liver injury and variable selection of patients. The long-term sequalae of this chronic injury in terms of morbidity and mortality are unclear, although rare vanishing bile duct syndrome is associated with an unfavourable prognosis, with increased risk of chronic liver failure and need for liver transplantation. Other forms of long-term sequalae associated with DILI are progressive fibrosis, autoimmune-like hepatitis, secondary sclerosing cholangitis, sinusoidal obstruction syndrome and, as a common final stage, the development of cirrhosis, portal hypertension and its complications. Immune checkpoint inhibitors, which can cause an autoimmune-like phenotype have also recently been shown to cause sclerosing cholangitis with cytotoxic T CD8+ cell infiltration in biliary tracts. DILI has been shown to have a significant impact on health-related quality of life but very little is known about its psychological consequences in the long-term. Further investigations with structured long-term follow-up and periodic quality of life surveys are needed to assess the impact of DILI on psychological outcomes, particularly in those with chronic sequelae.

Detailed Molecular Mechanisms Involved in Drug-Induced Non-Alcoholic Fatty Liver Disease and Non-Alcoholic Steatohepatitis: An Update

Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH) are some of the biggest public health challenges due to their spread and increasing incidence around the world. NAFLD is characterized by intrahepatic lipid deposition, accompanied by dyslipidemia, hypertension, and insulin resistance, leading to more serious complications. Among the various causes, drug administration for the treatment of numerous kinds of diseases, such as antiarrhythmic and antihypertensive drugs, promotes the onset and progression of steatosis, causing drug-induced hepatic steatosis (DIHS). Here, we reviewed in detail the major classes of drugs that cause DIHS and the specific molecular mechanisms involved in these processes. Eight classes of drugs, among the most used for the treatment of common pathologies, were considered. The most diffused mechanism whereby drugs can induce NAFLD/NASH is interfering with mitochondrial activity, inhibiting fatty acid oxidation, but other pathways involved in lipid homeostasis are also affected. PubMed research was performed to obtain significant papers published up to November 2021. The key words included the class of drugs, or the specific compound, combined with steatosis, nonalcoholic steatohepatitis, fibrosis, fatty liver and hepatic lipid deposition. Additional information was found in the citations listed in other papers, when they were not displayed in the original search.

A Rare Disease Presenting Postpartum: Acute Fatty Liver of Pregnancy

Acute fatty liver of pregnancy is a rare but highly fatal disease affecting women most frequently during the third trimester of pregnancy or in the postpartum period. It is considered a diagnosis of exclusion and requires a timely diagnosis to avoid maternal mortality. We present the case of a 33-year-old primigravida who required an emergency cesarean section due to fetal bradycardia. On postoperative day one, the patient was noted jaundiced, oliguric, and hypoglycemic. Laboratory tests revealed important hepatic dysfunction, coagulopathy, and renal failure. She was admitted to the Intensive Care Unit with the suspicion of acute fatty liver of pregnancy. Plasma exchange was started on postoperative day 5 with major clinical and laboratory improvement. A transjugular hepatic biopsy confirmed the diagnosis. The patient had satisfactory evolution and was discharged 15 days after delivery. Acute fatty liver of pregnancy is a highly morbid disease that needs a high index of suspicion to be diagnosed. Admission to an Intensive Care Unit to ensure maximum supportive care is mandatory in this disease.

The Utility of Liver Biopsy in the Evaluation of Liver Disease and Abnormal Liver Function Tests

OBJECTIVES

We aimed to assess the value of liver biopsy in the evaluation of abnormal liver tests.

METHODS

We analyzed consecutive liver biopsy specimens performed for evaluation of unexplained abnormal liver tests from 2014 to 2018. Diagnoses were categorized histologically and clinically. We determined whether histologic examination led to a specific diagnosis and whether prebiopsy laboratory variables predicted the underlying etiology.

RESULTS

Among the 383 liver biopsy specimens included, chronic hepatitis was the most common histologic (25%) and clinical (17%) diagnosis. Liver biopsy led to a clinical diagnosis in 87% of patients. The most likely clinical diagnoses were autoimmune hepatitis, nonalcoholic fatty liver disease, and drug-induced liver injury (38, 33, and 32 patients, respectively). Using sensitivity, specificity, and positive and negative predictive values, we found that liver tests were not predictive of a specific diagnosis. In patients with no history of liver disease or clinical features of portal hypertension, biopsy specimens revealed histologic cirrhosis in 5% of patients.

CONCLUSIONS

Histopathologic diagnoses were made in 85% of patients undergoing liver biopsy for investigation of unexplained liver tests, leading to a clinical diagnosis in 87% of patients. However, neither liver tests themselves nor their patterns were useful in predicting histologic or clinical diagnoses.

Hepatic manifestations of drug reaction with eosinophilia and systemic symptoms syndrome

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a potentially life-threatening drug reaction, which can affect multiple organs. Patients with DRESS syndrome and hepatic manifestations may present alterations ranging from mild hepatitis to acute liver failure. The diagnosis might be difficult, and the management of these patients is challenging. This report analyzes a series of five cases reporting the clinical presentation, which ranged from acute hepatitis to liver failure, and discussed their treatment.

Biomarkers of cholestasis

Cholestasis is a major pathological manifestation, often resulting in detrimental liver conditions, which occurs in a variety of indications collectively termed cholestatic liver diseases. The frequent asymptomatic character and complexity of cholestasis, together with the lack of a straightforward biomarker, hampers early detection and treatment of the condition. The 'omics' era, however, has resulted in a plethora of cholestatic indicators, yet a single clinically applicable biomarker for a given cholestatic disease remains missing. The criteria to fulfil as an ideal biomarker as well as the challenging molecular pathways in cholestatic liver diseases advocate for a scenario in which multiple biomarkers, originating from different domains, will be assessed concomitantly. This review gives an overview of classical clinical and novel molecular biomarkers in cholestasis, focusing on their benefits and drawbacks.

Role of liver biopsy in the era of clinical prediction scores for "drug-induced liver injury" (DILI): experience of a tertiary referral hospital

The clinical implications of the biopsy findings in cases of drug-induced liver injury (DILI) are not fully elucidated. The aim of this study was to evaluate the histopathological findings of cases diagnosed as DILI and to correlate them with clinical and biochemical findings (such as causality assessment algorithms). We searched our department database for all cases of liver biopsy with findings consistent with toxic liver disease and selected those with a clinical diagnosis of DILI. The causative relationships were established according to Roussel Uclaf Causality Assessment Method (RUCAM). A total of 53 cases of DILI were reviewed, most of them diagnosed in hospitalized patients (83%). The analytical toxicity profile was hepatocellular (R > 5) in 60% of the cases and cholestatic (R < 2) in 26.4% of cases. The group of drugs most implicated was the anti-microbials (18, 34%). The predominant histological patterns were "necroinflammation" (67.9%) and "cholestasis" (28.3%). The hepatocellular biochemical pattern was not associated with the presence of predominantly necroinflammatory findings in the biopsy (p = 0.44), and the biochemical cholestatic pattern was not associated with the presence of predominantly cholestatic findings in the biopsy (p = 0.51). This study supports that a better insight into the pathologic mechanisms associated with DILI should be based on liver biopsy due to the lack of a uniform correlation between clinical and biochemical patterns. Also, a liver biopsy may be used in those cases where clinical suspicion of DILI persists despite a low score on current causality assessment algorithms.