Recent Advances in the Histopathology of Drug-Induced Liver Injury

Severe acute liver disease in adults: Contemporary role of histopathology

Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).

RECAM-J 2023-Validation and development of the Japanese version of RECAM for the diagnosis of drug-induced liver injury

AIM

The diagnosis of drug-induced liver injury (DILI) is challenging. We modified the revised electronic version of the Roussel Uclaf Causality Assessment Method (RUCAM) for the diagnosis of DILI (RECAM), the scoring system developed in US and Spanish cohorts in 2022, and developed RECAM-J 2023 to align with the clinical practice in Japan. In the current study, we introduce RECAM-J 2023 and verify its performance in the context of Japanese patients with DILI.

METHODS

After translation of RECAM into Japanese, modifications were made to develop RECAM-J 2023 without any alteration to the scores. To examine the validity and performance of RECAM-J 2023, clinical information on DILI and non-DILI cases in Japan were retrospectively collected. The diagnosis of DILI was made by expert's decision. Then we scored each case using RECAM-J 2023, and calculated area under curve (AUC) values for identification for DILI.

RESULTS

We collected data from 538 DILI and 128 non-DILI cases. The sum of highly probable (HP) and probable (PR) cases categorized by RECAM-J 2023 were only 206 (38%) in DILI cases. As the primary cause of low scores was the deduction with missing hepatitis virus markers, which is unlikely to be an issue in prospective applications, we rescored without these deductions. At this time, the sum of HP and PR was raised to 421 (78%). The AUCs of RECAM-J 2023 without deductions were 0.70 and 0.88 for identifying at least HP, and at least PR, respectively.

CONCLUSION

RECAM-J 2023, when prospectively used without any missing hepatitis virus markers, provides acceptable performance for identifying at least PR DILI cases in Japanese daily clinical practice.

Histopathological findings from the investigation of paediatric acute hepatitis of unknown aetiology, United Kingdom 2022

In 2022, there were global reports of increased numbers of acute hepatitis not explained by hepatitis A-E virus infection in children. This manuscript summarises histopathology results from 20 patients in the United Kingdom who underwent liver transplant or had a liver biopsy as part of aetiological investigations. All available histopathological samples were reviewed centrally as part of the outbreak investigation. A working group comprised of infection specialists, hepatologists and histopathologists met virtually to review the cases, presentation, investigations and histopathology. All 20 liver samples had evidence of inflammation without significant interface activity, and submassive confluent pan-lobular or multilobular hepatocellular necrosis. Overall, the predominant histopathological findings were of acute nonspecific hepatitis with submassive hepatic necrosis and central vein perivenulitis and endothelitis. Histopathological findings were a poor indicator of aetiology.

Risk Assessment for Hepatobiliary Toxicity Liabilities in Drug Development

Risk assessment of hepatobiliary toxicities represents one of the greatest challenges and, more often than not, one of the most rewarding activities in which toxicologic pathologists can partake, and often times lead. This is in part because each liver toxicity picture is a bit different, informed by a broad range and diversity of relevant data, and also in part because the heavily relied upon animal models are imperfect regarding predictivity of hepatic effects in humans. Following identification and characterization of a hepatotoxicity hazard, typically in nonclinical toxicology studies, a holistic and integrated assessment of liver-relevant endpoints is conducted that typically incorporates ADME (absorption, distribution, metabolism, and excretion) information (ideally, including extensive transporter data, exposure margins, and possibly concentration of parent/metabolite at region of injury), target expression/function, in silico prediction data, in vitro hepatocyte data, liver/circulating biomarkers, and importantly, species specificity of any of these data. Of course, a thorough understanding, developed in close partnership with clinical colleagues, of the anticipated liver disease status of intended patient populations is paramount to hepatic risk assessment. This is particularly important since the likelihood of translatable determinant hepatic events observed in nonclinical models to occur in humans has been reasonably well established.

Mifepristone induced liver injury in a patient with Cushing syndrome: a case report and review of the literature

BACKGROUND

Mifepristone, also known as RU-486, is an anti-progestational steroid with similar chemical structure to anabolic steroids. Given as a single dose in conjunction with misoprostol, mifepristone is used to induce medical abortion. Mifepristone administered chronically at a higher dose is also approved for the management of hypercortisolism. There have been only 2 reported cases of mifepristone associated liver injury, in both cases, in the setting of Cushing syndrome. We report a third patient with Cushing syndrome with mifepristone induced liver injury with unique histological findings that provide insight to the pathophysiology of liver injury in mifepristone and anabolic steroids.

CASE PRESENTATION

Patient is a 63-year-old Caucasian female Cushing disease with no prior history of liver disease. She was started on mifepristone and semaglutide. Ninety days after initiating mifepristone, she developed deep jaundice, severe pruritus, fatigue, and nausea. Liver tests revealed a mixed hepatocellular/cholestatic pattern. Viral and autoimmune serologies were negative and there was no biliary dilatation on imaging. Liver biopsy showed severe cholestasis but no bile duct injury. Focal endothelialitis was present within a central venule. Cholestatic symptoms persisted for one month after presentation before slowly subsiding. Four months after stopping mifepristone, the patient's symptoms completely resolved, and liver tests became normal. Compilation of Roussell Uclaf Causality Assessment Method score indicated probable causality.

CONCLUSIONS

Mifepristone shares a similar chemical structure as synthetic anabolic/androgenic steroids and there are many similarities in the clinical presentation of liver injury. This case and the 2 other reported cases share similar clinical characteristics. The observation of endothelialitis in our patient may provide a mechanistic link between mifepristone, or anabolic steroids in general, and the development of vascular complications such as peliosis.

Identification of histological threshold concepts in health sciences curricula: Students' perception

Students' metacognitive skills and perceptions are considered important variables for high-quality learning. In this study, students' perceptions were used to identify histological threshold concepts (integrative, irreversible, transformative, and troublesome) in three health sciences curricula. A specific questionnaire was developed and validated to characterize students' perceptions of histological threshold concepts. A sample of 410 undergraduate students enrolled in the dentistry, medicine, and pharmacy degree programs participated in the study. Concepts assessed in the study were clustered to ten categories (factors) by exploratory and confirmatory factor analysis. Concepts linked to tissue organization and tissue functional states received the highest scores from students in all degree programs, suggesting that the process of learning histology requires the integration of both static concepts related to the constituent elements of tissues and dynamic concepts such as stem cells as a tissue renewal substrate, or the euplasic, proplasic and retroplasic states of tissues. The complexity of integrating static and dynamic concepts may pose a challenging barrier to the comprehension of histology. In addition, several differences were detected among the students in different degree programs. Dentistry students more often perceived morphostructural concepts as threshold concepts, whereas medical students highlighted concepts related to two-dimensional microscopic identification. Lastly, pharmacy students identified concepts related to tissue general activity as critical for the comprehension and learning of histology. The identification of threshold concepts through students' perceptions is potentially useful to improve the teaching and learning process in health sciences curricula.

Virtual liver needle biopsy from reconstructed three-dimensional histopathological images: Quantification of sampling error

INTRODUCTION

Prevalently considered as the "gold-standard" for diagnosis of hepatic fibrosis and cirrhosis, the clinical liver needle biopsy is known to be subject to inadequate sampling and a high mis-sampling rate. However, quantifying such sampling bias has been difficult as generating a large number of needle biopsies from the same living patient is practically infeasible. We construct a three-dimension (3D) virtual liver tissue volume by spatially registered high resolution Whole Slide Images (WSIs) of serial liver tissue sections with a novel dynamic registration method. We further develop a Virtual Needle Biopsy Sampling (VNBS) method that mimics the needle biopsy sampling process. We apply the VNBS method to the reconstructed digital liver volume at different tissue locations and angles. Additionally, we quantify Collagen Proportionate Area (CPA) in all resulting virtual needle biopsies in 2D and 3D.

RESULTS

The staging score of the center 2D longitudinal image plane from each 3D biopsy is used as the biopsy staging score, and the highest staging score of all sampled needle biopsies is the diagnostic staging score. The Mean Absolute Difference (MAD) in reference to the Scheuer and Ishak diagnostic staging scores are 0.22 and 1.00, respectively. The absolute Scheuer staging score difference in 22.22% of sampled biopsies is 1. By the Ishak staging method, 55.56% and 22.22% of sampled biopsies present score difference 1 and 2, respectively. There are 4 (Scheuer) and 6 (Ishak) out of 18 3D virtual needle biopsies with intra-needle variations. Additionally, we find a positive correlation between CPA and fibrosis stages by Scheuer but not Ishak method. Overall, CPA measures suffer large intra- and inter- needle variations.

CONCLUSIONS

The developed virtual liver needle biopsy sampling pipeline provides a computational avenue for investigating needle biopsy sampling bias with 3D virtual tissue volumes. This method can be applied to other tissue-based disease diagnoses where the needle biopsy sampling bias substantially affects the diagnostic results.

Hepatotoxicity Induced by Biological Agents: Clinical Features and Current Controversies

Novel biological agents including cytokines and recombinant fusion proteins are increasingly prescribed for cancer, rheumatologic, autoimmune, and inflammatory diseases, and are currently being evaluated in hepatocellular carcinoma (HCC). They are classified by their mechanism of action and include tumor necrosis factor-alpha (TNF-α) antagonists, T cell mediated antitumor inhibitors, interleukin receptor antagonists, and immune checkpoint inhibitors (ICIs). Some ICIs cause frequent hepatotoxicity with a variable clinical, biochemical, and serological presentation, especially in patients receiving another immunomodulatory agent. Half of the cases of liver damage induced by biological agents spontaneously regress after drug withdrawal, but the others require steroid therapy. Unfortunately, there are no widely accepted recommendation for the use of corticosteroids in these patients, even though international cancer societies have their own guidelines. Differentiating drug-induced autoimmune hepatitis (DIAIH) from classic AIH is challenging for pathologists, but liver biopsy is valuable, particularly in cases with unclear clinical presentation. Interesting, novel histological patterns have been described in liver damage induced by these agents (i.e., endothelitis, ring granuloma and secundary sclerosing cholangitis associated with lymphocytic infiltration of cytotoxic CD8+T cells). Here, we describe the clinical and biochemical characteristics of patients with hepatotoxicity induced by TNF-α antagonists and ICIs. Controversial issues involved in the administration of corticosteroid therapy, and hepatitis B virus (HBV) reactivation induced by immunosuppressive therapy are also discussed.

CFTR corrector C17 is effective in muscular dystrophy, in vivo proof of concept in LGMDR3

Limb-girdle muscular dystrophy R3 (LGMDR3) is caused by mutations in the SGCA gene coding for α-sarcoglycan (SG). Together with β- γ- and δ-SG, α-SG forms a tetramer embedded in the dystrophin associated protein complex crucial for protecting the sarcolemma from mechanical stresses elicited by muscle contraction. Most LGMDR3 cases are due to missense mutations, which result in non-properly folded, even though potentially functional α-SG. These mutants are prematurely discarded by the cell quality control. Lacking one subunit, the SG-complex is disrupted. The resulting loss of function leads to sarcolemma instability, muscle fiber damage and progressive limb muscle weakness. LGMDR3 is severely disabling and, unfortunately, still incurable. Here, we propose the use of small molecules, belonging to the class of cystic fibrosis transmembrane regulator (CFTR) correctors, for recovering mutants of α-SG defective in folding and trafficking. Specifically, CFTR corrector C17 successfully rerouted the SG-complex containing the human R98H-α-SG to the sarcolemma of hind-limb muscles of a novel LGMDR3 murine model. Notably, the muscle force of the treated model animals was fully recovered. To our knowledge, this is the first time that a compound designated for cystic fibrosis is successfully tested in a muscular dystrophy and may represent a novel paradigm of treatment for LGMDR3 as well as different other indications in which a potentially functional protein is prematurely discarded as folding-defective. Furthermore, the use of small molecules for recovering the endogenous mutated SG has an evident advantage over complex procedures such as gene or cell transfer.

Liver injury associated with drug intake during pregnancy

Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.

Ameliorative effect of Mangosteen (Garcinia mangostana L.) peel infusion on the histopathological structures of the liver and kidney of rats (Rattus norvegicus Berkenhout, 1769) after H2O2 induction

BACKGROUND AND AIM

Hydrogen peroxide (H2O2) is a free radical, widely use as a food preservative, may cause adverse effects to the body. Mangosteen contains various antioxidants may scavenge free radical produced by H2O2. This study examined the effects of mangosteen peel infusion on the liver and kidney of rats after H2O2 induction.

MATERIALS AND METHODS

Thirty-six female Wistar rats were divided into six groups: Negative control, positive control (1% H2O2), as well as mangosteen peel infusion groups at a concentration of 0.25; 0.5; 1, and 2%. H2O2 induction was administered orally every day for 2 months followed by mangosteen peel infusion treatment (1 month) after H2O2 induction for 1 month. At the end of the experiment, the rats were sacrificed. The liver and kidney of each rat were collected for reactive oxygen species (ROS) and histopathological examinations. Furthermore, blood was collected for creatinine examination.

RESULTS

H2O2 induction caused the highest ROS level elevation in the positive control group which was treated with H2O2 only. Meanwhile, 2% of mangosteen peel infusion returned the ROS levels to normal. It was also observed that mangosteen peel infusion restored creatinine levels to normal. Furthermore, 2% of mangosteen peel infusion improved the histopathological structure of the liver and kidneys after H2O2 induction.

CONCLUSION

Mangosteen peel infusion especially at a concentration of 2% has the potential to improve liver and kidney structure and functions after H2O2 induction.

Pathology of autoimmune hepatitis

Autoimmune hepatitis (AIH) is a relatively rare non-resolving chronic liver disease, which mainly affects women. It is characterized by hypergammaglobulinemia, circulating autoantibodies, interface hepatitis on liver histology and a favourable response to immunosuppression. The putative mechanism for the development of autoimmune hepatitis is thought to be the interaction between genetic predisposition, environmental triggers and failure of the native immune system.

AIH still remains a major diagnostic and therapeutic challenge, mainly because it is a very heterogeneous disease. Prompt and timely diagnosis is crucial since, if left untreated, AIH has a high mortality rate. Histological demonstration of hepatitis is required for the diagnosis of AIH and, therefore, liver biopsy is mandatory in the initial diagnostic work-up, before treatment. In this review, we summarize the histological features of AIH with the main aim of highlighting the most important clinical-pathological hallmarks useful in the routine diagnostic practice.

Drug-induced liver injury and prospect of cytokine based therapy; A focus on IL-2 based therapies

Drug-induced liver injury (DILI) is one of the most frequent sources of liver failure and the leading cause of liver transplant. Common non-prescription medications such as non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and other prescription drugs when taken at more than the recommended doses may lead to DILI. The severity of DILI is affected by factors such as age, ethnicity, race, gender, nutritional status, on-going liver diseases, renal function, pregnancy, alcohol consumption, and drug-drug interactions. Characteristics of DILI-associated inflammation include apoptosis and necrosis of hepatocytes and hepatic infiltration of pro-inflammatory immune cells. If untreated or if the inflammation continues, DILI and associated hepatic inflammation may lead to development of hepatocarcinoma. The therapeutic approach for DILI-associated hepatic inflammation depends on whether the inflammation is acute or chronic. Discontinuing the causative medication, vaccination, and special dietary supplementation are some of the conventional approaches to treat DILI. In this review, we discuss a concise overview of DILI-associated liver complications, and current therapeutic options with special emphasis on biologics including the scope of cytokine therapy in hepatic repair and resolution of inflammation caused by over- the-counter (OTC) or prescription drugs.

Mechanism of idiosyncratic drug induced liver injury (DILI): unresolved basic issues

Clinical features of idiosyncratic drug induced liver injury (DILI) are well described in cases that have been assessed for causality using the Roussel Uclaf Causality Assessment Method (RUCAM), but our understanding of the mechanistic steps leading to injury is fragmentary. The difficulties describing mechanistic events can be traced back to the lack of an animal model of experimental idiosyncratic DILI that can mimic the genetic requirements of human idiosyncratic DILI. However, immune tolerance plays a dominant role in the immune response of the liver, and impairment of immune tolerance with immune checkpoint inhibitors increases DILI in both humans and animals. This may provide one method to study the individual steps involved. In general. the human DILI liver is a secret keeper providing little insight into what occurs in the diseased organ. Sufficient evidence exists that most idiosyncratic cases are mediated by the adaptive immune system, which depends on stimulation of the innate immune system, but the triggering factors are unknown. It is attractive to hypothesize that the gut microbiome plays a role; however, it is very difficult to study. Similarly, exosomes are likely to play an important role in communication between hepatic cells and the immune system, but there is a lack of data on blood exosomes in affected patients. Reactive metabolites are likely to play an important role. This is supported by the current analysis, which revealed an association between metabolism by cytochrome P450 and drugs most commonly involved in causing idiosyncratic DILI with causality verified by RUCAM. Circumstantial evidence suggests that reactive oxygen species (ROS) generated by cytochrome P450 could be responsible for the initial steps of injury, but details are unknown. In conclusion, most of the mechanistic steps leading to idiosyncratic DILI remain unclear.

Efficacy and safety of spleen aminopeptide oral lyophilized powder in ameliorating liver injury in infants and children with human cytomegalovirus infection: a single-center study in China

BACKGROUND

Liver injury is both very common in infants and children and associated with low immune function. This study aimed to investigate the effect of spleen aminopeptide oral lyophilized powder (SAOLP) on liver injury in infants and children with human cytomegalovirus (HCMV) infection.

METHODS

In this prospective observational study, 217 infants and children with both liver damage and HCMV infection who were admitted to the Department of Pediatric Gastroenterology, Children's Hospital of Nanjing Medical University between July 2018 and May 2020 were investigated. The median age of patients was 0.75 years (0.36-3.77 years), with 105 male and 112 female participants. All 217 patients received ursodeoxycholic acid (UDCA) and/or reduced glutathione (GDC) therapy. Of these 217 patients, 114 also received SAOLP. Liver function, cellular immunity levels, HCMV antibody titer, and HCMV-DNA load values were measured 1 day before treatment, and on the second and fourth week after treatment.

RESULTS

After 4 weeks, patients treated with SAOLP showed median levels of serum alanine aminotransferase (ALT), total bilirubin (TB), and direct bilirubin (DB) which were significantly lower than those seen in patients who did not receive it. In addition, the percentage of CD4+ cells was significantly higher in those treated with SAOLP in comparison to those treated with UDCA and/or GDC alone. The number of positive HCMV-immunoglobin M (IgM) patients was also sharply decreased in the group receiving SAOLP.

CONCLUSIONS

The addition of SAOLP to UDCA and/or GDC therapy may significantly relieve liver injury and reduce the jaundice index by enhancing immune function and anti-HCMV infection ability in infants and children.

[Drug-induced liver injury-significance of pathology]

Many different medical agents, herbal products, and dietary supplements can induce drug-induced liver injury (DILI) as a clinically relevant complication. DILI, which is direct toxic or idiosyncratic, can have a broad spectrum of clinical appearances from elevation of liver enzymes to acute liver failure. DILI is categorized clinically according to the pattern of serum parameters or pathologically according to the pattern of histomorphology. Histopathological patterns can be described as hepatitic, granulomatous, cholestatic, ductopenic, fibrotic, steatotic, steatohepatitic, and vascular. Correlation to the corresponding drug can be carried out with the corresponding databases (US National Library of Medicine, Liver Tox; www.ncbi.nlm.nih.gov/books/NBK547852/ ). Liver biopsy, in contrast to a clinical/serological diagnostic, has the advantage of an exact resolution with evidence of pathophysiology, activity, regeneration, chronification, and prognosis. Co-occurrence of underlying liver disease can be excluded or confirmed. Histological patterns of DILI are described and illustrated. A diagnostic algorithm for the interpretation of liver biopsies is provided.

Pathology in Patients with Chronic Liver Disease: A Practical Approach to Liver Biopsy Interpretation in Patients with Acute and Chronic Liver Diseases

Liver biopsy and histologic examination are the mainstay for diagnosing liver diseases, despite advances in imaging and molecular procedures. Liver biopsy can provide useful information regarding the structural integrity and type and degree of injury, disease activity, response to treatment, progression of disease and degree/staging of fibrosis. Liver biopsies evaluate acute and chronic liver diseases, and mass-forming lesions. The role of the pathologist is to integrate clinical, serologic, and biochemical data with morphologic changes and provide a comprehensive diagnosis. This review focuses on basic principles necessary for proper interpretation of liver biopsy specimens in patients with chronic liver disease.

Acute hepatitis and acute liver failure: Pathologic diagnosis and differential diagnosis

Acute hepatitis and acute liver failure are severe medical conditions that require early clinical intervention. Histopathologic findings on a liver biopsy or a liver explant may help identify the underlying etiology or provide an important direction for further clinical, laboratory and radiographical investigation. This review is divided into two main portions. The first portion concentrates on various etiologies and discusses unique histologic features that can be associated with specific etiologies. The second portion describes the general morphologic features based on which the diagnosis of acute hepatitis and acute liver failure are made. Histopathologic distinction between collapse and cirrhosis and limitations of histopathologic assessment for underlying etiologies are addressed in this portion. Another focus of this review is non-necrotic acute liver failure, which typically features diffuse microvesicular steatosis secondary to various etiologies causing mitochondrial dysfunction. Molecular testing serves an increasingly important role in the diagnosis and management of this group of disorders.

Clinicopathological features of He Shou Wu-induced liver injury: This ancient anti-aging therapy is not liver-friendly

BACKGROUND & AIMS

Polygonum Multiflorum Thumb (PMT), an ancient anti-aging Chinese herb known traditionally as He Shou Wu, has side effects of liver toxicity. To determine the main clinical and pathological characteristics of liver toxicity induced by PMT and the clinical course after its cessation.

METHODS

Data of patients, diagnosed as drug-induced liver injury and hospitalised in Beijing Friendship Hospital from August 2005 to August 2017, were retrospectively reviewed. Clinical, pathological data and outcome after cessation of He Shou Wu were obtained and analysed. Kruskal-Wallis and Chi-square (χ² ) tests were performed.

RESULTS

Twenty-nine patients with He Shou Wu-induced liver injury were enrolled. The median age was 53 years (range 15-74) and 75.9% (22/29) were women. The most common symptom was jaundice (79.3%, 23/29). Of nine patients with liver biopsies, six showed acute cholestatic hepatitis, two acute, and one chronic hepatocellular injury pattern. The latency, liver chemistries and outcomes were comparable between pure He Shou Wu (5 patients) and its compounds (24 patients). Twenty-five of 29 patients (86.2%) had normal serum alanine aminotransferase levels after 45 days (range: 10-138 days) and total bilirubin of 46 days (range: 0-551 days). One patient was rechallenged with He Shou Wu and two developed autoimmune features. One patient died of liver failure and three had chronic persistent liver injury.

CONCLUSIONS

The main clinicopathological injury pattern of He Shou Wu-induced liver injury is moderate to severe hepatitis with or without cholestasis. Most patients recover completely; however, chronic disease and death do occur.