EASL Clinical Practice Guidelines: Drug-induced liver injury

Understanding antituberculosis drug-induced hepatotoxicity: Risk factors and effective management strategies in the pediatric population

Antituberculosis drug-induced hepatotoxicity (ATDIH) is a significant concern while managing pediatric tuberculosis. There is limited data on pediatric ATDIH, and much of the management practices are extrapolated from adult experiences. This article provides a comprehensive overview of the incidence, risk factors, clinical presentation, and management strategies for ATDIH in children. Pyrazinamide, isoniazid, and rifampicin are the most hepatotoxic first-line antituberculosis therapy (ATT). Though pyrazinamide has the highest potential for ATDIH, isoniazid is most frequently implicated. Hepatotoxicity typically manifests within the first 2-8 weeks of treatment, particularly during the intensive phase. Risk factors include younger age, female gender, malnutrition, hypoalbuminemia, and baseline liver dysfunction. Extra-pulmonary TB, particularly tuberculous meningitis, and concomitant hepatotoxic medications such as antiretro viral therapy or antiepileptic drugs further increase susceptibility. Genetic predisposition, including N-acetyltransferase 2 and cytochrome P4502E1 polymorphisms and specific HLA alleles also contribute to the increased risk. Clinically, ATDIH ranges from asymptomatic transaminase elevation to severe acute liver failure (ALF), necessitating prompt recognition and intervention. Diagnosis relies on the temporal association of liver injury with ATT initiation, supported by liver function tests, improvement upon ATT cessation, and recurrence upon reintroduction. Management involves discontinuing hepatotoxic drugs, initiating non-hepatotoxic regimens, and sequential reintroduction of ATT under close monitoring. For children with ALF, care in a tertiary center with liver transplantation expertise is essential. While pediatric ATDIH generally has favorable outcomes with timely intervention, delays can result in significant morbidity and mortality. Improved understanding of risk factors, vigilant monitoring protocols, and standardized pediatric management strategies are critical for optimizing outcomes in pediatric ATDIH.

Glucocorticoids accelerate the reduction of disease severity and biochemical parameters in drug-induced liver injury: Assess the causal relationship using the updated RUCAM scale

BACKGROUND

The efficacy and clinical application of glucocorticoids (GCs) in patients with drug-induced liver injury (DILI) remain controversial.

AIMS

To determine the efficacy and suitable population of GCs in patients with DILI.

METHODS

This was a single-center, retrospective study. Patients with moderate-to-severe DILI who met the diagnostic criteria from January 1, 2009 to December 31, 2024 were enrolled. Patients in the GC group and the non-GC group were matched 1:1 by propensity score-matched (PSM), and the reduction of disease severity and biochemical parameters were compared between the two groups. According to the level of TB, the patients with DILI were divided into three groups, and the efficacy of GCs in each subgroup was compared.

RESULTS

Patients with DILI in our study were evaluated by the updated RUCAM causality assessment scale. All patients had RUCAM scores≥6 and causal relationship graded as " probable" or " highly probable". The use of GC treatment differs according to the severity of patients, especially the baseline level of TB (% in patients with TB <5 ULN, % in patients with 5ULN≤TB≤10ULN, and % in TB≥10ULN). After PSM analysis, 163 patients were included in each group. After PSM, the time of severity reduction was faster in the GC group than the non-GC group (P=0.022). The adjusted cumulative rate of severity reduction was 62% in the GC group and 43.6% in the non-GC group. The cumulative rates of reaching 50% reduction in AST, ALP, TB level was higher in the GC group than in the non-GC group (P<0.001, P=0.0086 and P=0.003). Patients were divided into three subgroups according to baseline TB level. We found the cumulative rates of who achieved severity reduction and 50% reduction in liver biochemical parameters at discharge was higher in the GC group than in the non-GC group in patients with 5ULN≤ TB level ≤10ULN but not in patients with TB <5ULN and TB>10ULN. Multivariate analysis showed that sex, age, treatment group and severity were significantly associated with disease severity reduction of patients with DILI. After PSM, there were 56 patients with drug-induced autoimmune hepatitis (DI-AIH) and 270 patients with DILI with no autoimmune features cases in our cohort. The cumulative rate of severity reduction at discharge in the GC group was higher than that in the non-GC group in patients with DI-AIH (P=0.049). Although the incidence of side effects in the GC group was higher than that in the non-GC group, the adverse reactions were basically relieved with the withdrawal of GCs.

CONCLUSIONS

GCs accelerated the reduction of disease severity and liver biochemical parameters, especially in patients with 5ULN≤baseline TB level≤10ULN. Sex, age, treatment group and severity were significantly associated with disease severity reduction of patients with DILI.

Atorvastatin versus rosuvastatin in acute myocardial infarction with elevated liver enzymes: a target trial emulation study

BACKGROUND

Statins are associated with liver-related adverse events, with risk varying by statin type. However, current guidelines lack specific recommendations for statin selection in acute myocardial infarction (AMI) patients with elevated liver enzymes.

METHODS

This cohort study used a target trial emulation approach to include AMI patients treated with percutaneous coronary intervention between 2013 and 2022 from the Tianjin Health and Medical Data Platform, China. Eligible patients with atorvastatin or rosuvastatin prescriptions during hospitalization were matched 1:1 using propensity scores in those with elevated liver enzymes and normal liver enzymes respectively, and tracked for 1 year or until death (intention-to-treat analysis). Nonadherent patients were censored in the per-protocol analysis. The primary outcome was 1-year all-cause mortality, with secondary outcomes including recurrent MI and stroke.

RESULTS

In a matched cohort of 25,728 patients with elevated liver enzymes, 614 deaths (2.4%) occurred. Atorvastatin was associated with higher all-cause mortality compared to rosuvastatin (hazard ratio [HR]: 1.29, 95% confidence interval [CI] 1.10-1.51), consistent in the per-protocol analysis, and the in-hospital mortality difference was confirmed in an independent cohort. No significant differences were observed for recurrent MI (HR: 0.98, 95% CI 0.87-1.11) or stroke (HR: 1.10, 95% CI 0.93-1.28). Similar target trial emulation design among 18,270 AMI patients with normal liver enzymes at admission (9135 per group) found no significant differences between the two statins in all-cause mortality (HR: 1.09, 95% CI 0.88-1.35), recurrent MI (HR: 1.05, 95% CI 0.90-1.23), or stroke (HR: 1.07, 95% CI 0.90-1.28).

CONCLUSIONS

Atorvastatin treatment was associated with a higher risk of 1-year all-cause mortality than Rosuvastatin in a target trial emulation study of patients with elevated liver enzymes following AMI.

Postoperative pain management using high-dose oral acetaminophen for enhanced recovery after colorectal cancer surgery

PURPOSE

Postoperative pain management is important for enhanced recovery. High-dose oral acetaminophen is effective; however, the safety of its long-term use has not been established in gastrointestinal surgeries. This study aimed to investigate drug-induced liver injury (DILI) in patients with colorectal cancer using high-dose acetaminophen.

METHODS

One hundred sixty-eight consecutive colorectal cancer using high-dose oral acetaminophen (3600 mg/day between postoperative day 1 and 7) were enrolled.

RESULTS

One hundred forty-nine patients (88.7%) completed the administration of high-dose oral acetaminophen. DILI occurred in 58 patients (34.5%), and the cumulative incidence rates were 20.4% and 37.9% on postoperative 6 and 7, respectively. The severity of liver injury was grade 1 in all cases and returned to normal without treatment. Patients with DILI had a higher frequency of dyslipidemia (44.8% vs. 23.6%, P = 0.0047) and M1 staging (10.3% vs. 1.0%, P = 0.0036). A multivariate analysis showed that the presence of dyslipidemia (OR 2.61, P = 0.0067) and M1 stage (OR 12.4, P = 0.0053) were independent risk factors for DILI.

CONCLUSION

The long-term use of high-dose oral acetaminophen in colorectal cancer patients enrolled in enhanced recovery protocols is feasible. Moreover, the presence of dyslipidemia and M status are risk factors for DILI.

Insights into medication-induced liver injury: Understanding and management strategies

Drug-induced liver injury (DILI) has increasingly become a major concern in Western countries since the late 1960s, with an estimated annual incidence of 13.9-19.1 cases per 100,000 people. DILI is a significant cause of acute liver failure, exhibiting a high mortality rate of 10-50 %. Its etiology includes medications, herbal products, and dietary supplements, exacerbated by pre-existing liver conditions, sonorities, pregnancy, and nutritional deficiencies. It is categorized into intrinsic and idiosyncratic reactions. Intrinsic DILI, dose-dependent and predictable, is primarily caused by substances like paracetamol, which leads to liver toxicity through direct metabolic pathways. In contrast, idiosyncratic DILI is less common, unpredictable, and affects susceptible individuals, with non-steroidal anti-inflammatory drugs, antibiotics, and cardiovascular agents frequently implicated in hospitals. Oxidative stress, mitochondrial dysfunction, bile salt export inhibition, and stress on the endoplasmic reticulum are some DILI-related pathophysiology. Diagnosis relies on biochemical tests, serological markers, radiological investigations, and liver biopsy. Management strategies emphasize the identification and cessation of the offending drugs, supportive care, and specific treatment options targeted to the culprit drugs. Management depends on the severity and nature of the injury.

Advanced liver-on-chip model mimicking hepatic lobule with continuous microvascular network via high-definition laser patterning

There is a great demand for development of advanced in vitro liver models to predict the efficacy and safety of drug candidates accurately in the preclinical drug development. Despite the great efforts to develop biomimetic models, it remains challenging to precisely mimic a functional unit of the liver (i.e., hepatic lobule) with a continuous microvascular network. Recent progress in laser patterning has allowed us to create arbitrary biomimetic structures with high resolution. Here, we propose an advanced liver-on-chip model mimicking the hepatic lobule with a continuous microvascular network, ranging from the microvessels to the central vein of the liver, utilizing femtosecond laser patterning. Firstly, we optimize the laser power to pattern microchannels mimicking the microvessel and central vein of the hepatic lobule by using a femtosecond laser within a collagen-based hydrogel containing hepatic cells. Secondly, we construct continuous microvessels with luminal structures by comparing different microchannel sizes in diameter. Finally, we assemble a millimeter-scale hepatic lobule-like structure with multiple layers of microvascular networks in the liver-on-chip. Furthermore, our liver-on-chip model exhibits major liver functions and drug-induced hepatotoxicity, as evidenced by albumin and urea productions and by a toxic response to acetaminophen, respectively. Our approach provides valuable strategies for the development of advanced physiological and pathological liver-on-chip models for pharmaceutical and toxicological studies.

Identification and Management of Medical Comorbidities in Patients With HR+/HER2- Metastatic Breast Cancer Treated With CDK4/6 Inhibitors: Literature Review and Recommendations From Experts in Spain Opinion

Approximately one-third of patients with breast cancer have comorbidities at the time of their diagnosis. Recommendations for managing metastatic breast cancer are usually based on the results of clinical trials, which often limit patients with comorbidities. However, comorbidities greatly influence the quality of life, patient survival rate and treatment choice, particularly in older patients. The objective of this review was to identify clinically relevant comorbidities in patients with metastatic breast cancer, analyze the clinical approach to the treatment of these comorbidities, and propose recommendations from experts. An expert panel of eight medical oncologists identified seven therapeutic areas associated with the most relevant comorbidities in metastatic breast cancer: cardiovascular, gastrointestinal, endocrine/metabolic, renal, geriatric, psychological, and pain related. A clinical specialist from each therapeutic area specific to the relevant comorbidities (n = 8) joined the panel of experts (n = 8) to provide guidance on the appropriate management of these comorbidities. The specific comorbidities analyzed were hypertension, atrial fibrillation, venous thromboembolism, obesity, diabetes mellitus, cancer cachexia, chronic kidney disease, age-related disorders, arthritis, and fibromyalgia. In most cases, patients with metastatic breast cancer and medical comorbidities are polymedicated and/or vulnerable to toxicity. The oncologists provided recommendations on initial assessment and monitoring, follow-up recommendations, and warning signs and symptoms for referral to corresponding specialists based on their experience. The panel of experts also explored clinical scenarios related to each comorbidity and recommended a preferred CDK4/6 inhibitor based on available evidence regarding drug-drug interactions and potential for toxicity.

Natural History of Idiosyncratic Drug-Induced Liver Injury and Prognostic Models

BACKGROUND AND AIMS

Drug-induced liver injury (DILI) remains a leading cause of acute liver failure worldwide. Drugs such as isoniazid, alone or in combination with other anti-tuberculosis drugs, as well as a growing number of herbal and complementary medicines, have been implicated in most cases of acute liver failure in registry studies.

METHODS

This review summarizes current knowdledge on the acute and chronic outcomes in patients with idiosyncratic DILI and discusses several of the existing prognostic models.

RESULTS AND CONCLUSIONS

The reasons why some individuals progress from DILI to end-stage liver disease are still largely unknown. However, collaborative efforts over the past few decades have provided figures on the relative incidence of drug-induced acute liver failure and allowed the development of prognostic models to predict this worse outcome at the onset of the event. The outcome of chronic DILI is less well characterised due to the lack of sufficient follow-up in cohort studies, but several phenotypes of DILI can progress to chronicity, and specific drugs such as nitrofurantoin or amiodarone are classic examples of agents leading to chronic forms of DILI. Therapy for drug-induced acute liver failure and chronic DILI is mainly supportive, although some randomised clinical trials have shown beneficial effects of N-acetylcysteine and corticosteroids.

A New Discovery: Corydalis yanhusuo Causes Idiosyncratic Hepatotoxicity and Its Potential Mechanisms

Corydalis yanhusuo W.T.Wang (YHS) is a commonly used traditional Chinese medicine, often prescribed for treating a variety of pains. In recent years, there has been a gradual increase in the number of reports to liver injury caused by YHS and its preparations, but the exact type and mechanism of hepatotoxicity are still unclear. In the present study, we demonstrated that YHS could induce idiosyncratic drug-induced liver injury (IDILI) in the inflammatory activation models. A total of 459 differential genes and 25 differential metabolites were identified by transcriptomics and metabolomics, which were significantly enriched in the TNF and NF-κB signaling pathways as well as glycerophospholipid metabolism, sphingolipid metabolism, and arachidonic acid metabolism. In addition, YHS significantly increased the levels of TNF-α, IL-1β, and IL-6. Therefore, we believe that the mechanism of toxicity may be related to the TNF and NF-κB signaling pathways, with glycerophospholipid metabolism, sphingolipid metabolism, and arachidonic acid metabolism also playing important roles. It provides a reference for the safe and rational use of YHS in clinical practice and contributes to the precise prevention and control of the risk of liver toxicity associated with YHS.

The evaluation and molecular mechanisms of hepatotoxicity induced by trans-emodin dianthrones isolated from Polygonum multiflorum Thunb. in vitro

ETHNOPHARMACOLOGICAL RELEVANCE

Polygonum multiflorum Thunb. (PM) is a traditional Chinese medicine with pharmacological activities such as anti-inflammatory, anti-oxidation and anti-aging. An increasing number of reports have documented liver injury associated with PM both domestically and internationally. In our previous study, we found that dianthrones from PM showed strong hepatotoxicity in the zebrafish model and may be potential toxicity markers. However, the in vitro hepatotoxicity and molecular mechanisms of dianthrones remain to be elucidated.

AIM OF THE STUDY

Trans-emodin dianthrones is a dianthrones compound isolated from PM. In this study, we focused on the hepatotoxicity and molecular mechanism of the trans-emodin dianthrones.

MATERIALS AND METHODS

HepG2 cells were used to evaluate hepatotoxicity and study the molecular mechanism of trans-emodin dianthrones in vitro. After administration of trans-emodin dianthrones, CCK-8 was used to detect cell viability, biochemical method was used to detect hepatotoxicity and antioxidant levels, reactive oxygen species (ROS) content and mitochondrial membrane potential (MMP) were analyzed by flow cytometry, the expression levels of JNK/Bax signaling pathway, PI3K/AKT/mTOR signaling pathway and apoptosis-related proteins were detected by Western blotting. Redox and mitochondria-related gene expression levels were detected by qPCR.

RESULTS

Trans-emodin dianthrones reduced cell viability and activated apoptosis and the process was regulated by JNK/Bax and PI3K/AKT/mTOR pathways. Trans-emodin dianthrones activates JNK and AKT, thereby initiating the ROS-driven apoptosis cascade and increasing ROS-mediated cell damage, highlighting the importance of ROS stress in PM-induced hepatotoxicity.

CONCLUSION

Trans-emodin dianthrones exhibited significant hepatotoxicity at the level of HepG2 cells, and its mechanism is related to inhibiting the antioxidant system, causing mitochondrial dysfunction and inducing apoptosis induced by JNK/Bax and PI3K/AKT/mTOR pathways.

Molecular docking- and reporter-based screening identify dicoumarol against ER stress-induced liver injury in mice through inhibiting IRE1α activity

AIMS

Drug-induced liver injury is among the most challenging liver disorders. Endoplasmic reticulum (ER) is responsible for the correct protein folding and secretion, which are highly active in hepatocytes. Failure in maintaining the proper protein folding under pathological condition or external stimuli leads to the unfolded protein response (UPR) to restore ER homeostasis or induce cell death. IRE1α pathway is the most conserved UPR branch with diverse physiological and pathological functions. This study aimed to screen for natural compounds to alleviate hepatic ER stress and liver injury by modulating IRE1α activity.

MATERIALS AND METHODS

ATP-competitive molecules from chemical libraries were recognized by virtual screening for targeting the IRE1α kinase domain. IRE1α activity-based XBP1s-reporter cell lines with flow cytometric analysis were employed to validate candidates from chemical libraries. Then the functions of the top candidate compound on IRE1α signaling were analyzed followed by the treatment with ER stress agonists in vitro. Finally, the candidate compound was used to treat ER stress-induced acute liver injury to evaluate its protective effect in vivo.

KEY FINDINGS

Dicoumarol (DIC) was discovered as a potential inhibitor of IRE1α activation in HEK293T cells, HepG2 cells and primary hepatocytes. Particularly, DIC ameliorates tunicamycin (Tm)- and carbon tetrachloride (CCl4)-induced acute hepatic ER stress to protect against liver injury.

SIGNIFICANCE

This study established a drug screening strategy against IRE1α activation and identified potential new therapeutic effects of DIC in treating liver injury-related diseases.

Steroid initiation dose and duration of steroid reduction for immune checkpoint inhibitor-induced liver injury

AIM

Treatment for severe immune checkpoint inhibitor (ICI)-induced liver injury (≥ Grade 3) requires prednisolone (PSL) administration and interruption of the underlying malignancy treatment. If the liver injury improves steadily, a lower initial dose of PSL is beneficial. We aimed to investigate the relationship between the initial dose of PSL and the response to PSL or the duration of PSL dose reduction.

METHODS

We retrospectively collected clinical data of patients treated with ICIs at Nagoya University Hospital between September 2014 and December 2023. Patients who received PSL for severe ICI-induced liver injury were divided according to the starting dose into group A (0.8 mg/kg/day) and group B (1.0 mg/kg/day). The time to improvement in liver injury and the reduction of the PSL dose to 10 mg/day were compared between the groups.

RESULTS

Overall, 1271 patients were treated with ICIs, of whom 80 experienced severe ICI-induced liver injury. Of the patients, 29 did not receive steroids, and five used PSL doses of <0.5 mg/kg/day. There were no significant differences in the baseline characteristics or laboratory data between the groups. The time to dose reduction to 10 mg/day PSL was significantly shorter in group A than in group B. The time to improvement in liver injury did not differ between the two groups.

CONCLUSION

In some patients with severe ICI-induced liver injury, a dose of 0.8 mg/kg/day of PSL is sufficient to achieve a therapeutic effect and shorten the time required to reduce the dose to 10 mg/day.

EASL Clinical Practice Guidelines on the management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic liver disease of unknown aetiology which may affect any patient irrespective of age, sex, and ethnicity. At baseline, the clinical spectrum of the disease varies largely from asymptomatic cases to acute liver failure with massive hepatocyte necrosis. The aim of these EASL guidelines is to provide updated guidance on the diagnosis and management of AIH both in adults and children. Updated guidance on the management of patients with variants and specific forms of AIH is also provided, as is detailed guidance on the management of AIH-associated cirrhosis, including surveillance for portal hypertension and hepatocellular carcinoma, as well as liver transplantation in decompensated cirrhosis.

Changing perspectives: unveiling the risks of ashwagandha-induced hepatotoxicity

Ashwagandha, an herb popular in Ayurvedic medicine, is renowned for its health-enhancing properties. However, its association with liver damage in recent years has raised significant concerns, necessitating careful assessment and management. This case underscores the dangers of Ashwagandha, particularly for individuals with preexisting liver conditions, where it can lead to life-threatening acute-on-chronic liver failure. The lack of solid clinical evidence supporting Ashwagandha's health claims emphasizes the need for an evidence-based approach. Public education is essential to raise awareness of the risks associated with herbal supplements and prevent liver diseases.

Efficacy and Toxicity Analysis of Selective BET Bromodomain Inhibitors in Models of Inflammatory Liver Disease

BET bromodomain inhibitors demonstrate significant promise as anti-inflammatory agents. However, clinical data demonstrated that nonselective BET bromodomain inhibitors led to significant dose-limiting toxicity in clinical settings. Here, we use three orally bioavailable inhibitors, 1-3, that are either BRD4-D1 selective or pan-D1-biased + BRD4-D2, for assessing their cellular and in vivo efficacy and safety profile compared to known BET inhibitors in two inflammatory disease models. Our results show that pan-D1-biased + BRD4-D2 inhibitor, 3, is as efficacious as pan-BET inhibitor, I-BET151, in reducing inflammation in both models, whereas pan-D2 inhibitors are less effective. BRD4-D1 selective inhibitors are also efficacious; however, inhibitors with improved cellular engagement will be necessary to better assess their effects. Finally, BRD4-D1 selective inhibitors are better tolerated in a preclinical thrombocytopenia model than 3, while gastrointestinal toxicity may be a BRD4-driven effect. These results highlight the importance of assessing specific BET bromodomain functions due to their diverse roles in disease models.

GNF-5837 attenuates acute liver injury by inhibiting oxidative stress

BACKGROUND

Acute liver injury is caused by various reasons and results in abnormal liver function, serving as the basis for various liver diseases. However, there has not been much progress in research on the prevention and treatment of acute liver injury, and drugs directly or specifically used for acute liver injury are still lacking. Recent studies have shown that several types of cell death are closely associated with the onset, progression, and prognosis of liver injury.

METHODS AND RESULTS

In this study, we identified a small molecule compound, GNF-5837, which attenuates the severity of acute liver injury by inhibiting apoptosis, pyroptosis, and ferroptosis. Mechanically, we found that GNF-5837 reduces the generation of reactive oxygen species (ROS) and alleviates oxidative stress by capturing excessive oxidative free radicals generated during cell death, which effectively inhibits apoptosis, pyroptosis, and ferroptosis. The results of animal experiments showed that GNF-5837 can effectively alleviate Con A-induced acute liver injury in vivo by blocking multiple modes of cell death.

CONCLUSIONS

Therefore, our research indicates that the small molecule compound GNF-5837 is an oxygen radical scavenger with significant peroxide removal effects, which offer a potential therapeutic approach for cell death caused by imbalances in intracellular oxidative stress levels and provides new insights into the study of acute liver injury.

Retrospective analysis of clinical features of liver injury induced by levofloxacin

BACKGROUND

Current understanding of the relationship between levofloxacin exposure and hepatic injury primarily relies on case reports. This article aims to investigate the features of levofloxacin-induced liver injury.

RESEARCH DESIGN AND METHODS

We incorporated case series and reports regarding levofloxacin-induced hepatotoxicity published prior to 30 June 2024, utilizing an extensive search database. The data from 40 patients were collected and subjected to descriptive analysis.

RESULTS

The median age of the 40 patients was 60 years (range 10, 99), and the median time to exacerbation was 5 days (range 1 199). Liver injury was categorized as hepatocellular (62.5%), cholestatic (12.5%), and mixed (25.0%). Clinical manifestations included asymptomatic elevations in liver enzymes, jaundice, dark urine, nausea, vomiting, anorexia, hepatic encephalopathy. Laboratory evaluations revealed varying degrees of elevation in aminotransferases and total bilirubin. Biopsy results indicated hepatic necrosis, cholestasis, steatosis, and inflammatory infiltrates. After levofloxacin discontinuation, the median time to normalization of liver function was 21 days (range 3, 103), and 8 patients ultimately succumbing to the condition.

CONCLUSIONS

Hepatotoxicity is an uncommon but severe adverse effect associated with levofloxacin. Immediate discontinuation of levofloxacin is warranted if there is a rapid increase in aminotransferase levels or the emergence of hepatitis symptoms.

Model of baseline clinicopathological features predicts non-resolution of drug-induced liver injury at 6 months

INTRODUCTION

Chronicity in drug-induced liver injury (DILI) is assessed at 12 months, leading to a large time gap from its initial presentation. In this study, we developed a model that could predict biochemical non-resolution in DILI (DILI-NR) patients at 6 months using baseline clinicopathological data.

PATIENTS AND METHODS

Cases of DILI with liver biopsies were enrolled between January 2016 and December 2021. BSEP, MDR3, and MRP2 were assessed immunohistochemically. DILI-NR was considered a biochemical non-resolution 6 months after the onset of DILI. A separate cohort of 126 patients was taken as a validation cohort.

RESULTS

DILI-NR was noted in 59/407 patients (14.5%). DILI-NR patients had significantly higher body mass index, lower hemoglobin, more severe disease at the presentation, autoantibody positivity, higher IgG, association with co-morbidities, and were more aged. Pathologically, DILI-NR had increased ductular reaction, duct damage, duct loss, ductular bile plugs, and autoimmune hepatitis-like morphology along with lesser expression of canalicular transporters. On multivariate logistic regression (LR) analysis and XGBoost analysis, BMI, hemoglobin, presence of autoantibodies, disease severity at baseline, and lower expression of any one transporter were associated with DILI-NR (AUROC = 0.92). After calibrating the model on the test cohort, the LR model showed AUROC of 0.89 with an accuracy of 87.3% and precision of 91.5%, confirming the effectiveness of the model.

CONCLUSION

The model encompassing hemoglobin, BMI, presence of autoantibodies, disease severity, and reduced expression of canalicular proteins at baseline predicts the biochemical non-resolution of DILI at six months.

Clinicopathological characteristics of autoimmune‑like hepatitis after drug‑induced liver injury

Autoimmune hepatitis (AIH) can be induced by drugs, but the underlying mechanisms remain unclear. The present study attempted to elucidate the clinicopathological characteristics of autoimmune-like hepatitis following drug-induced liver injury (DILI-ALH). The medical records of 57 patients diagnosed with AIH at Mie General Medical Center (Yokkaichi, Japan) were retrospectively reviewed, paying particular attention to the history of drug administration. Patients were classified into three groups: De novo AIH, drug-induced ALH (DI-ALH) and DILI-ALH. DILI-ALH was newly defined as cases in which the patient had a history of DILI and where the liver injury initially improved after drug discontinuation, but later worsened and was diagnosed as AIH. Of the 57 patients diagnosed with AIH, 42 patients were included in this study. De novo AIH was diagnosed in 29 patients, DI-ALH in 10 patients and DILI-ALH in 3 patients. Suspected causative drugs for drug-related pathologies were variable, including statins, health foods and supplements. No significant differences in sex or mean age were observed for DI-ALH and DILI-ALH compared with those for AIH. Distinguishing DI-ALH or DILI-ALH from AIH serologically and pathologically is difficult. No significant differences in the number of steroids used or the recurrence rate were observed between any groups. These findings suggest that drugs may present a more diverse cause of ALH than generally predicted. In particular, some AIH cases clearly present with DILI-ALH. Clarifying the involvement of drugs in the pathogenesis of AIH and establishing guidelines for diagnosis and treatment represent important issues for the future.

Analysis of Immunometabolic Profiles in Patients With Chronic Drug-Induced Liver Injury and Validation in Mice to Reveal Potential Mechanisms

BACKGROUND

The mechanism underlying chronic drug-induced liver injury (DILI) remains unclear. Immune activation is a common feature of DILI progression and is closely associated with metabolism. We explored the immunometabolic profile of chronic DILI and the potential mechanism of chronic DILI progression.

METHODS

Plasma and peripheral blood mononuclear cells from patients with chronic DILI were analyzed using multiplex immunoassays and untargeted metabolomics to reveal their immunometabolic profile. The effects and potential mechanisms of chronic DILI-related metabolite on acute or chronic liver injury induced by LPS or CCl4 in mice were investigated.

RESULTS

Patients with chronic DILI exhibited elevated plasma IL-6, IL-12p70, IL-15 and reduced IL-10 levels. The percentage of IL-12+ monocytes was higher, while that of CD206+ monocytes, IL-10+ monocytes, Th2, Treg, and IL-10+ CD4+ T cells were lower in patients with chronic DILI compared to those with acute DILI. We identified the most significantly increased metabolite in patients with chronic DILI was cis-aconitic acid (CAA). Administration of CAA can attenuate liver injury in mice with acute liver injury induced by LPS or CCl4 and promote the spontaneous resolution of liver fibrosis in mice with chronic live injury induced by CCl4. The protective mechanism of CAA against liver injury is associated with the inhibition of hepatic macrophage infiltration and polarization, which is achieved by inhibiting the secretion of neutrophil-derived IL-33 and subsequent phosphorylation of GATA3.

CONCLUSIONS

CAA, which is elevated in patients with chronic DILI, protects against liver injury by inhibiting hepatic macrophage infiltration and polarization through the suppression of the IL-33/GATA3 pathway, suggesting that CAA may serve as a potential target for regulating tissue repair in liver injury.

British Society of Gastroenterology guidelines for diagnosis and management of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a chronic inflammatory liver disease which, if untreated, often leads to cirrhosis, liver failure and death. The last British Society of Gastroenterology (BSG) guideline for the management of AIH was published in 2011. Since then, our understanding of AIH has advanced in many areas. This update to the previous guideline was commissioned by the BSG and developed by a multidisciplinary group. The aim of this guideline is to review and summarise the current evidence, in order to inform and guide diagnosis and management of patients with AIH and its variant syndromes. The main focus is on AIH in adults, but the guidelines should also be relevant to older children and adolescents.

Efficacy and safety of polymyxin B sulfate versus colistin sulfate in ICU patients with nosocomial pneumonia caused by carbapenem-resistant Acinetobacter baumannii: a multicenter, propensity score-matched, real-world cohort study

BACKGROUND

Despite the widespread use of colistin sulfate (CS) in clinical settings in China over recent years, supported by several studies demonstrating its clinical efficacy, there remains a lack of comparative data on the efficacy and safety of polymyxin B sulfate (PMB) versus CS, specifically for carbapenem-resistant Acinetobacter baumannii (CRAB)-caused nosocomial pneumonia.

OBJECTIVE

To compare the efficacy and safety of PMB and CS in intensive care unit (ICU) patients with nosocomial pneumonia caused by CRAB.

METHODS

We conducted a multicenter retrospective cohort study, including patients diagnosed with CRAB-caused nosocomial pneumonia and treated with intravenous PMB or CS in the ICU of the study hospitals between January 1, 2020, and June 30, 2024. Propensity score matching (PSM) was employed to adjust for potential baseline confounders between cohorts. Multivariate logistic regression analysis and Cox logistic regression analyses were performed to identify for factors potentially influencing the clinical outcomes and adverse events.

RESULTS

Following matching, a total of 190 patients were analyzed. There was no statistical significance in the rates of clinical success, microbiological eradication and 28-day mortality between the PMB and CS cohorts. While the incidence of acute kidney injury (AKI) and hepatotoxicity were comparable in both cohorts, but dermal toxicity was significantly higher in patients receiving PMB compared to those receiving CS (18.9% vs. 0%, P < 0.05). Among all the patients, hypertension, baseline renal insufficiency, usage of vasoactive drugs and in combination with three or more antibiotics were independent risk factors associated with AKI; while age, duration of polymyxins ≤ 7 days and Sequential Organ Failure Assessment (SOFA) score were risk factors associated with 28-day all-cause mortality.

CONCLUSION

This study establishes that PMB and CS have similar efficacy in treating CRAB induced nosocomial pneumonia in the ICU settings. The incidence of AKI and hepatotoxicity of both polymyxins are comparable for both polymyxins, although PMB is associated with a significantly higher incidence of skin toxicity. Ensuring adequate therapy duration is key to better outcomes in the treatment of CRAB-induced nosocomial pneumonia in ICU patients, regardless of the type of polymyxins.

Hepatic Safety Considerations in the Use of Ulipristal Acetate for Symptomatic Uterine Fibroids

Introduction

Ulipristal acetate (UPA, 5 mg) demonstrated efficacy in symptom reduction for patients with symptomatic fibroids. While registration and post-marketing trials assessing UPA identified few hepatic concerns, post-marketing concerns about potential drug-induced liver injury (DILI) led to significant restrictions, including indication restriction, warning labels and mandatory liver function monitoring. These measures, along with two marketing suspensions, resulted in a decline in UPA use, ultimately leading to the withdrawal of its marketing authorization previously in Canada, Australia, as well as Singapore and in 2024, at the request of the marketing authorization holder for commercial reasons, also for the European Union.

Methods

This narrative review critically evaluates the hepatic safety considerations associated with UPA.

Results

On reassessment, the risk of severe DILI with UPA is low at 13.5:100.000, with an incidence of 1 in 200,000 for liver transplantation. These numbers are lower than with many other widely prescribed medications, where no regular liver monitoring is recommended. UPA was subjected to strict liver test monitoring although proof of effectiveness of these measures in preventing serious DILI was lacking. While the risk of severe hepatotoxic events is important to consider, a balanced approach to safety measures is needed, particularly in light of the higher risks associated with alternative treatment options such as surgical intervention.

Conclusion

While UPA had a unique place in the treatment of uterine fibroids, overly cautious regulatory measures due to exceedingly rare DILI incidences led to the withdrawal of its marketing authorization in most parts of the world. There is a need for an improved understanding of DILI mechanisms and causality assessments to aid in the development of more proportional regulatory responses, balancing patient safety and sustained access to effective innovative treatment.

Does the hepatologist still need to rely on aminotransferases in clinical practice? A reappraisal of the role of a classic biomarker in the diagnosis and clinical management of chronic liver diseases

Aminotransferases, particularly alanine aminotransferase (ALT), are commonly used in the detection, diagnosis, and management of chronic liver diseases. ALT, a sensitive and cost-effective marker of liver injury, remains pivotal in predicting clinical outcomes and guiding interventions in several chronic liver diseases including metabolic dysfunction-associated steatotic liver disease, and chronic viral hepatitis. This study aims to explore the evolving role of ALT as a biomarker. A comprehensive review of evidence was conducted, focusing on studies evaluating ALT thresholds, diagnostic accuracy, and integration with non-invasive liver assessment tools. Special emphasis was given to novel approaches, including artificial intelligence-driven algorithms. Expert opinions from hepatology care perspectives were considered to assess the practical implications of refining ALT-based diagnostic strategies. ALT levels are influenced by diverse factors such as age, gender, and metabolic risks, challenging the use of specific thresholds as biomarker of disease and prognosis. Emerging evidence suggests redefining ALT ranges to enhance sensitivity and accuracy in detecting liver abnormalities. The integration of ALT with advanced non-invasive diagnostic tools, artificial intelligence, and comprehensive patient assessments can optimize early detection of liver disease, thus reducing underdiagnosis, particularly in asymptomatic or vulnerable populations. This work highlights the urgency to tailor the diagnostic approaches in primary and specialised care, ensuring timely and targeted intervention to effectively address the global burden of liver diseases.

Clinical Manifestations and Risk Factors of Liver Injury Induced by PD-1 Inhibitors in Patients with Malignancies: A Case-Control Study

Background

Hepatic injury induced by immune checkpoint inhibitors (ICPIs) is an inevitable challenge in the era of innovative anti-tumor therapies. However, studies on immune-related liver injury are relatively insufficient, and the associated risk factors are still lacking. The purpose of this study was to explore the incidence and clinical manifestations of immunotherapy-related liver injury.

Methods

A retrospective case-control study was conducted involving patients treated with PD-1 inhibitors at Weifang People's Hospital, a tertiary general hospital in China, from January 1, 2021 and July 31, 2024. Univariate and multivariate logistic regression analyses were employed to identify the potential risk factors. Then, the predictive value of these risk factors was evaluated using receiver operating characteristic (ROC) curve analysis.

Results

In total, 300 patients were included. Among these patients, 52 patients experienced liver injury. The mean time from the initiation of immunotherapy to the onset of liver injury was 28.4 days, with a range from 2 to 219 days. 71.15% of patients developed liver injury within the first 30 days. 82.69% presented with mild cases (grade 1), 13.46% with moderate cases (grade 2), and 3.84% with severe cases (grades 3-4). The overall incidence of PD-1 inhibitors-related liver injury was 0.34%. Specifically, nivolumab exhibited the highest incidence at 2.86%, followed by sintilimab at 0.41%. Both toripalimab and camrelizumab exhibited an incidence of 0.34%, while tislelizumab had the lowest at 0.28%. Multivariate logistic regression analysis showed that GGT and AST were independent risk factors for liver injury. ROC curve analysis revealed that patients with baseline ALT≥19.5 U/L, AST≥19.5 U/L, and GGT≥28.5 U/L were at increased risk of developing liver injury.

Conclusion

In clinical therapy, close monitoring of liver function is recommended, especially for patients with baseline ALT≥19.5 U/L, AST≥19.5 U/L, and GGT≥28.5 U/L during immunotherapy with PD-1 inhibitors.

From mechanisms to medicine: Ferroptosis as a Therapeutic target in liver disorders

In recent 10 years, ferroptosis has become a hot research direction in the scientific research community as a new way of cell death. Iron toxicity accumulation and lipotoxicity are unique features. Several studies have found that ferroptosis is involved in the regulation of the hepatic microenvironment and various hepatic metabolisms, thereby mediating the progression of related liver diseases. For example, NRF2 and FSP1, as important regulatory proteins of ferroptosis, are involved in the development of liver tumors and liver failure. In this manuscript, we present the mechanisms involved in ferroptosis, the concern of ferroptosis with the liver microenvironment and the progression of ferroptosis in various liver diseases. In addition, we summarize recent clinical advances in targeted ferroptosis therapy for related diseases. We expect that this manuscript can provide a new perspective for clinical treatment of related diseases.

Efficacy and safety of switching from entecavir to tenofovir alafenamide in chronic hepatitis B patients with low-level viremia: a real-world 48-week extension study

Chronic hepatitis B (CHB) patients receiving entecavir (ETV) treatment might develop low-level viremia (LLV), which is proven to be associated with worse clinical outcomes, such as risk of drug-related mutations, progression to cirrhosis, and even hepatocellular carcinoma. This real-world prospective study evaluated the efficacy and safety of switching from ETV to tenofovir alafenamide fumarate (TAF) in CHB patients with LLV. From August 2020 to August 2023, 351 ETV-experienced CHB patients with LLV were enrolled from eight hospitals. Patients either continued ETV or switched to TAF. The primary efficacy endpoint was the complete virological response (CVR) at week 48; the safety endpoint was the first occurrence of any clinical adverse event during the treatment; and the renal safety and change in blood lipids were also assessed. Inverse probability treatment weighting (IPTW) generated 350.9 cases in the ETV group and 351.4 cases in the TAF group. After the 48-week treatment, the CVR and ALT normalization rates in the TAF group were 75.3% and 67.8%, which were significantly higher than 11.4% and 17.1% in the ETV group (P < 0.001). The two strategies showed comparable impact on renal function and lipid profiles, regarding low-density lipoprotein (LDL) cholesterol and the total cholesterol to high-density lipoprotein (TC/HDL) ratio. Therefore, for ETV-treated patients with LLV, switching to TAF is superior compared with continuing ETV treatment in terms of virological and biochemical response, with non-inferior renal safety and lipid profiles.CLINICAL TRIALSThis study is registered with the Chinese Clinial Trial Registry as ChiCTR2400089257.

Role of liver biopsy in the management of idiosyncratic DILI

Drug-induced liver injury (DILI) presents unique challenges in clinical practice. While some types of DILI are mild and resolve quickly after removing the drug, other situations are more complex, with competing aetiologies or underlying liver disease. Guidelines from professional societies agree that the liver biopsy retains a role in understanding and managing DILI in certain situations. Liver biopsy allows characterization of the histological pattern of injury as well as assessment of severity. Inflammatory infiltrates, bile duct injury or loss and vascular injury are all revealed by liver biopsy. Communication between the hepatopathologist and clinical team with clinicopathological correlation of the findings is necessary for the best determination of causality and differentiation from other diseases of exclusion, like autoimmune hepatitis and graft-versus-host disease. This review highlights important aspects of the role of liver biopsy in DILI evaluation.

Drug-Induced Liver Injury Caused by Metamizole: Identification of a Characteristic Injury Pattern

BACKGROUND AND AIMS

Drug-induced liver injury (DILI) due to metamizole has gained increasing attention. Causality assessment remains a challenge, especially in patients with co-medications. We therefore aimed to further characterise metamizole DILI cases.

METHODS

The data of patients with metamizole intake from our prospective study on acute liver injury with potential drug-related causes were analysed. Diagnosis and causality assessment were based on a thorough work-up and long-term follow-up.

RESULTS

DILI was associated with metamizole in 61 of 324 DILI patients (prevalence 18.8%). A highly characteristic clinical pattern was observed in 43 of the 61 patients, characterised by marked elevation of transaminases peaking at the time of DILI recognition and a more pronounced increase of bilirubin within the first 3 days of clinical presentation. Patients fitting this picture had higher rates of jaundice, coagulopathy, and acute liver failure, however outcomes did not differ significantly when compared to non-metamizole DILI and autoimmune hepatitis (AIH) patients. Overall, fatal adverse outcomes defined by death or liver transplantation were observed in 13.1% of metamizole DILI patients. On multivariate analysis, only aspartate aminotransferase (AST) and INR were independently associated with a fatal adverse outcome. INR, in particular, performed better than Hy's law, bilirubin, transaminases, and the model for end-stage liver disease (MELD), with a c-statistic of 0.85 (95% CI: 0.70-1.0). At a cut-off of ≥ 2.1, sensitivity and specificity for a fatal adverse outcome were 75% and 96%, respectively.

CONCLUSIONS

Metamizole DILI can present with a characteristic pattern that can help clinicians to identify metamizole as the causative agent. Outcome, however, is not associated with this clinical picture and should rather be predicted by INR at onset.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02353455.

Methods for causality assessment of idiosyncratic drug-induced liver injury

The diagnosis of idiosyncratic drug-induced liver injury (DILI) is a challenging task due to the lack of specific features or definitive diagnostic tools. A minimum of clinical and pharmacological information is required, together with laboratory and imaging tests to exclude other causes of liver injury. Several standardized methods have been developed to support clinical judgement and establish causality assessment, the most widely used being the Roussel Uclaf Causality Assessment Method-RUCAM-and structured Expert Opinion. More recently, an evidence-based, revised RUCAM, Electronic Causality Assessment Method-RECAM-has been developed and, although still a work in progress, may replace RUCAM scoring in the future. International collaborative networks and ongoing research efforts are key to advancing biomarker qualification and validation and developing new in vitro patient-based methods that will help improve DILI diagnosis and move towards a personalized medicine approach.

Artificial Intelligence: An Emerging Tool for Studying Drug-Induced Liver Injury

Drug-induced liver injury (DILI) is a complex and potentially severe adverse reaction to drugs, herbal products or dietary supplements. DILI can mimic other liver diseases clinical presentation, and currently lacks specific diagnostic biomarkers, which hinders its diagnosis. In some cases, DILI may progress to acute liver failure. Given its public health risk, novel methodologies to enhance the understanding of DILI are crucial. Recently, the increasing availability of larger datasets has highlighted artificial intelligence (AI) as a powerful tool to construct complex models. In this review, we summarise the evidence about the use of AI in DILI research, explaining fundamental AI concepts and its subfields. We present findings from AI-based approaches in DILI investigations for risk stratification, prognostic evaluation and causality assessment and discuss the adoption of natural language processing (NLP) and large language models (LLM) in the clinical setting. Finally, we explore future perspectives and challenges in utilising AI for DILI research.

[Acute Liver Failure]

Acute liver failure (ALF) is a severe, potentially reversible form of liver insufficiency, which is defined by the occurrence of hepatic coagulopathy and hepatic encephalopathy in patients with no previous hepatic disease. Acute liver failure is preceded by severe acute liver injury (ALI) with an increase in transaminases, jaundice, and deterioration in general condition over a period of hours to weeks. Every year 200-500 people develop ALF in Germany, most frequently on the background of toxic liver injury (e.g. drug induced liver injury). Other potential causes include viral infections (e.g. hepatitis A and B), autoimmune hepatitis, Budd-Chiari Syndrome or Wilson's disease. Patients usually present at the stage of acute liver damage. Initial diagnostics should include a detailed medical history, clinical examination, laboratory diagnostics and abdominal sonography. The course of acute liver failure is very difficult to predict, so all patients with severe acute liver damage should be evaluated for transfer to a center. At the latest when hepatic encephalopathy occurs and thus when all the definition criteria of acute liver failure are met, the patient should be transferred to a liver transplant center immediately. While specific medical therapies may be available in the early stages of the disease, depending on the etiology, the focus in advanced stages is on preventing complications and treating associated organ dysfunctions. In progressive cases, liver transplantation is often the only life-saving measure. Overall, the mortality rate in Germany is 47%, and approximately 8% of annual liver transplants in the European Union are performed due to ALF.

Drug-induced hepatic sinusoidal obstruction syndrome: current advances and future perspectives

Hepatic sinusoidal obstruction syndrome (HSOS) has gained recognition as a rare form of drug-induced liver injury (DILI) in recent years. Although extensively studied in the context of hematopoietic stem cell transplantation (HSCT), the applicability of this knowledge to drug-induced HSOS remains limited due to distinct etiological factors. The primary causes of drug-induced HSOS include the ingestion of pyrrolizidine alkaloid (PA)-containing plants, as well as the use of chemotherapeutic agents and immunosuppressive drugs. The underlying pathogenesis is not yet fully understood. Noninvasive diagnostic imaging modalities such as ultrasonography, computed tomography, and magnetic resonance imaging play a valuable role in diagnosis. Further research is essential to develop standardized severity grading systems and optimize treatment strategies. This review summarizes the key etiologies, pathological mechanisms, clinical features, diagnostic approaches, severity assessment, and therapeutic options for drug-induced HSOS.

Medication Hazards and Outcome Patterns of Pediatric Drug-Associated Liver Injury in Taiwan: An Analysis of 1998-2017 Spontaneous Adverse Drug Reaction Reports

BACKGROUND AND OBJECTIVES

Accumulating pediatric efficacy and safety data on drug use is inherently challenging yet essential. This study aimed to analyze the frequency and compute the odds of pediatric drug-associated liver injury across age groups (early childhood, middle childhood, and adolescence) and therapeutic categories using adverse drug reactions (ADRs) reporting data spanning nearly two decades.

METHODS

We analyzed the reports of suspected ADRs occurring in children and adolescents in the Taiwan National Adverse Drug Reaction Reporting System during the period from May 1998 until July 2017. Standardized Medical Dictionary for Regulatory Activities Queries were utilized to identify suspected hepatic ADRs. Outcome patterns across age groups were compared using the chi-squared test, and disproportionality analysis was employed to calculate reporting odds ratios (RORs) of hepatic versus nonhepatic reports.

RESULTS

Among 16,673 reports, 484 (2.9%) were identified as suspected hepatic ADRs, involving 193 distinct drugs. The mean age of affected individuals was 8.2 years. Outcome types in adolescents were predominantly serious (91.8%). Antibacterials for systemic use (18.8%) and antiepileptics (8.7%) were the most frequently implicated therapeutic categories. Drugs with high ADR occurrence rates and significant RORs included oxacillin (5.2%; ROR: 12.07), methotrexate (4.1%; ROR: 9.07), and phenobarbital (2.7%; ROR: 5.04). Some medications exhibited higher ratios of used-versus-recommended doses, suggesting inappropriate dosing.

CONCLUSIONS

Pediatric drug-associated liver injury was not uncommon and may result in serious outcomes. This study underscores the need for heightened vigilance in administering certain high-risk drugs and attentiveness in proper dosing for children, including adolescents.

Ursodeoxycholic Acid for the Management of Drug-induced Liver Injury: Role of Hepatoprotective and Anti-cholestatic Mechanisms

Drug-induced liver injury (DILI) is a harmful reaction to medications, herbs, and dietary supplements that results in liver dysfunction. Based on the distinct clinical patterns of liver damage, DILI can be categorized into hepatocellular, cholestatic, and mixed types. Hepatocellular DILI is linked to inflammation, apoptosis, and necrosis, while cholestatic DILI is commonly associated with bile plugs and, in rare cases, ductopenia. Ursodeoxycholic acid (UDCA) is the therapeutic agent most widely used for the treatment of cholestatic hepatopathies of diverse etiologies and has been mainly used as a supportive treatment in cholestatic DILI. In this review, we presented a more structured and systematic framework for the potential application of this hepatoprotective agent across a broader range of DILI scenarios. A MEDLINE search of the literature from 1995 to the present retrieved 41 preliminary clinical studies suggesting that UDCA may offer curative and preventive benefits for hepatocellular DILI as well. This aligns with preclinical studies in rodents, showing beneficial effects of UDCA in experimental DILI irrespective of the clinical patterns of injury involved. This could be due to the broad range of potentially beneficial effects of UDCA, which may address the various types of liver damage with different causes and mechanisms seen in all forms of DILI. UDCA's beneficial properties include anticholestatic, antioxidant, anti-inflammatory, anti-apoptotic, anti-necrotic, mitochondrial protective, endoplasmic reticulum stress-relieving, and immunomodulatory effects. Controlled studies with systematic use of standardized causality assessments are eagerly awaited to properly validate the use of UDCA in DILI. Meanwhile, we hope this article helps clarify and systematize the use of this versatile and safe hepatoprotective medication for different types of liver toxicity.

Hepatic adverse events with CDK4/6 inhibitors: a systematic review combining meta-analysis and FAERS database

BACKGROUND

Cell-cycle protein-dependent kinase 4 and 6 inhibitors (CDK4/6is) in combination with endocrine therapy (ET) are widely used in patients with early and advanced breast cancer (BC). CDK4/6is also lead to numerous side effects. This study aims to elucidate the relationship between CDK4/6is and hepatotoxicities.

RESEARCH DESIGN AND METHODS

As of 31 March 2024, we conducted a systematic search of PubMed, Embase, and the Cochrane Library databases, as well as several oncology conference proceedings. We included 20 randomized controlled trials (RCTs) with 24,342 breast cancer (BC) patients and 400 cases from the FDA Adverse Event Reporting System (FAERS). Fixed-effect and random-effect models were used to calculate odds ratios (ORs) of hepatotoxicity in the RCTs, while Reporting Odds Ratios (RORs) were calculated for the FAERS data.

RESULTS

Overall, CDK4/6 inhibitors (CDK4/6is) were associated with significant hepatotoxicities compared to controls (OR = 1.76, 95%CI 1.40-2.22, I2 = 75%). Palbociclib, ribociclib, and abemaciclib exhibited significant hepatotoxicities, while dalpiciclib did not. FAERS data showed significant liver enzyme and organ toxicity signals for ribociclib and abemaciclib but not for palbociclib.

CONCLUSIONS

CDK4/6is increase the risk of hepatotoxicities in patients with BC. Palbociclib, ribociclib, and abemaciclib caused liver damage, while dalpiciclib did not. The most common manifestations were elevated ALT and AST levels.

Biomarkers for the prediction and monitoring of the antipsychotic/antidepressant-induced hepatotoxicity: study protocol

AIM

This study is designed to address the connection between antidepressant and antipsychotic-induced hepatotoxicity with pharmacogenetic and epigenetic indicators, using a novel combined approach of CYP450 polymorphism determination and early liver injury detection via microRNA testing.

METHODS

The multi-centric retrospective case-control study in Slovakia involves 151 cases with signs of hepatotoxicity and 604 controls without. Participants will be tested for selected CYP450, UGT1A1 polymorphisms, and microRNAs.

RESULTS

Anticipated findings will test if patients with specific CYP450 and UGT1A1 polymorphisms are at higher risk for drug-induced hepatotoxicity and if plasma microRNAs hsa-miR-122-5p and hsa-miR-192-5p, alone or combined, can differentiate patients with abnormal liver function.

CONCLUSION

The findings could contribute to personalized treatment approach by combining genetic and epigenetic biomarkers.

Persistent hepatocyte secretory failure in lopinavir/ritonavir related to drug-induced liver injury: a case report

Lopinavir/ritonavir, an anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) drug, may be associated with the development of liver injury. In this paper, we reported an elderly female patient with drug-induced liver injury secondary to lopinavir/ritonavir, which was evaluated for their causality using the updated Roussel Uclaf Causality Assessment Method (RUCAM) of 2016. She had a RUCAM score of 8 which was equivalent to a probable causality grading. Her clinical course was complicated by persistent hepatocyte secretion failure (PHSF), followed by septic shock and SARS-CoV-2 re-infection during her hospitalization. Her response to any medical intervention, including ursodeoxycholic acid, glutathione, methylprednisolone sodium succinate, rifampicin, artificial liver support, and endoscopic nasobiliary drainage (ENBD) was very poor, and her family members refused liver transplantation. Finally, she died. In summary, this case suggests the possibility that lopinavir/ritonavir can cause DILI and even PHSF in our clinical practice.

Drug-induced autoimmune-like hepatitis: A disproportionality analysis based on the FAERS database

BACKGROUND

Drug-induced autoimmune-like hepatitis (DI-ALH) is a potentially life-threatening condition that can lead to acute liver failure and necessitate liver transplantation. While the association between certain drugs and DI-ALH has been documented, a comprehensive analysis of drug-related signals in a large, real-world pharmacovigilance database is lacking. This study aimed to systematically identify drugs linked to DI-ALH by analyzing adverse event reports from the U.S. Food and Drug Administration's (FDA) Adverse Event Reporting System (FAERS) database.

METHODS

We searched the FAERS database for the term "autoimmune hepatitis" and extracted DI-ALH reports from the first quarter of 2004 to the first quarter of 2024. Positive signal drugs were identified using Proportional Reporting Ratio (PRR), Reporting Odds Ratio (ROR), Bayesian Confidence Propagation Neural Network (BCPNN), and Empirical Bayesian Geometric Mean (EBGM). To confirm a significant drug-adverse event association, each method had to meet predefined thresholds: for PRR and ROR, values were considered significant if the lower 95% confidence interval (CI) was greater than 1 and at least three reports were identified; for BCPNN, an Information Component (IC025) greater than 0 indicated a signal; for EBGM, a value greater than 2 for the lower 95% confidence interval (EBGM05) was used to denote a positive signal.

RESULTS

A total of 5,723 DI-ALH reports were extracted from the FAERS database. Disproportionality analysis identified 50 drugs with strong associations to DI-ALH, with biologics, statins, antibiotics, and antiviral drugs representing the most common categories. Among these, nitrofurantoin (ROR 94.79, CI 78.53-114.41), minocycline (ROR 77.82, CI 65.09-93.05), and nivolumab (ROR 47.12, CI 15.06-147.39) exhibited the strongest signals. Additionally, several previously unreported drugs, including mesalazine, aldesleukin, onasemnogene abeparvovec-xioi, and nefazodone, were identified as having strong associations with DI-ALH. These findings were consistent across all four signal detection methods, further validating the robustness of the associations.

CONCLUSION

This study provides a comprehensive assessment of drugs associated with DI-ALH through a rigorous analysis of the FAERS database using multiple signal detection methods. By identifying both well-known and previously underreported drugs, this study contributes to a more complete understanding of drug-induced liver injury. The findings have important implications for pharmacovigilance strategies and clinical risk assessment. However, limitations inherent in the FAERS database, such as underreporting and the potential for reporting bias, should be considered. Further clinical validation is warranted to confirm these associations.

Liver diseases: epidemiology, causes, trends and predictions

As a highly complex organ with digestive, endocrine, and immune-regulatory functions, the liver is pivotal in maintaining physiological homeostasis through its roles in metabolism, detoxification, and immune response. Various factors including viruses, alcohol, metabolites, toxins, and other pathogenic agents can compromise liver function, leading to acute or chronic injury that may progress to end-stage liver diseases. While sharing common features, liver diseases exhibit distinct pathophysiological, clinical, and therapeutic profiles. Currently, liver diseases contribute to approximately 2 million deaths globally each year, imposing significant economic and social burdens worldwide. However, there is no cure for many kinds of liver diseases, partly due to a lack of thorough understanding of the development of these liver diseases. Therefore, this review provides a comprehensive examination of the epidemiology and characteristics of liver diseases, covering a spectrum from acute and chronic conditions to end-stage manifestations. We also highlight the multifaceted mechanisms underlying the initiation and progression of liver diseases, spanning molecular and cellular levels to organ networks. Additionally, this review offers updates on innovative diagnostic techniques, current treatments, and potential therapeutic targets presently under clinical evaluation. Recent advances in understanding the pathogenesis of liver diseases hold critical implications and translational value for the development of novel therapeutic strategies.

Angel or devil: the dual roles of 2,3,5,4'-tetrahydroxystilbene-2-O-β-D-glucopyranoside in the development of liver injury based on integrating pharmacological techniques: a systematic review

Background and purpose

2,3,5,4'-tetrahydroxystilbene-2-O-β-D-glucoside (TSG) exhibits a dualistic pharmacological profile, acting as both a hepatoprotective and hepatotoxic agent, which is intricately linked to its interaction with multiple signaling pathways and its stereoisomeric forms, namely, cis-SG and trans-SG. The purpose of this study is to evaluate both the hepatoprotective and hepatotoxic effects of TSG and give therapeutic guidance.

Methods

This study performed a systematic search of eight databases to identify preclinical literature up until March 2024. The CAMARADES system evaluated evidence quality and bias. STATA and Python were used for statistical analysis, including dose-effect maps, 3D maps and radar charts to show the dose-time-effect relationship of TSG on hepatoprotection and hepatotoxicity.

Results

After a rigorous screening process, a total of 24 studies encompassing 564 rodents were selected for inclusion in this study. The findings revealed that TSG exhibited bidirectional effects on the levels of ALT and AST, while also regulating the levels of ALT, AST, TNF-α, IL-6, serum TG, serum TC, SOD, MDA, IFN-γ, and apoptosis rate. The histological analysis of liver tissue confirmed the regulatory effects of TSG, and a comprehensive analysis revealed the optimal protective dosage range was 27.27-38.81 mg/kg/d and the optimal toxic dosage range was 51.93-76.07 mg/kg/d. TSG exerts the dual effects on liver injury (LI) through the network of Keap1/Nrf2/HO-1/NQO1, NF-κB, PPAR, PI3K/Akt, JAK/STAT and TGF-β pathways.

Conclusion

TSG could mediate the pathways of oxidation, inflammation, and metabolism to result in hepatoprotection (27.27-38.81 mg/kg/d) and hepatotoxicity (51.93-76.07 mg/kg/d).

Isorhapontigenin alleviates acetaminophen-induced liver injury by promoting fatty acid oxidation

Acetaminophen (APAP) is a widely used analgesic and antipyretic medicine. It is frequently employed to alleviate pain and mitigate fever-related symptoms, but it can cause liver injury or even liver failure when overdosed. Isorhapontigenin, a compound derived from Chinese herbs and grapes, has been demonstrated to exhibit antioxidant and anti-inflammatory effects. This study focused on evaluating the effect of isorhapontigenin in alleviating APAP-induced liver injury. In the study, a single intraperitoneal administration of APAP was employed to induce liver injury, and isorhapontigenin was given orally 3 days before or 1 h after APAP administration. The results revealed that isorhapontigenin significantly mitigated liver injury by effectively inhibiting APAP-induced apoptosis, oxidative stress, and inflammation. Furthermore, transcriptomic RNA sequencing of liver tissues indicated that isorhapontigenin probably protected against APAP-induced liver injury by promoting fatty acid oxidation. Pharmacological experiments also demonstrated that isorhapontigenin treatment led to a significant reduction in triglyceride accumulation, increased ATP levels and direct fatty acid oxidation activity, as well as enhanced expression of proteins associated with fatty acid oxidation, including PPAR-α, PGC-1α, and CPT-1A. Moreover, the protective effects of isorhapontigenin against APAP-induced liver injury were abolished by a CPT-1A inhibitor, etomoxir. Notably, we found that combining isorhapontigenin with NAC (N-acetyl-L-cysteine) resulted in a more significant alleviation of APAP-induced liver injury compared to NAC alone. In conclusion, our study indicates that isorhapontigenin is a potential therapeutic strategy that works by regulating fatty acid oxidation to alleviate APAP-induced liver injury.

Ginsenoside Rg1: A bioactive therapeutic agent for diverse liver diseases

Diverse liver diseases are characterised by late diagnosis and rapid progression and have become one of the major threats to human health. To delay the transition from benign tissue lesions to a substantial organ injury, scientists have gradually applied natural compounds derived from plants as a complementary therapy in the field of hepatology. Ginseng (Panax ginseng C. A. Meyer) is a tonic traditional Chinese herbal medicine, and natural products, including ginsenoside Rg1 (G-Rg1), which is a kind of 20(S)-protopanaxatriol saponin with a relatively high biological activity, can be isolated from the roots or stems of ginseng. Given these information, this review aimed to summarise and discuss the metabolic mechanisms of G-Rg1 in the regulation of diverse liver diseases and the measures to improve its bioavailability. As a kind of monomer in Chinese medicine with multitarget pharmacological effects, G-Rg1 can provide significant therapeutic benefits in the alleviation of alcoholic liver disease, nonalcoholic fatty liver disease, liver fibrosis, viral hepatitis, etc., which mainly rely on the inhibition of apoptosis, strengthening endogenous anti-inflammatory and antioxidant mechanisms, activation of immune responses and regulation of efflux transport signals, to improve pathological changes in the liver caused by lipid deposition, inflammation, oxidative stress, accumulation of hepatotoxic product, etc. However, the poor bioavailability of G-Rg1 must be overcome to improve its clinical application value. In summary, focusing on the hepatoprotective benefits of G-Rg1 will provide new insights into the development of natural Chinese medicine resources and their pharmaceutical products to target the treatment of liver diseases.

Deciphering the Molecular Mechanisms of HAART-Induced Hepatotoxicity

Highly active antiretroviral therapy (HAART), consisting of three or more antiretroviral drugs, is recommended for patients with HIV infection. HAART effectively reduces HIV RNA levels, lowers the risk of opportunistic infections, and improves immune function and survival rates. However, it is also associated with an increased risk of liver injury in HIV-infected individuals. This review aims to summarize the mechanisms underlying HAART-induced liver injury. A comprehensive search was conducted in PubMed and EMBASE using keywords such as "Antiretroviral/ARV drugs and drug-induced liver injury (DILI)," "HAART and DILI," "Antiretroviral therapy and DILI," and "HIV infection and DILI." Relevant papers published before March 2024 were included. Experimental studies have demonstrated that zidovudine and efavirenz can cause structural alterations in mitochondria, impair the respiratory chain, generate free radicals, and deplete mitochondrial DNA, leading to oxidative and endoplasmic reticulum stress, as well as the accumulation of advanced glycation end products in liver tissue. Zidovudine disrupts lipid homeostasis by increasing fatty acid synthesis and reducing metabolism. Efavirenz and its metabolite, 8-hydroxyefavirenz, induce hepatocellular death and activate proapoptotic markers through c-Jun N-terminal kinase signaling. Additionally, lamivudine has been shown to induce liver injury and oxidative stress in rats. Clinically, approximately 50% of HIV patients on HAART regimens containing non-nucleoside reverse transcriptase inhibitors experience mild to moderate liver injury. HAART regimens that include efavirenz, lamivudine, and tenofovir impair glucose and lipid homeostasis in rats, highlighting the need for caution in HIV patients with fatty liver disease. Patients with viral hepatitis coinfection, those taking antitubercular drugs or cotrimoxazole, and those on nevirapine-containing regimens are at particularly high risk. Regular monitoring of liver function is essential to prevent liver damage associated with HAART in HIV-infected patients. While HAART significantly improves survival rates in HIV patients, it also poses a considerable risk of liver injury, necessitating careful monitoring and management.

Small Extracellular Vesicles Engineered Using Click Chemistry to Express Chimeric Antigen Receptors Show Enhanced Efficacy in Acute Liver Failure

Acetaminophen (APAP) overdose can cause severe liver injury and life-threatening conditions that may lead to multiple organ failure without proper treatment. N-acetylcysteine (NAC) is the accepted and prescribed treatment for detoxification in cases of APAP overdose. Nonetheless, in acute liver failure (ALF), particularly when the ingestion is substantial, NAC may not fully restore liver function. NAC administration in ALF has limitations and potential adverse effects, including nausea, vomiting, diarrhoea, flatus, gastroesophageal reflux, and anaphylactoid reactions. Mesenchymal stromal cell (MSC)-based therapies using paracrine activity show promise for treating ALF, with preclinical studies demonstrating improvement. Recently, MSC-derived extracellular vesicles (EVs) have emerged as a new therapeutic option for liver injury. MSC-derived EVs can contain various therapeutic cargos depending on the cell of origin, participate in physiological processes, and respond to abnormalities. However, most therapeutic EVs lack a distinct orientation upon entering the body, resulting in a lack of targeting specificity. Therefore, enhancing the precision of natural EV delivery systems is urgently needed. Thus, we developed an advanced targeting technique to deliver modified EVs within the body. Our strategy aims to employ bioorthogonal click chemistry to attach a targeting molecule to the surface of small extracellular vesicles (sEVs), creating exogenous chimeric antigen receptor-modified sEVs (CAR-sEVs) for the treatment. First, we engineered azido-modified sEVs (N3-sEVs) through metabolic glycoengineering by treating MSCs with the azide-containing monosaccharide N-azidoacetyl-mannosamine (Ac4ManNAz). Next, we conjugated N3-sEVs with a dibenzocyclooctyne (DBCO)-tagged single-chain variable fragment (DBCO-scFv) that targets the asialoglycoprotein receptor (ASGR1), thus producing CAR-sEVs for precise liver targeting. The efficacy of CAR-sEV therapy in ALF models by targeting ASGR1 was validated. MSC-derived CAR-sEVs reduced serum liver enzymes, mitigated liver damage, and promoted hepatocyte proliferation in APAP-induced injury. Overall, CAR-sEVs exhibited enhanced hepatocyte specificity and efficacy in ameliorating liver injury, highlighting the significant advancements achievable with cell-free targeted therapy.

Useful biomarkers for predicting poor prognosis of patients with drug-induced liver injury: A retrospective cohort study

BACKGROUND

Drug-induced liver injury (DILI) plays an important role in liver failure and causes mortality. Patients with DILI compatible with Hy's law are associated with poorer outcomes. However, the predictive accuracy of Hy's law is not good enough in clinical practice. This study aimed to investigate the optimal values of biomarkers associated with the prognosis of DILI.

METHODS

From June 1, 2014-May 30, 2022, patients with reported DILI were included. Patients' characteristics, drugs, DILI type, liver enzymes, and comorbidities were assessed. The associations with DILI-related comorbidities and survival were analyzed.

RESULTS

Ninety-five DILI patients were enrolled, 5 patients died of liver failure, and 23 patients died within 56 weeks after DILI. This study found that 15 mg/dL of total bilirubin, 1000 U/L of ALT, and 2 of PT-INR were optimal cut-off values in predicting DILI-related mortality. For the overall survival, patients with sepsis (HR:5.053, 95% CI:1.594-16.018, p = 0.006), malignancy (HR:4.371, 95% CI:1.573-12.147, p = 0.005), or end-stage renal disease (HR:7.409, 95% CI:1.404-39.103, p = 0.018) were independent poor prognostic factors in multivariate Cox regression analysis.

CONCLUSIONS

Total bilirubin >15 mg/dL, ALT >1000 U/L, and PT-INR >2 are useful biomarkers in predicting DILI-related mortality. DILI patients with sepsis, malignancy, or end-stage renal disease are associated with worse overall survival.

Acute Liver Injury Following Herbal Drink Consumption With Steatosis and Immune Activation: A Case Report

Herbal medicines are widely used for their perceived health benefits; however, their potential for liver toxicity is well-documented. We report a case of acute liver injury (ALI) in a 32-year-old male patient following the consumption of a multi-herbal drink. The patient, with a history of cholecystectomy for gallstones and nephrolithiasis, presented with severe epigastric pain radiating to the right shoulder, nausea, high blood pressure (170/113 mmHg), and a rapid heart rate. Laboratory tests revealed significant liver damage, with aspartate aminotransferase (AST) at 1,043 U/L, alanine aminotransferase (ALT) at 1,645 U/L, and total bilirubin at 4.8 mg/dL. Ultrasound imaging showed fatty liver disease without bile duct obstruction. Autoimmune testing was negative for antinuclear antibodies (ANA) and antimitochondrial antibodies (AMA), while elevated immunoglobulin G (IgG) levels suggested immune activation as a potential mechanism. The patient improved with supportive care. This case highlights the potential liver toxicity of polyherbal remedies and underscores the importance of early recognition and management to prevent long-term complications.