Antibiotic-associated acute vanishing bile duct syndrome: a pattern associated with severe, prolonged, intrahepatic cholestasis

Connecting Gut Microbial Diversity with Plasma Metabolome and Fecal Bile Acid Changes Induced by the Antibiotics Tobramycin and Colistin Sulfate

The diversity of microbial species in the gut has a strong influence on health and development of the host. Further, there are indications that the variation in expression of gut bacterial metabolic enzymes is less diverse than the taxonomic profile, underlying the importance of microbiome functionality, particularly from a toxicological perspective. To address these relationships, the gut bacterial composition of Wistar rats was altered by a 28 day oral treatment with the antibiotics tobramycin or colistin sulfate. On the basis of 16S marker gene sequencing data, tobramycin was found to cause a strong reduction in the diversity and relative abundance of the microbiome, whereas colistin sulfate had only a marginal impact. Associated plasma and fecal metabolomes were characterized by targeted mass spectrometry-based profiling. The fecal metabolome of tobramycin-treated animals had a high number of significant alterations in metabolite levels compared to controls, particularly in amino acids, lipids, bile acids (BAs), carbohydrates, and energy metabolites. The accumulation of primary BAs and significant reduction of secondary BAs in the feces indicated that the microbial alterations induced by tobramycin inhibit bacterial deconjugation reactions. The plasma metabolome showed less, but still many alterations in the same metabolite groups, including reductions in indole derivatives and hippuric acid, and furthermore, despite marginal effects of colistin sulfate treatment, there were nonetheless systemic alterations also in BAs. Aside from these treatment-based differences, we also uncovered interindividual differences particularly centering on the loss of Verrucomicrobiaceae in the microbiome, but with no apparent associated metabolite alterations. Finally, by comparing the data set from this study with metabolome alterations in the MetaMapTox database, key metabolite alterations were identified as plasma biomarkers indicative of altered gut microbiomes resulting from a wide activity spectrum of antibiotics.

Vanishing bile duct syndrome after drug-induced liver injury

BACKGROUND

Vanishing bile duct syndrome (VBDS) is a serious cholestatic liver disease that can be a complication of drug-induced liver injury (DILI). While journals have published case reports of this condition, large studies on a cohort of these patients are lacking. We aimed to compile published case reports and case series of patients with VBDS and DILI to describe the clinical and laboratory characteristics of the disease and identify factors associated with good and poor outcomes.

METHODS

We included case reports and case series of VBDS secondary only to DILI. We extracted demographic, clinical, laboratory, treatment, and exposure data from each case report and categorized cases by outcome, good versus poor. We defined poor outcomes as cases with severe long-term complications or death. We analyzed risk factors for poor outcomes using logistic regression.

RESULTS

We identified a total of 59 eligible cases. Of those, 39 (59%) were female, the median age was 36 (IQR:12-58), and 18 (31%) were pediatric cases (≤18 years). The most common offending drug class was antibiotics, especially beta-lactams. Patients with increased total bilirubin (OR=4.69; 95% CI=1.55-15.49; p = 0.008), increased direct bilirubin (OR=6.50; 95% CI=1.34-48.91; p = 0.034), lower liver synthetic activity (OR=0.11; 95% CI=0.02-0.55; p = 0.013), and older age (OR=3.31; 95% CI=1.15-10.04; p = 0.029) were more likely to develop poor outcomes.

CONCLUSIONS

In patients with VBDS and DILI, antibiotics were the most common offending agents. Higher total and direct bilirubin levels were associated with poor outcomes.

Long-term sequelae of drug-induced liver injury

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

Drug-Induced Vanishing Bile Duct Syndrome: From Pathogenesis to Diagnosis and Therapeutics

The most concerned issue in the context of drug/herb-induced chronic cholestasis is vanishing bile duct syndrome. The progressive destruction of intrahepatic bile ducts leading to ductopenia is usually not dose dependent, and has a delayed onset that should be suspected when abnormal serum cholestasis enzyme levels persist despite drug withdrawal. Immune-mediated cholangiocyte injury, direct cholangiocyte damage by drugs or their metabolites once in bile, and sustained exposure to toxic bile salts when biliary epithelium protective defenses are impaired are the main mechanisms of cholangiolar damage. Current therapeutic alternatives are scarce and have not shown consistent beneficial effects so far. This review will summarize the current literature on the main diagnostic tools of ductopenia and its histological features, and the differential diagnostic with other ductopenic diseases. In addition, pathomechanisms will be addressed, as well as the connection between them and the supportive and curative strategies for ductopenia management.

Helicobacter pylori and non-alcoholic fatty liver disease

Helicobacter pylori is the most prevalent infection worldwide, while non-alcoholic fatty liver disease emerged as the most frequent liver disease. The common occurrence can be either by chance or due to certain pathogenetic factors. Epidemiologic studies revealed that the risk of non-alcoholic liver disease is increased in patients infected with Helicobacter pylori. DNA fragments of Helicobacter pylori were rarely identified in human samples of liver carcinoma and fatty liver. Helicobacter pylori could influence the development of non-alcoholic fatty liver either by hormonal (ghrelin? gastrin? insulin?), or by effect of pro-inflammatory cytokines (interleukin 1 and 8, tumor necrosis factor ɑ, interferon ɣ) and by changes of gut microbiome as well. Probiotic supplementation could improve some clinical parameters of non-alcoholic fatty liver disease and eradication rates of Helicobacter pylori. Regimens used for eradication can be safely administered, although non-alcoholic fatty liver increases the risk of drug-induced liver damage. Controlled studies of the effect of eradication on the development and progression of non-alcoholic fatty liver are warranted.

Clinical, clinicopathologic, and hepatic histopathologic features associated with probable ketoconazole-induced liver injury in dogs: 15 cases (2015-2018)

OBJECTIVE

To characterize clinical, clinicopathologic, and hepatic histopathologic features and outcome for dogs with probable ketoconazole-induced liver injury.

ANIMALS

15 dogs with suspected ketoconazole-induced liver injury that underwent liver biopsy.

PROCEDURES

Medical record data were summarized regarding signalment, clinical signs, clinicopathologic and hepatic histopathologic findings, concurrent medications, ketoconazole dose, treatment duration, and outcome.

RESULTS

Median age and body weight were 8.2 years (range, 5 to 15 years) and 13.0 kg (28.6 lb; range, 8.2 to 38.0 kg [18.0 to 83.6 lb]), respectively. The most common breed was Cocker Spaniel (n = 5). All dogs received ketoconazole to treat cutaneous Malassezia infections. Median daily ketoconazole dose was 7.8 mg/kg (3.5 mg/lb; range, 4.4 to 26.0 mg/kg [2.0 to 11.8 mg/lb]), PO. Treatment duration ranged from 0.3 to 100 cumulative weeks (intermittent cyclic administration in some dogs); 6 dogs were treated for ≤ 10 days. Common clinical signs included lethargy, anorexia, and vomiting. All dogs developed high serum liver enzyme activities. Hepatic histopathologic findings included variable lobular injury, mixed inflammatory infiltrates, and conspicuous aggregates of ceroid-lipofuscin-engorged macrophages that marked regions of parenchymal damage. Five dogs developed chronic hepatitis, including 3 with pyogranulomatous inflammation. Of the 10 dogs reported to have died at last follow-up, survival time after illness onset ranged from 0.5 to 165 weeks, with 7 dogs dying of liver-related causes.

CONCLUSIONS AND CLINICAL RELEVANCE

Findings for dogs with hepatotoxicosis circumstantially associated with ketoconazole treatment suggested proactive monitoring of serum liver enzyme activities is advisable before and sequentially after initiation of such treatment.

Successful liver transplantation for drug-induced vanishing bile duct syndrome

Drug-induced cholestasis has a wide range of clinical presentations, and in a small number of patients, it can progress to severe ductopenia. A 63-year-old woman was referred to our department with progressive cholestasis and hyperbilirubinaemia following a course of flucloxacillin. Despite the comprehensive laboratory, imaging and genetic investigations, no other cause for the cholestasis was demonstrated. Sequential liver biopsies confirmed the development of vanishing bile duct syndrome. She developed significant cachexia and pruritus that did not respond to medical therapy, and hence she was listed for liver transplantation. She underwent liver transplantation 6 months after the initial drug-induced injury. She has remained well with good graft function at 1-year follow-up. The case highlights an extreme form of drug-induced ductopenia and underscores the need for meticulous hepatology input and consideration of liver transplantation in some patients.

EASL Clinical Practice Guidelines: Drug-induced liver injury

Idiosyncratic (unpredictable) drug-induced liver injury is one of the most challenging liver disorders faced by hepatologists, because of the myriad of drugs used in clinical practice, available herbs and dietary supplements with hepatotoxic potential, the ability of the condition to present with a variety of clinical and pathological phenotypes and the current absence of specific biomarkers. This makes the diagnosis of drug-induced liver injury an uncertain process, requiring a high degree of awareness of the condition and the careful exclusion of alternative aetiologies of liver disease. Idiosyncratic hepatotoxicity can be severe, leading to a particularly serious variety of acute liver failure for which no effective therapy has yet been developed. These Clinical Practice Guidelines summarize the available evidence on risk factors, diagnosis, management and risk minimization strategies for drug-induced liver jury.

Reference limits for hepatic bile duct-to-arteriole and bile duct-to-portal tract ratios in healthy cats

OBJECTIVE To establish reference limits for hepatic bile duct-to-arteriole ratio (BD:A) and bile duct-to-portal tract ratio (BD:PT) in healthy cats and assess whether these parameters could be used to support a diagnosis of biliary ductopenia in cats. SAMPLE Hepatic biopsy samples from healthy cats (n = 20) and cats with ductopenia (2). PROCEDURES Hepatic biopsy samples from healthy cats were used to count the number of bile ducts and hepatic arterioles in 20 portal tracts for each cat. Mean BD:A and mean BD:PT for each cat were calculated, and these values were used to determine reference limits for mean BD:A and mean BD:PT. Results of histologic evaluation, including immunohistochemical staining in some instances, were compared for healthy cats versus cats with ductopenia. RESULTS Of the 400 portal tracts from healthy cats, 382 (95.5%) and 396 (99.0%) had BD:A and BD:PT, respectively, ≥ 1.0, with less variability in BD:A. Mean BD:A and BD:PT were markedly lower in both cats with ductopenia, compared with values for healthy cats. However, only mean BD:A for cats with ductopenia was below the reference limit of 0.59. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that systematic evaluation of BD:A, with a lower reference limit of 0.59 to define biliary ductopenia in cats, may be a discrete and easily applied morphometric tool to enhance detection of ductopenia in cats. However, application of this ratio required evaluation of ≥ 20 portal tracts with cross-sectioned portal elements to determine a mean BD:A value.

Nonacetaminophen Drug-Induced Acute Liver Failure

Acute liver failure of all causes is diagnosed in between 2000 and 2500 patients annually in the United States. Drug-induced acute liver failure is the leading cause of acute liver failure, accounting for more than 50% of cases. Nonacetaminophen drug injury represents 11% of all cases in the latest registry from the US Acute Liver Failure Study Group. Although rare, acute liver failure is clinically dramatic when it occurs, and requires a multidisciplinary approach to management. In contrast with acetaminophen-induced acute liver failure, non-acetaminophen-induced acute liver failure has a more ominous prognosis with a lower liver transplant-free survival.

Drug-induced liver injury due to antibiotics

Drug-induced liver injury (DILI) is an important differential diagnosis in patients with abnormal liver tests and normal hepatobiliary imaging. Of all known liver diseases, the diagnosis of DILI is probably one of the most difficult one to be established. In all major studies on DILI, antibiotics are the most common type of drugs that have been reported. The clinical phenotype of different types of antibiotics associated with liver injury is highly variable. Some widely used antibiotics such as amoxicillin-clavulanate have been shown to have a delayed onset on liver injury and recently cefazolin has been found to lead to liver injury 1-3 weeks after exposure of a single infusion. The other extreme is the nature of nitrofurantoin-induced liver injury, which can occur after a few years of treatment and lead to acute liver failure (ALF) or autoimmune-like reaction. Most patients with liver injury associated with use of antibiotics have a favorable prognosis. However, patients with jaundice have approximately 10% risk of death from liver failure and/or require liver transplantation. In rare instances, the hepatoxicity can lead to chronic injury and vanishing bile duct syndrome. Given, sometimes very severe consequences of the adverse liver reactions, it cannot be over emphasized that the indication for the different antibiotics should be evidence-based and symptoms and signs of liver injury from the drugs should lead to prompt cessation of therapy.

Drug-induced cholestasis

Cholestatic drug-induced liver injury (DILI) can be a diagnostic challenge due to a large differential diagnosis, variability in clinical presentation, and lack of serologic biomarkers associated with this condition. The clinical presentation of drug-induced cholestasis includes bland cholestasis, cholestatic hepatitis, secondary sclerosing cholangitis, and vanishing bile duct syndrome. The associate mortality of cholestatic DILI can be as high as 10%, and thus prompt recognition and removal of the offending agent is of critical importance. Several risk factors have been identified for drug-induced cholestasis, including older age, genetic determinants, and properties of certain medications. Antibiotics, particularly amoxicillin/clavulanate, remain the predominant cause of cholestatic DILI, although a variety of other medications associated with this condition have been identified. In this review, we summarize the presentation, clinical approach, risk factors, implicated medications, and management of drug-induced cholestatic liver injury. (Hepatology Communications 2017;1:726-735).

Clinical presentations and outcomes of bile duct loss caused by drugs and herbal and dietary supplements

Bile duct loss during the course of drug-induced liver injury is uncommon, but can be an indication of vanishing bile duct syndrome (VBDS). In this work, we assess the frequency, causes, clinical features, and outcomes of cases of drug-induced liver injury with histologically proven bile duct loss. All cases of drug-induced liver injury enrolled into a prospective database over a 10-year period that had undergone liver biopsies (n = 363) were scored for the presence of bile duct loss and assessed for clinical and laboratory features, causes, and outcomes. Twenty-six of the 363 patients (7%) with drug-, herbal-, or dietary-supplement-associated liver injury had bile duct loss on liver biopsy, which was moderate to severe (<50% of portal areas with bile ducts) in 14 and mild (50%-75%) in 12. The presenting clinical features of the 26 cases varied, but the most common clinical pattern was a severe cholestatic hepatitis. The implicated agents included amoxicillin/clavulanate (n = 3), temozolomide (n = 3), various herbal products (n = 3), azithromycin (n = 2), and 15 other medications or dietary supplements. Compared to those without, those with bile duct loss were more likely to develop chronic liver injury (94% vs. 47%), which was usually cholestatic and sometimes severe. Five patients died and 2 others underwent liver transplantation for progressive cholestasis despite treatment with corticosteroids and ursodiol. The most predictive factor of poor outcome was the degree of bile duct loss on liver biopsy.

CONCLUSION

Bile duct loss during acute cholestatic hepatitis is an ominous early indicator of possible VBDS, for which at present there are no known means of prevention or therapy. (Hepatology 2017;65:1267-1277).

Persistent liver biochemistry abnormalities are more common in older patients and those with cholestatic drug induced liver injury

OBJECTIVES

The long-term outcomes of patients with drug induced liver injury (DILI) are not well described. The aim of this study was to determine the frequency and severity of persistent liver biochemistry abnormalities in DILI patients followed over 2 years.

METHODS

Subjects with evidence of liver injury at 6 months after DILI onset were offered a month 12 and 24 study visit.

RESULTS

Amongst the 99 patients with definite, probable, or very likely DILI and available laboratory data at 12 months after DILI onset, 74 (75%) had persistent liver injury (persisters) defined as a serum aspartate aminotransferase (AST) or alanine aminotransferase (ALT) >1.5 × upper limit of normal (ULN) or an alkaline phosphatase >ULN, while 25 (25%) had resolved liver injury (resolvers). On multivariate analysis, month 12 persisters were significantly older (52.6 vs. 43.7 years, P=0.01) and more likely to have a cholestatic lab profile at DILI onset (54 vs. 20%, P<0.01) than resolvers. The month 12 persisters also had significantly poorer SF-36 physical summary scores at DILI onset and throughout follow-up compared with the resolvers (P<0.01). Amongst the 17 subjects with a liver biopsy obtained at a median of 387 days after DILI onset, 9 had chronic cholestasis, 3 had steatohepatitis, and 3 had chronic hepatitis.

CONCLUSIONS

In all, 75% of subjects with liver injury at 6 months after DILI onset have laboratory evidence of persistent liver injury during prolonged follow-up. Higher serum alkaline phosphatase levels at presentation and older patient age were independent predictors of persistent liver injury. Subjects with persistent liver injury at 12 months after DILI onset should be carefully monitored and assessed for liver disease progression.

Drug-induced liver injury: an overview over the most critical compounds

There has been a substantial interest in drug-induced liver injury (DILI) recently. National Institutes of Health has sponsored a multicenter study in the USA for the last 10 years, which has collected valuable information in this context. Idiosyncratic DILI is like other adverse effects of drugs underestimated and underreported in most epidemiological studies. A recent prospective population-based study from Iceland found a crude incidence of approximately 19 cases per 100,000 and year. Antibiotic is the class of drugs most commonly implicated in patients with DILI. Amoxicillin-clavulanate continues to be the most commonly implicated agent occurring in approximately 1 out of 2,300 users. Drugs with the highest risk of DILI in the Icelandic study were azathioprine and infliximab. Although rare, statin-induced hepatotoxicity has been well documented. Liver injury associated with the use of herbal medicines and dietary supplements seems to be increasing. Information on the documented hepatotoxicity of drugs has recently been made easier by a website available in the public domain: LiverTox ( http://livertox.nlm.nih.gov ). Unfortunately, at the current time, pre-therapy risk assessment for DILI in the individual patient is difficult but previous well-documented hepatotoxicity is usually a contraindication for a subsequent treatment with the same drug.

Antibiotic induced liver injury: what about children?

Antimicrobial agents are important causes of drug-induced liver injury. They are responsible for about 45% of cases of drug hepatotoxicity. Hepatic damage mechanisms are intrinsic or idiosyncratic. Usually, antibiotics are responsible for idiosyncratic toxicity. This review summarizes the rate of incidence and clinical features of hepatotoxicity due to antibiotics and chemotherapics, with particular attention to data regarding paediatric population. Liver injury features have been systematically evaluated for the most commonly administered antibiotics and chemotherapics in adults, even though there is little information about other widely used compounds, as cephalosporine or clarithromycin, and about antibiotics active against multi-resistant bacteria, as carbapenems, vancomycin, clindamycin, and linezolid. By contrast, there is an abundance of case reports in paediatrics, but very few structured studies have been carried out in children. Children are an important class of antibiotic users, with specific metabolic characteristics, so more studies on them should be carried out.

Drug-induced cholestasis

Drug-induced cholestasis manifests as an acute self-limiting injury or as a chronic perpetuating injury, resulting in duct loss and cirrhosis. The number of drugs implicated in drug-induced cholestasis grows every year as new drugs are developed and approved. Other agents such as herbals, nutritional supplements, and complementary and alternative medicines are also reported to cause cholestatic liver injury. Recent literature on molecular transporters involved in bile transport has improved our understanding of patterns of drug-induced liver injury and the mechanisms of cholestasis. This article summarizes the probable offending drugs, and the diagnosis and management of drug-induced cholestasis.

Drug-induced cholestasis

Cholestasis caused by drugs is an important differential diagnosis in patients presenting with a biochemical cholestatic pattern. The extent of serologic tests and radiological imaging depends on the clinical context. The underlying condition of the patient and detailed information on drug use, results of rechallenge, and the documented hepatotoxicity of the drug are important to establish a diagnosis of drug-induced liver injury (DILI). Most cases of cholestatic DILI are mild, but in rare cases, ductopenia and cholestatic cirrhosis can develop. Approximately 10% of patients with cholestatic jaundice caused by drugs develop liver failure.

Xenobiotic-induced liver injury and fibrosis

INTRODUCTION

Many different drugs and xenobiotics (chemical compounds foreign to an organism) can injure the bile duct epithelium and cause inflammatory bile duct diseases (cholangiopathies) ranging from transient cholestasis to vanishing bile duct syndrome, sclerosing cholangitis with development of biliary fibrosis and cirrhosis. Animal models of xenobiotic-induced liver injury have provided major mechanistic insights into the molecular mechanisms of xenobiotic-induced cholangiopathies and biliary fibrosis including primary biliary cirrhosis and primary sclerosing cholangitis.

AREAS COVERED

In this review, the authors discuss the basic principles of xenobiotic-induced liver and bile duct injury and biliary fibrosis with emphasis on animal models. A PubMed search was performed using the search terms "xenobiotic," "liver injury," "cholestasis," and "biliary fibrosis." Reference lists of retrieved articles were also searched for relevant literature.

EXPERT OPINION

Xenobiotic-induced cholangiopathies are underestimated and frequently overlooked medical conditions due to their often transient nature. However, biliary disease may progress to vanishing bile duct syndrome, biliary fibrosis, and cirrhosis. Moreover, xenobiotics may prime the liver for subsequent liver disease by other agents and may also contribute to the development of hepatobiliary cancer though interaction with resident stem cells.

A case of amoxicillin-induced hepatocellular liver injury with bile-duct damage

Amoxicillin, an antibiotic that is widely prescribed for various infections, is associated with a very low rate of drug-induced liver injury; hepatitis and cholestasis are rare complications. Here we present a case of a 39-year-old woman who was diagnosed with abdominal actinomycosis and received amoxicillin treatment. The patient displayed hepatocellular and bile-duct injury, in addition to elevated levels of liver enzymes. The patient was diagnosed with amoxicillin-induced cholestatic hepatitis. When amoxicillin was discontinued, the patient's symptoms improved and her liver enzyme levels reduced to near to the normal range.

Hepatic safety of antibiotics used in primary care

Antibiotics used by general practitioners frequently appear in adverse-event reports of drug-induced hepatotoxicity. Most cases are idiosyncratic (the adverse reaction cannot be predicted from the drug's pharmacological profile or from pre-clinical toxicology tests) and occur via an immunological reaction or in response to the presence of hepatotoxic metabolites. With the exception of trovafloxacin and telithromycin (now severely restricted), hepatotoxicity crude incidence remains globally low but variable. Thus, amoxicillin/clavulanate and co-trimoxazole, as well as flucloxacillin, cause hepatotoxic reactions at rates that make them visible in general practice (cases are often isolated, may have a delayed onset, sometimes appear only after cessation of therapy and can produce an array of hepatic lesions that mirror hepatobiliary disease, making causality often difficult to establish). Conversely, hepatotoxic reactions related to macrolides, tetracyclines and fluoroquinolones (in that order, from high to low) are much rarer, and are identifiable only through large-scale studies or worldwide pharmacovigilance reporting. For antibiotics specifically used for tuberculosis, adverse effects range from asymptomatic increases in liver enzymes to acute hepatitis and fulminant hepatic failure. Yet, it is difficult to single out individual drugs, as treatment always entails associations. Patients at risk are mainly those with previous experience of hepatotoxic reaction to antibiotics, the aged or those with impaired hepatic function in the absence of close monitoring, making it important to carefully balance potential risks with expected benefits in primary care. Pharmacogenetic testing using the new genome-wide association studies approach holds promise for better understanding the mechanism(s) underlying hepatotoxicity.

Drug-induced cholestasis

Recent progress in understanding the molecular mechanisms of bile formation and cholestasis have led to new insights into the pathogenesis of drug-induced cholestasis. This review summarizes their variable clinical presentations, examines the role of transport proteins in hepatic drug clearance and toxicity, and addresses the increasing importance of genetic determinants, as well as practical aspects of diagnosis and management.

Drug-induced hepatotoxicity or drug-induced liver injury

Drug-induced hepatotoxicity is underreported and underestimated in the United States. It is an important cause of acute liver failure. Common classes of drugs causing drug-induced hepatotoxicity include antibiotics, lipid lowering agents, oral hypoglycemics, psychotropics, antiretrovirals, acetaminophen, and complementary and alternative medications. Hepatotoxic drugs often have a signature or pattern of liver injury including patterns of liver test abnormalities, latency of symptom onset, presence or absence of immune hypersensitivity, and the course of the reaction after drug withdrawal.

Hepatotoxicity due to antibiotics

Antimicrobial drugs are important causative agents in idiosyncratic drug-induced liver injury (DILI). As with idiosyncratic DILI in general, antibiotic-induced liver injury is rare but difficult to diagnose and almost impossible to predict. Diagnosis requires awareness of possible causal agents, vigilance in monitoring symptoms and sometimes biochemical tests, attention to careful history taking and establishing temporal association, and exclusion of competing etiologies. In most instances, patients with antibiotic-associated DILI recover if the offending agent is withdrawn in a timely fashion.

Long-term follow-up of patients with mild to moderate drug-induced liver injury

AIM

To evaluate the long-term prognosis of patients diagnosed with drug-induced liver injury, and the nature of the liver injury.

METHODS

Patients with a diagnosis of drug-induced liver injury between 1994 and 2005 were identified in a university hospital clinic. Patients surviving drug-induced liver injury-associated liver failure were excluded.

RESULTS

Seventy-seven cases were identified and those who were alive (69) were invited to attend follow-up. Of those patients who had died, none had died of liver disease. Of those patients who had survived, 59 were reviewed in the clinic. Patients had a median follow-up of 48 months. Before the diagnosis of drug-induced liver injury, nine had a chronic liver disease, four with autoimmune hepatitis, two with non-alcoholic liver disease, one each with non-alcoholic fatty liver disease, primary biliary cirrhosis and primary sclerosing cholangitis. There was no evidence of progression of their liver disease during follow-up. Among 50 patients without a known liver disease prior to the drug-induced liver injury, 10 had abnormal liver tests. Diagnostic work-up revealed alternative cause of liver disease in all except three patients (6%), who had asymptomatic abnormal liver tests (but normal bilirubin in all).

CONCLUSIONS

Chronic abnormalities in liver tests, not explained by an identified liver disease, are very rare in patients previously diagnosed with drug-induced liver injury. This group of patients did not seem to have a clinically significant liver injury at long-term follow-up.

Immunochemical detection of flucloxacillin adduct formation in livers of treated rats

Flucloxacillin is a semi-synthetic penicillin widely used in the prophylaxis and treatment of staphylococcal infections. Severe liver reactions, characterised by delayed cholestatic hepatitis and a prolonged course of recovery, are associated with flucloxacillin therapy. Clinical findings are suggestive of an immune mediated reaction but there exists little supporting experimental evidence. The formation of drug modified hepatic protein adducts has been proposed to play an important role in the hepatotoxicity of many drugs. The aim of the present study was to investigate whether flucloxacillin treatment results in adduct formation in vivo. Flucloxacillin was conjugated to rabbit serum albumin by formation of a penicilloyl determinant and used as an immunogen to raise a polyclonal antiserum specific for flucloxacillin-modified proteins. Antibody specificity was confirmed by competitive enzyme-linked immunosorbent assay (ELISA) with free drug. The antiserum was used in combination with western blotting to detect adduct formation in the livers of flucloxacillin treated rats. Western blot analysis of rat liver subcellular fractions revealed the formation of six flucloxacillin adducts in various subcellular fractions. These studies demonstrate for the first time that treatment with flucloxacillin results in the formation of hepatic protein adducts.

Risk of cholestatic liver disease associated with flucloxacillin and flucloxacillin prescribing habits in the UK: cohort study using data from the UK General Practice Research Database

AIMS

To provide additional quantification of the risk of flucloxacillin-related liver disease and to describe time trends in flucloxacillin prescribing in the UK.

METHODS

This was a cohort study using data from the UK General Practice Research Database. We identified patients with a first-time prescription for flucloxacillin or, for comparison, oxytetracycline from 1992 to 2002 and cases who developed clinically documented cholestatic liver disease of uncertain origin after first-time use of these drugs. We also determined the annual frequency of first-time use of flucloxacillin from 1991 to 2000.

RESULTS

We identified 283 097 and 131 189 first-time users of flucloxacillin and oxytetracycline, respectively. The risk of cholestatic liver disease per 100 000 first-time users was 8.5 (95% CI 5.4, 12.6) in the 1-45 days and 1.8 (95% CI 0.6, 4.1) in the 46-90 days after starting flucloxacillin, and 0.8 (95% CI 0.02, 4.3) in the 1-45 days after starting oxytetracycline. The frequency of first-time use of flucloxacillin remained stable between 1991 and 2000.

CONCLUSIONS

Flucloxacillin is now established as an important cause of cholestatic liver disease. Warnings about the risk have not had an impact on prescribing practices in the UK, where it remains the predominantly prescribed antistaphylococcal oral antibiotic. This situation in the UK is in sharp contrast to regulatory actions and changes in prescribing habits in Australia after identification of the risk of cholestasis associated with flucloxacillin, and to the predominant use of the alternative drug dicloxacillin in the USA.

Unusual severe hypercholesterolaemia and xanthomas in a patient with hepatolithiasis

A 47-year-old woman had undergone cholecystectomy for gallstones in December 1994 at a local hospital. In December 1995 she presented at the surgical outpatient department with intermittent right upper quadrant pain. Laboratory studies revealed serum albumin 4.3 g/dl (normal 3.5–5.3 g/dl), total cholesterol 307 mg/dl (normal <200 mg/dl), total bilirubin 1.8 mg/dl (normal 0.0–1.3 mg/dl), alkaline phosphatase 602 U/litre (normal 28–94 U/litre), aspartate aminotransferase (AST) 129 U/litre (normal 0–34 U/litre), and alanine aminotransferase (ALT) 196 U/litre (normal 0–36 U/litre). Liver sonography revealed multiple stones in dilated intrahepatic and common hepatic ducts. However, the patient did not receive further studies of her hepatolithiasis at that time. The patient underwent percutaneous transhepatic cholangiostomy drainage for intrahepatic stones and jaundice in a medical centre in January 1998. In February 1998 she was transferred to the surgical department because of persistent jaundice. Physical examination revealed that the woman was markedly icteric, with an old scar on the right upper abdominal wall, and no xanthoma was found on the body. Laboratory results included that serum albumin was 4.1 g/dl, total cholesterol was 256 mg/dl, total bilirubin was 12 mg/dl, alkaline phosphatase was 512 U/litre, AST was 101 U/litre and ALT was 100 U/litre. Cholangiogram showed a dilated biliary tree with multiple stones in intrahepatic ducts, common hepatic ducts and the common bile duct.

The patient underwent choledocholithotomy with choledochojejunostomy, Roux-en-Y jejunojejunostomy, and a T-tube drainage in the common bile duct in February 1998. The liver biopsy displayed cholestasis and no cirrhotic change. Following surgery the woman was regularly followed up in the outpatient department and intrahepatic stones were removed intermittently via a T-tube. Cholangitis was noted during follow-up, and the patient received five 7-day courses of amoxicillin 1000 mg/day in divided doses from September 1998 to February 1999. The jaundice was persistent during follow up, and painful xanthomas developed on both hands and elbows in February 1999, particularly on the palmar side (Figure 1). Laboratory tests revealed significantly raised serum total cholesterol, total bilirubin, and alkaline phosphatase levels (Figure 2). Lipoprotein electrophoresis displayed that total cholesterol was 1046 mg/dl, β-lipoprotein (low-density lipoprotein) was 72.6% (normal 36–61%), pre-β-lipoprotein (very low-density lipoprotein) was 15.7% (normal 2–30%), and α-lipoprotein (high-density lipoprotein) was 11.7% (normal 22–48%). Subsequently, the patient received no more amoxicillin, and the xanthomas gradually regressed. Total regression of hypercholesterolaemia and xanthomas was achieved in November 2000, at which point total serum cholesterol was 200 mg/dl, total bilirubin was 12 mg/dl, and alkaline phosphatase was 676 U/litre.

Hepatotoxicity of antibiotics and antifungals

Hepatotoxicity associated with any antibiotic is rare. With the wide-spread use of antimicrobial agents, however, hepatic injury is not an infrequent occurrence. Penicillins remain a widely used class of antimicrobials with a well defined record of low hepatotoxicity. The combination of clavulanate with amoxicillin may be associated with the greatest risk for liver injury from any antimicrobial agent. Significant hepatotoxicity also may occur with sulfamethoxazole/ trimethoprim and combination regimens used to treat tuberculosis. An autoimmune-like hepatitis may result from minocycline or nitrofurantoin exposure and most often resolves with cessation of therapy. Treatment with high doses of tetracycline and oxacillin may be associated with severe hepatotoxicity. Early suspicion of hepatocellular injury in the setting of antimicrobial exposure should prompt cessation of therapy and avoidance of rechallenge.

Drug-induced cholestasis

Drugs may cause several overlapping syndromes of cholestasis, the pathophysiological syndrome resulting from impaired bile flow. These reactions comprise approximately 17% of all hepatic adverse drug reactions (ADRs) and they may be severe. Causes of 'pure' (bland) cholestasis include oestrogens and anabolic steroids; rarer associations are with antimicrobials and NSAIDs. 'Cholestatic hepatitis' is a common drug reaction in which liver injury and inflammation cause significant elevation of serum alanine aminotransferase (ALT) as well as cholestasis. Chlorpromazine and ketoconazole are classic examples, but it is now exemplified by amoxycillin-clavulanate and other oxy-penicillins. Chronic cholestasis results from small bile duct injury leading to the vanishing bile duct syndrome (VBDS), a disorder mimicking primary biliary cirrhosis, or from injury to larger bile ducts causing secondary sclerosing cholangitis. Whilst there is increasing evidence of a genetic predisposition to cholestatic drug reactions, there are currently no pretreatment tests to predict drug safety. Prevention of severe reactions therefore relies on early detection of liver injury and prompt drug withdrawal. Symptomatic management includes relief of pruritus and correction of fat-soluble vitamin deficiency. In small cohort studies, ursodeoxycholic acid (UDCA) arrested progressive cholestasis in two-thirds of cases, but evidence for use of corticosteroids is anecdotal. This review considers diagnosis, pathogenesis, prevention and management of drug-induced cholestasis, with particular reference to frequently- and newly-described causes.

Vanishing bile duct syndrome associated with elevated pancreatic enzymes after short-term administration of amoxicillin

Amoxicillin is a widely used antibiotic, rarely being considered a cause of hepatic injury. We report the case of a 45-year-old woman who developed a vanishing bile duct syndrome 8 weeks after initiation of amoxicillin therapy. Liver biopsy showed destruction and loss of preformed bile ducts together with an inflammatory infiltrate involving eosinophilic leucocytes. Cholestasis was progressive despite prednisolone treatment and was accompanied by elevation of pancreatic enzymes. The patient died after 18 months from progressive liver failure. This case illustrates that amoxicillin alone can be a cause of progressive and ultimately fatal vanishing bile duct syndrome.

[Amoxicillin-clavulanic acid induced hepatotoxicity with progression to cirrhosis]

Amoxicillin-clavulanic acid is a commonly used antibiotic in clinical practice. It is usually prescribed on an empirical basis and several cases of hepatotoxicity with cholestasis have been described. We report the case of a 42-year-old man who developed an acute hepatocellular lesion with progression to cirrhosis. The patient received amoxicillin-clavulanic acid twice with an interval of four months. Other causes of hepatic failure were excluded. Although amoxicillin-clavulanic acid-induced hepatotoxicity has been widely documented, there are no other reports describing its progression to cirrhosis in an adult.

Three-dimensional visualization and physiologic evaluation of bile canaliculi in the rat liver slice by confocal laser scanning microscopy

We evaluated the morphology and physiologic function of the bile canaliculi (BC) in the rat liver slice (RLS) by confocal laser scanning microscopy (CLSM). Lucifer yellow (LY) dye was injected into the RLS, and the distribution of LY was serially evaluated. After the injection of LY, hepatocytes were initially visualized, followed by visualization of the BC. There was no significant difference in the distribution of LY between zones 1 and 3 in the hepatic lobule. In zone 1, the reticular distribution of the BC was observed, whereas the part of BC was linearly visualized in zone 3 along the course of sinusoids. When changes in the bile canalicular fluorescence (BCF) were serially evaluated, the BCF was decreased to the minimal level (88% of the value obtained immediately after the LY injection) 10 min after the LY injection, and it tended to increase thereafter. The intralobular hepatocyte fluorescence (ILHF) was decreased to 58.9% of the initial value during the first 40 min. However, the ILHF was transiently increased 30 min after the LY injection, suggesting the possibility of reabsorption of LY by hepatocytes. Three-dimensional (3-D) reconstruction images of the BC facilitated the evaluation of the stereoscopic structure of BC. Confocal laser scanning microscopy facilitated the evaluation of structures and physiologic function of the BC.

Cholangiopathy after short-term administration of piperacillin and imipenem/cilastatin

We describe a patient who suffered from intestinal perforation after abdominal trauma. Perioperatively, he was treated with a single dose of piperacillin and 9 doses of imipenem/cilastatin over 3 days. The patient was discharged 5 days after surgery in good clinical condition and with normal liver values except for a marginal elevation of alanine aminotransferase. Two weeks after discharge, he developed fatigue, fever and pruritus, necessitating rehospitalization. He was jaundiced and had elevated alkaline phosphatase and transaminases. After exclusion of an intra-abdominal fluid collection, a vascular problem, and infectious or autoimmune liver disease, a liver biopsy was performed. The biopsy revealed centrizonal bilirubinostasis, a portal infiltrate rich in eosinophils and cholangitis. Lymphocyte transformation tests for piperacillin and imipenem/cilastatin were positive, suggesting an immunological mechanism for the observed hepatopathy. Cholestasis gradually decreased but was detectable for several weeks. The patient had a full clinical and biochemical recovery after 3 months. We conclude that short-term therapy with piperacillin, imipenem/cilastatin or the combination of these drugs can lead to the same type of hepatopathy as described for amoxycillin/clavulanic acid or antistaphylococcal penicillins. Liver biopsy and positive lymphocyte transformation are compatible with an immunological mechanism.

Vanishing bile duct syndrome in Hodgkin's disease: case report

CONTEXT

Liver damage is relatively common in patients affected by Hodgkin's disease. A smaller proportion of cases develops jaundice. Recently, the vanishing bile duct syndrome was described in Hodgkin's disease. The mechanisms of this severe complication have been poorly understood until now.

OBJECTIVE

To describe a rare case of intra-hepatic cholestasis due to vanishing bile duct syndrome.

DESIGN

Case report.

CASE REPORT

A 38-year-old male patient affected by Hodgkin's disease. Liver biopsy showed no detectable Hodgkin's disease. Intra-hepatic cholestasis was found and none of the six portal tracts analyzed contained normal bile ducts. The treatment was based on conventional and high-dose escalation chemotherapy. The patient died from an irreversible liver failure while in complete remission from Hodgkin's disease.

Rapidly progressive cholestasis: An unusual reaction to amoxicillin/clavulanic acid therapy in a child

Hepatotoxity associated with amoxicillin/clavulanic acid is usually a self-limited disease with complete recovery. We report a rapidly progressing liver disease with ductopenia and portal fibrosis in a 3-year-old boy treated with Augmentin.

Total paracentesis in cirrhotic patients with tense ascites and dilutional hyponatremia

OBJECTIVE

The safety of large-volume paracentesis with plasma expander infusion in ascitic cirrhotic patients with advanced liver disease, hyponatremia, or renal failure has not been elucidated. Our aim was to investigate the safety of total paracentesis in cirrhotic patients with ascites and severe hyponatremia.

METHODS

Forty-five cirrhotic patients with tense ascites were treated with total paracentesis and infusion of plasma expanders. At inclusion, 20 patients showed severe hyponatremia (serum sodium <130 mEq/L). In the remaining 25 patients, serum sodium was >130 mEq/L (range, 133-146 mEq/L).

RESULTS

Plasma renin activity (PRA) and plasma aldosterone concentration (PAC) were significantly higher in patients with hyponatremia (PRA: 19.7 +/- 5.8 ng/mL/h; PAC: 217 +/- 35 ng/dL) than in those patients without hyponatremia (PRA: 4.9 +/- 1.1 ng/mL/h; PAC: 95 +/- 31 ng/dL), indicating a more severe systemic hemodynamic deterioration. After paracentesis, PRA and PAC increased similarly in both groups of patients. Serum sodium levels remained unchanged after paracentesis in patients with hyponatremia (127 +/- 0.5 to 128 +/- 1.5 mEq/L) and decreased slightly in patients without hyponatremia (137 +/- 1 to 135 +/- 1 mEq/L; p < 0.005). The incidence of complications during the first hospitalization, the probability of readmission for complications of cirrhosis, and the probability of survival at 1 yr were similar in both groups of patients.

CONCLUSIONS

These results indicate that therapeutic paracentesis is a safe treatment for tense ascites in cirrhotic patients with severe hyponatremia.

Overview of chronic cholestatic conditions in adults: terminology and definitions

The cholangiopathies represent diseases and syndromes affecting the biliary system at any site between the canals of Hering and the ampulla of Vater. Hepato-canalicular cholestasis reflects biliary secretory failure of the hepatocyte caused by disturbances of intracellular organelles or damage to the bile canalicular excretory functions. Drug reactions are related especially to antibiotics, phenothiazine derivates and carbamazepine. Immune-mediated cholangiopathies cause destruction and reduction of interlobular bile ducts, and are sometimes called vanishing bile duct diseases. They include primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune cholangitis, chronic hepatic allograft rejection, graft-versus-host disease and chronic cholestatic sarcoidosis. Ischemic (vascular) cholangiopathies include traumatic, hepatic arteritis and mechanical causes. Infectious cholangiopathies usually are associated with the immunosuppressed patient.

Idiopathic biliary ductopenia in adults without symptoms of liver disease

BACKGROUND

Idiopathic adulthood ductopenia is a severe cholestatic liver disease of unknown cause characterized by loss of the interlobular bile ducts in more than 50 percent of the portal tracts. In most reported cases, cirrhosis and liver failure develop.

METHODS

We studied 24 adults with abnormal results on liver-function tests but no symptoms of liver disease. All had liver biopsies that showed a lack of bile ducts in many of the portal tracts.

RESULTS

The 17 women and 7 men had a mean age of 41 years (range, 27 to 57). All were asymptomatic and had high serum gamma-glutamyltransferase concentrations (mean [+/-SD], 179 +/- 84 U per liter); 75 percent also had abnormal serum alanine aminotransferase concentrations. The proportion of portal tracts that had bile ducts was 62 +/- 7 percent (range, 55 to 78 percent). Three patients had a second liver biopsy three to nine years after the first; there were no changes over time. In four of the five patients treated with 600 to 900 mg of ursodiol two to three times daily, results of liver-function tests returned to normal.

CONCLUSIONS

Idiopathic biliary ductopenia, with an apparently nonprogressive clinical course, can occur in adults who have no symptoms of biliary disease.

Antibiotic-associated hepatitis: update from 1990

OBJECTIVE

To review the literature on the recent available evidence of antibiotic-associated acute liver injury.

DATA SOURCES

All published articles from January 1990 to July 1995 were extracted from the monthly updated HEPATOX database. Additional articles were found using MEDLINE, EMBASE, and PASCAL searches. Hepatic injuries associated with antituberculous, antimycotic, antiviral, antiprotozoal, and antiseptic compounds were excluded form this review.

STUDY SELECTION

As the amount of literature was large, only case reports, series and epidemiologic data were used. Results from clinical trials were reviewed only when other information was available.

DATA EXTRACTION

Original articles were reviewed to select relevant material. Information regarding the clinical description, histologic features, severity, outcome, and possible risk factors was extracted. Data on incidence were provided by epidemiologic studies or spontaneous reporting to regulatory agencies.

DATA SYNTHESIS

Antibiotic-associated acute injury is rare, with an incidence not exceeding 1 case 10,000 users for most drugs. Among beta-lactams, amoxicillin/clavulanic acid and penicillinase-resistant penicillins are associated with predominant and sometimes protracted cholestasis. The hepatotoxic potential of all available erythromycin salts is confirmed, and recent evidence suggests that roxithromycin could be added to the list of antibiotic-induced liver injury. Among fluoroquinolones, only ciprofloxacin has been associated with serious hepatitis. Trimethoprim/sulfamethoxazole-induced hepatitis often reported, but trimethoprim alone also appears as a possible cause of acute liver injury. Finally, acute bile duct injuries and ductopenia have been described with several antibiotics.

CONCLUSIONS

The most important recent information is the possibility of protracted liver cholestasis with bile duct injuries induced by several antibiotics, particularly penicillinase-resistant penicillins, and the identification of new potentially hepatotoxic antibiotics, namely, roxithromycin, ciprofloxacin, and trimethoprim.