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Hountondji L, Faure S, Palassin P, Viel PWD, Dupuy M, Larrey D, Lamoureux A, Coustal C, Pureur D, Lesage C, Assenat É, Rivière B, Faillie JL, Quantin X, Pageaux GP, Maria ATJ, Meunier L. Time to use the right classification to predict the severity of checkpoint inhibitor-induced liver injury, as assessed for causality using the updated RUCAM. Aliment Pharmacol Ther 2024. [PMID: 39315730 DOI: 10.1111/apt.18276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/15/2024] [Accepted: 09/02/2024] [Indexed: 09/25/2024]
Abstract
BACKGROUND AND AIMS While immune checkpoint inhibitors (ICIs) are revolutionising cancer therapy, checkpoint inhibitor-induced liver injury is a significant immune-related side effect of this immunotherapy. This study focuses on the severity classifications and characteristics of patients with checkpoint inhibitor-induced hepatitis. METHODS A retrospective analysis of patients with severe Checkpoint Inhibitor-induced hepatitis grade 3 and 4 according to the recommended Common Terminology Criteria for Adverse Events (CTCAE) classification was conducted. Data on clinicobiological characteristics, treatment and outcomes were collected from 3 university hospitals, and causality was assessed by using the updated Roussel Uclaf Causality Assessment Method. The severity of hepatitis was assessed using the Model for End-stage Liver Disease score, the Drug-Induced Liver Injury Network, and the Drug-Induced Liver Injury International Expert Working Group classifications. RESULTS We retrospectively included 100 patients presenting various hepatitis patterns with a median time to onset of 20 days after checkpoint inhibitors. Severity grading varied significantly among the classifications used. A lower incidence of severe cases was observed when using the Drug-Induced Liver Injury classifications instead of the recommended CCTCAE classification, and this was correlated with outcomes. CONCLUSIONS This retrospective study challenges the efficacy of the CTCAE classification in defining the severity of Checkpoint Inhibitor-induced hepatitis and suggests that the traditional hepatology-focused scores may be more relevant. The CTCAE classification is inconsistent and gives equal weight to jaundice and elevated transaminases, which leads to steroid overtreatment and limits the rechallenge of ICIs.
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Affiliation(s)
- Lina Hountondji
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Stéphanie Faure
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Pascale Palassin
- Department of Medical Pharmacology and Toxicology, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
| | - Philine Witkowski Durand Viel
- Department of Medical Oncology, Montpellier Cancer Institute, Montpellier University Hospital, Montpellier, France
- Internal Medicine, Beziers Hospital, Béziers, France
| | - Marie Dupuy
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Dominique Larrey
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- REFHEPS, Montpellier, France
| | - Anouck Lamoureux
- Department of Dermatology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Cyrille Coustal
- Internal Medicine & Immuno-Oncology (MedI2O), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Dimitri Pureur
- Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Candice Lesage
- Department of Dermatology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Éric Assenat
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- Department of Oncology, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- Montpellier University, Montpellier, France
| | - Benjamin Rivière
- Department of Pathology, Montpellier University Hospital, University of Montpellier, Montpellier, France
| | - Jean-Luc Faillie
- Department of Medical Pharmacology and Toxicology, Lapeyronie Hospital, Montpellier University Hospital, Montpellier, France
- Montpellier University, Montpellier, France
| | - Xavier Quantin
- Department of Medical Oncology, Montpellier Cancer Institute, Montpellier University Hospital, Montpellier, France
| | - Georges-Philippe Pageaux
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- Montpellier University, Montpellier, France
| | - Alexandre Thibault Jacques Maria
- Internal Medicine & Immuno-Oncology (MedI2O), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- Montpellier University, Montpellier, France
- Internal Medicine & Immuno-Oncology (MedI2O), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
| | - Lucy Meunier
- Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
- REFHEPS, Montpellier, France
- Internal Medicine & Immuno-Oncology (MedI2O), Institute for Regenerative Medicine and Biotherapy (IRMB), Saint Eloi Hospital, Montpellier University Hospital, Montpellier, France
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2
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Chiang HC, Wu IC. Useful biomarkers for predicting poor prognosis of patients with drug-induced liver injury: A retrospective cohort study. Am J Med Sci 2024:S0002-9629(24)01412-5. [PMID: 39182648 DOI: 10.1016/j.amjms.2024.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 08/15/2024] [Accepted: 08/15/2024] [Indexed: 08/27/2024]
Abstract
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.
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Affiliation(s)
- Hsueh-Chien Chiang
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan; Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - I-Chin Wu
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
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3
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Bessone F, Hernandez N, Medina-Caliz I, García-Cortés M, Schinoni MI, Mendizabal M, Chiodi D, Nunes V, Ridruejo E, Pazos X, Santos G, Fassio E, Parana R, Reggiardo V, Tanno H, Sanchez A, Tanno F, Montes P, Tagle M, Arrese M, Brahm J, Girala M, Lizarzabal MI, Carrera E, Zerega A, Bianchi C, Reyes L, Arnedillo D, Cordone A, Gualano G, Jaureguizahar F, Rifrani G, Robles-Díaz M, Ortega-Alonso A, Pinazo-Bandera JM, Stephens C, Sanabria-Cabrera J, Bonilla-Toyos E, Niu H, Alvarez-Alvarez I, Lucena MI, Andrade RJ. Drug-induced Liver Injury in Latin America: 10-year Experience of the Latin American DILI (LATINDILI) Network. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00605-0. [PMID: 38992407 DOI: 10.1016/j.cgh.2024.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/28/2024] [Accepted: 06/20/2024] [Indexed: 07/13/2024]
Abstract
BACKGROUND & AIMS Latin America is a region of great interest for studying the clinical presentation of idiosyncratic drug-induced liver injury (DILI). A comprehensive analysis of patients enrolled into the LATINDILI Network over a decade is presented. METHODS Demographics, clinical presentation, histological findings and outcome of prospectively recruited DILI cases in the LATINDILI Network were analyzed. Suspected culprit drugs were classified according to the Anatomical Therapeutic Chemical classification. Causality was assessed using the Roussel Uclaf Causality Assessment Method (RUCAM) scale. RESULTS Overall, 468 idiosyncratic DILI cases were analyzed (62% women; mean age, 49 years). Hepatocellular injury predominated (62%); jaundice was present in 60% of patients, and 42% were hospitalized. Of the cases, 4.1% had a fatal outcome, and 24 patients (12%) developed chronic DILI. The most common drug classes were systemic anti-infectives (31%), musculoskeletal agents (12%), antineoplastic and immunomodulating agents (11%), and herbal and dietary supplements (9%). Notably, none of the patients with DILI due to antibacterials or immunosuppressants had a fatal outcome. In fact, Hy's law showed to have drug-specific predictive value, with anti-tuberculosis drugs, nimesulide, and herbal and dietary supplements associated with the worst outcome, whereas DILI caused by amoxicillin-clavulanate, nitrofurantoin, and diclofenac, which fulfilled Hy's law, did not have a fatal outcome. CONCLUSION Features of DILI in Latin America are comparable to other prospective registries. However, the pattern of drugs responsible for DILI differs. An increasing incidence of herbal and dietary supplements, with high mortality rate, and likewise, nimesulide and nitrofurantoin, was noted. Thus, public health policies should raise awareness of the potential adverse effects of these compounds.
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Affiliation(s)
- Fernando Bessone
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina.
| | - Nelia Hernandez
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Inmaculada Medina-Caliz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
| | - Miren García-Cortés
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - María I Schinoni
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador de Bahia, Brazil
| | | | - Daniela Chiodi
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Vinicius Nunes
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador de Bahia, Brazil
| | - Ezequiel Ridruejo
- Centro de Educación Médica e Investigaciones Clínicas, Buenos Aires, Argentina
| | - Ximena Pazos
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Genario Santos
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador de Bahia, Brazil
| | | | - Raymundo Parana
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador de Bahia, Brazil; Facultad de Medicina, Universidad Nacional de Bahia, Salvador de Bahia, Brazil
| | - Virginia Reggiardo
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Hugo Tanno
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Adriana Sanchez
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Federico Tanno
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Pedro Montes
- Hospital Nacional Daniel Alcides Carrion, Callao, Peru
| | | | - Marco Arrese
- Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | - Javier Brahm
- Pontificia Universidad Católica de Chile, Santiago de Chile, Chile
| | | | | | | | - Alina Zerega
- Hospital Allende, Ciudad de Córdoba, Córdoba, Argentina
| | - Carla Bianchi
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Laura Reyes
- Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Daina Arnedillo
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Antonella Cordone
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | | | - Fernanda Jaureguizahar
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Gabriel Rifrani
- Hospital Provincial del Centenario, Facultad de Medicina, Universidad Nacional de Rosario, Rosario, Argentina
| | - Mercedes Robles-Díaz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Aida Ortega-Alonso
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - José M Pinazo-Bandera
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Camilla Stephens
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Judith Sanabria-Cabrera
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos IBIMA, Plataforma ISCIII de Investigación Clínica, SCReN, Madrid, Spain
| | - Elvira Bonilla-Toyos
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos IBIMA, Plataforma ISCIII de Investigación Clínica, SCReN, Madrid, Spain
| | - Hao Niu
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos IBIMA, Plataforma ISCIII de Investigación Clínica, SCReN, Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos IBIMA, Plataforma ISCIII de Investigación Clínica, SCReN, Madrid, Spain
| | - M Isabel Lucena
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain; Plataforma de Investigación Clínica y Ensayos Clínicos IBIMA, Plataforma ISCIII de Investigación Clínica, SCReN, Madrid, Spain
| | - Raul J Andrade
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
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Mao Y, Ma S, Liu C, Liu X, Su M, Li D, Li Y, Chen G, Chen J, Chen J, Zhao J, Guo X, Tang J, Zhuge Y, Xie Q, Xie W, Lai R, Cai D, Cai Q, Zhi Y, Li X. Chinese guideline for the diagnosis and treatment of drug-induced liver injury: an update. Hepatol Int 2024; 18:384-419. [PMID: 38402364 DOI: 10.1007/s12072-023-10633-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 12/18/2023] [Indexed: 02/26/2024]
Abstract
Drug-induced liver injury (DILI) is an important adverse drug reaction that can lead to acute liver failure or even death in severe cases. Currently, the diagnosis of DILI still follows the strategy of exclusion. Therefore, a detailed history taking and a thorough and careful exclusion of other potential causes of liver injury is the key to correct diagnosis. This guideline was developed based on evidence-based medicine provided by the latest research advances and aims to provide professional guidance to clinicians on how to identify suspected DILI timely and standardize the diagnosis and management in clinical practice. Based on the clinical settings in China, the guideline also specifically focused on DILI in chronic liver disease, drug-induced viral hepatitis reactivation, common causing agents of DILI (herbal and dietary supplements, anti-tuberculosis drugs, and antineoplastic drugs), and signal of DILI in clinical trials and its assessment.
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Affiliation(s)
- Yimin Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China.
| | - Shiwu Ma
- Department of Infectious Diseases, The 920th Hospital of Chinese PLA Joint Logistics Support Force, Kunming, 650032, Yunnan, China
| | - Chenghai Liu
- Institute of Liver Diseases, Shuguang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Xiaoyan Liu
- Department of Pharmacy, Huangpu Branch of the 9th People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, 200011, China
| | - Minghua Su
- Department of Infectious Diseases, The First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, Guangxi, China
| | - Dongliang Li
- Department of Hepatobiliary Medicine, The 900th Hospital of Chinese PLA Joint Logistics Support Force, Fuzhou, 350025, Fujian, China
| | - Yiling Li
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, 110001, Liaoning, China
| | - Gongying Chen
- Department of Liver Diseases, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, 310015, Zhejiang, China
| | - Jun Chen
- Department of Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, 518112, Guangdong, China
| | - Jinjun Chen
- Hepatology Center, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Jingmin Zhao
- Department of Pathology and Hepatology, Fifth Medical Center of Chinese PLA General Hospital, Beijing, 100039, China
| | - Xiaoyan Guo
- Department of Gastroenterology, Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, China
| | - Jieting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
| | - Yuzheng Zhuge
- Department of Gastroenterology, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, 210008, Jiangsu, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Wen Xie
- Center of Liver Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, 100088, China
| | - Rongtao Lai
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 200025, China
| | - Dachuan Cai
- Department of Infectious Diseases, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qingxian Cai
- Department of Infectious Diseases, Shenzhen Third People's Hospital, Shenzhen, 518112, Guangdong, China
| | - Yang Zhi
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
| | - Xiaoyun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, NHC Key Laboratory of Digestive Diseases, Shanghai Research Center of Fatty Liver Disease, Shanghai, 200001, China
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5
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Ma Z, Li M, Wang Y, Zou C, Wang Y, Guo T, Su Y, Zhang M, Meng Y, Jia J, Zhang J, Zou Z, Zhao X. Association of BMI with mortality in drug-induced liver injury. Eur J Gastroenterol Hepatol 2024; 36:220-228. [PMID: 38047742 DOI: 10.1097/meg.0000000000002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2023]
Abstract
BACKGROUND To clarify the associations between BMI and the incidences of all-cause death or liver-related death (LRD)/liver transplantation (LT) in drug-induced liver injury (DILI). METHODS DILI patients from three hospitals were retrospectively retrieved and follow-up from 2009 to 2021. They were categorized into underweight (BMI < 18.5 kg/m 2 ), normal weight (BMI of 18.5-23.9 kg/m 2 ), overweight (BMI of 24-27.9 kg/m 2 ) and obese (BMI ≥ 28 kg/m 2 ) groups. Cox regression models were conducted to reveal the effect of BMI on all-cause death or LRD/LT. RESULTS A total of 1469 eligible DILI patients were included: underweight 73 (4.97%), normal weight 811 (55.21%), overweight 473 (32.20%) and obese 112 (7.62%). Eighty-nine patients (6.06%) had all-cause death, of which 66 patients (4.49%) had LRD/LT. The median age was 52 years old, and females were 1039 (70.73%). The associations between BMI and all-cause mortality ( nonlinear test P < 0.01) or liver-related mortality/LT ( nonlinear test P = 0.01) were J-shaped. Multivariate Cox regression analysis showed that underweight (HR: 3.02, 95% CI: 1.51-6.02) was significantly associated with all-cause mortality after adjusting for age and sex. Furthermore, obese males were significantly associated with liver-related mortality/LT (HR: 3.49, 95% CI: 1.13-10.72) after additional adjustment for serological indices and comorbidities. CONCLUSION Association between BMI and mortality is a J-shape. The overall mortality was significantly higher in underweight and obese group. Male obesity is independently associated with LRD/LT. These findings indicate that DILI patients with extreme BMI would have a high risk of dismal outcomes, which warrants extra medical care.
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Affiliation(s)
- Zikun Ma
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Min Li
- Clinical Epidemiology and EBM Unit, Beijing Friendship Hospital, Capital Medical University; Beijing Clinical Research Institute
| | - Yan Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Cailun Zou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Yu Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Tiantian Guo
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Yu Su
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Mengmeng Zhang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Yao Meng
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Jidong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
| | - Jing Zhang
- The Third Unit, the Department of Hepatology, Beijing You'an Hospital, Capital Medical University
| | - Zhengsheng Zou
- Senior Department of Hepatology, the Fifth Medical Center of PLA General Hospital, Beijing, China
| | - Xinyan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University
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Dara L, Ghabril M, Phillips E, Kleiner D, Chalasani N. A 68-Year-Old Woman With Unexplained Liver Enzyme Elevation and Active Chronic Hepatitis: Beware of Drug-Induced Autoimmune-Like Hepatitis. Gastroenterology 2024; 166:259-266.e1. [PMID: 37797776 DOI: 10.1053/j.gastro.2023.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/07/2023]
Affiliation(s)
- Lily Dara
- Division of GI and Liver Diseases, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Elizabeth Phillips
- Center for Drug Interactions and Immunology, Division of Infectious Diseases, Department of Medicine, Department of Dermatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Kleiner
- Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana.
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7
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Mazumder NR, Fontana RJ. MELD 3.0 in Advanced Chronic Liver Disease. Annu Rev Med 2024; 75:233-245. [PMID: 37751367 DOI: 10.1146/annurev-med-051322-122539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.
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Affiliation(s)
- Nikhilesh R Mazumder
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
- Gastroenterology Section, Ann Arbor Veterans Affairs Healthcare System, Ann Arbor, Michigan, USA
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA; ,
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8
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Medina-Cáliz I, Sanabria-Cabrera J, Villanueva-Paz M, Aukštikalnė L, Stephens C, Robles-Díaz M, Pinazo-Bandera JM, García-Cortes M, Conde I, Soriano G, Bessone F, Hernandez N, Nunes V, Paraná R, Lucena MI, Andrade RJ, Niu H, Alvarez-Alvarez I. Characterization of drug-induced liver injury associated with drug reaction with eosinophilia and systemic symptoms in two prospective DILI registries. Arch Toxicol 2024; 98:303-325. [PMID: 38051367 PMCID: PMC10761448 DOI: 10.1007/s00204-023-03630-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) associated with drug reactions with eosinophilia and systemic symptoms (DRESS) is poorly characterized among patients of Western countries. We aimed to comprehensively assess the clinical characteristics, outcomes, and causative agents in a prospective, well-vetted cohort of DILI patients with DRESS (DILI-DRESS). We identified 53 DILI-DRESS cases from the Spanish DILI Registry and the Latin American DILI Network. For comparison purposes, we defined a group of DILI patients (n = 881). DILI-DRESS cases were younger (47 vs. 53 years, respectively; p = 0.042) and presented more frequently with cholestatic/mixed damage (p = 0.018). Most DILI-DRESS patients showed moderate liver injury, 13% developed severe damage, and only one patient (with hepatocellular injury due to anti-tuberculosis drugs) progressed to acute liver failure and died. DILI-DRESS cases showed a distinctive causative drug pattern compared to DILI cases. The most frequent drugs were carbamazepine (13%), anti-tuberculosis drugs (13%), amoxicillin-clavulanate (11%), and allopurinol and lamotrigine (7.6% each). Among all cases of DILI due to allopurinol and lamotrigine, 67% presented with a DILI-DRESS phenotype, respectively. Higher total bilirubin (TBL) levels at DILI recognition (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and absence of eosinophilia (OR 8.77; 95% CI 1.11-69.20) increased the risk for developing a severe-fatal injury in DILI-DRESS patients. DILI-DRESS patients have a more frequent cholestasis/mixed pattern of injury at presentation, with antiepileptics as distinctive causative drug class. Most of the lamotrigine and allopurinol cases present with this phenotype. Higher TBL levels and absence of eosinophilia at DILI recognition are markers of poor outcomes.
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Affiliation(s)
- Inmaculada Medina-Cáliz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
| | - Judith Sanabria-Cabrera
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Plataforma de Investigación Clínica y Ensayos Clínicos, Plataforma ISCIII de Investigación Clínica, UICEC-IBIMA, Madrid, Spain
| | - Marina Villanueva-Paz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Lauryna Aukštikalnė
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Camilla Stephens
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mercedes Robles-Díaz
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - José M Pinazo-Bandera
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren García-Cortes
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Isabel Conde
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Unidad de Hepatología, Hospital Universitari I Politècnic La Fe, Servicio de Aparato Digestivo, Valencia, Spain
| | - German Soriano
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Servicio de Gastroenterología, Hospital de La Santa Creu I Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | | | - Vinicius Nunes
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador, Brazil
| | - Raymundo Paraná
- Hospital Universitário Prof. Edgard Santos-UFBA, Salvador, Brazil
| | - M Isabel Lucena
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain.
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
- Plataforma de Investigación Clínica y Ensayos Clínicos, Plataforma ISCIII de Investigación Clínica, UICEC-IBIMA, Madrid, Spain.
- Departamento de Farmacología, Facultad de Medicina, Universidad de Málaga, Boulevard Louis, Pasteur 32, 29010, Málaga, Spain.
| | - Raúl J Andrade
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Plataforma de Investigación Clínica y Ensayos Clínicos, Plataforma ISCIII de Investigación Clínica, UICEC-IBIMA, Madrid, Spain
| | - Hao Niu
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Plataforma de Investigación Clínica y Ensayos Clínicos, Plataforma ISCIII de Investigación Clínica, UICEC-IBIMA, Madrid, Spain
| | - Ismael Alvarez-Alvarez
- Servicios de Aparato Digestivo y Farmacología Clínica, Hospital Universitario Virgen de La Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
- Plataforma de Investigación Clínica y Ensayos Clínicos, Plataforma ISCIII de Investigación Clínica, UICEC-IBIMA, Madrid, Spain
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9
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Wang Y, Zou CL, Zhang J, Qiu LX, Huang YF, Zhao XY, Zou ZS, Jia JD. Development and validation of a novel model to predict liver-related mortality in patients with idiosyncratic drug-induced liver injury. Hepatobiliary Pancreat Dis Int 2023; 22:584-593. [PMID: 37308361 DOI: 10.1016/j.hbpd.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/26/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Early identification of patients with high mortality risk is critical for optimizing the clinical management of drug-induced liver injury (DILI). We aimed to develop and validate a new prognostic model to predict death within 6 months in DILI patients. METHODS This multicenter study retrospectively reviewed the medical records of DILI patients admitted to three hospitals. A DILI mortality predictive score was developed using multivariate logistic regression and was validated with area under the receiver operating characteristic curve (AUC). A high-mortality-risk subgroup was identified according to the score. RESULTS Three independent DILI cohorts, including one derivation cohort (n = 741) and two validation cohorts (n = 650, n = 617) were recruited. The DILI mortality predictive (DMP) score was calculated using parameters at disease onset as follows: 1.913 × international normalized ratio + 0.060 × total bilirubin (mg/dL) + 0.439 × aspartate aminotransferase/alanine aminotransferase - 1.579 × albumin (g/dL) - 0.006 × platelet count (109/L) + 9.662. The predictive performance for 6-month mortality of DMP score was desirable, with an AUC of 0.941 (95% CI: 0.922-0.957), 0.931 (0.908-0.949) and 0.960 (0.942-0.974) in the derivation, validation cohorts 1 and 2, respectively. DILI patients with a DMP score ≥ 8.5 were stratified into high-risk group, whose mortality rates were 23-, 36-, and 45-fold higher than those of other patients in the three cohorts. CONCLUSIONS The novel model based on common laboratory findings can accurately predict mortality within 6 months in DILI patients, which should serve as an effective guidance for management of DILI in clinical practice.
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Affiliation(s)
- Yan Wang
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Cai-Lun Zou
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Jing Zhang
- The Third Unit, Department of Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Li-Xia Qiu
- The Third Unit, Department of Hepatology, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China
| | - Yong-Fa Huang
- Liver Transplantation Center, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Diseases, Beijing 100050, China; Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing 100050, China
| | - Xin-Yan Zhao
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing 100050, China
| | - Zheng-Sheng Zou
- Senior Department of Hepatology, the Fifth Medical Center of Chinese PLA General Hospital, Beijing 100039, China.
| | - Ji-Dong Jia
- Liver Research Center, Beijing Friendship Hospital, Capital Medical University; Key Laboratory on Translational Medicine on Cirrhosis; National Clinical Research Center for Digestive Diseases, Beijing 100050, China.
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10
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Chen YF, Li LJ. A new prognostic model for drug-induced liver injury especially suitable for Chinese population. Hepatobiliary Pancreat Dis Int 2023; 22:551-553. [PMID: 37704560 DOI: 10.1016/j.hbpd.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Yan-Fei Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Lan-Juan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China.
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11
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Pinazo-Bandera JM, García-Cortés M, Andrade RJ. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury: also useful for hepatobiliary surgeons. Hepatobiliary Surg Nutr 2023; 12:746-751. [PMID: 37886185 PMCID: PMC10598316 DOI: 10.21037/hbsn-23-319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/22/2023] [Indexed: 10/28/2023]
Affiliation(s)
- Jose María Pinazo-Bandera
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren García-Cortés
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Raúl J. Andrade
- Service of Gastroenterology and Hepatology, University Hospital Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma Bionand, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédico en Red Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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12
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Fontana RJ, Bjornsson ES, Reddy R, Andrade RJ. The Evolving Profile of Idiosyncratic Drug-Induced Liver Injury. Clin Gastroenterol Hepatol 2023; 21:2088-2099. [PMID: 36868489 DOI: 10.1016/j.cgh.2022.12.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/02/2022] [Accepted: 12/19/2022] [Indexed: 03/05/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is an infrequent but important cause of liver disease. Newly identified causes of DILI include the COVID vaccines, turmeric, green tea extract, and immune checkpoint inhibitors. DILI is largely a clinical diagnosis of exclusion that requires evaluation for more common causes of liver injury and a compatible temporal association with the suspect drug. Recent progress in DILI causality assessment includes the development of the semi-automated revised electronic causality assessment method (RECAM) instrument. In addition, several drug-specific HLA associations have been identified that can help with the confirmation or exclusion of DILI in individual patients. Various prognostic models can help identify the 5%-10% of patients at highest risk of death. Following suspect drug cessation, 80% of patients with DILI fully recover, whereas 10%-15% have persistently abnormal laboratory studies at 6 months of follow-up. Hospitalized patients with DILI with an elevated international normalized ratio or mental status changes should be considered for N-acetylcysteine therapy and urgent liver transplant evaluation. Selected patients with moderate to severe drug reaction with eosinophilia and systemic symptoms or autoimmune features on liver biopsy may benefit from short-term corticosteroids. However, prospective studies are needed to determine the optimal patients and dose and duration of steroids to use. LiverTox is a comprehensive, freely accessible Web site with important information regarding the hepatotoxicity profile of more than 1000 approved medications and 60 herbal and dietary supplement products. It is hoped that ongoing "omics" studies will lead to additional insight into DILI pathogenesis, improved diagnostic and prognostic biomarkers, and mechanism-based treatments.
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Affiliation(s)
- Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.
| | - Einar S Bjornsson
- Deparment of Internal Medicine, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Raul J Andrade
- Division of Gastroenterology and Hepatology, University Hospital-IBIMA Platform BIONAND, University of Malaga, CIBERehd, Spain
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13
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Fontana RJ, Liou I, Reuben A, Suzuki A, Fiel MI, Lee W, Navarro V. AASLD practice guidance on drug, herbal, and dietary supplement-induced liver injury. Hepatology 2023; 77:1036-1065. [PMID: 35899384 PMCID: PMC9936988 DOI: 10.1002/hep.32689] [Citation(s) in RCA: 47] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Liou
- University of Washington, Seattle, Washington, USA
| | - Adrian Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ayako Suzuki
- Division of Gastroenterology, Duke University, Durham, North Carolina, USA
| | - M. Isabel Fiel
- Department of Pathology, Mount Sinai School of Medicine, New York City, New York, USA
| | - William Lee
- Division of Gastroenterology, University of Texas Southwestern, Dallas, Texas, USA
| | - Victor Navarro
- Department of Medicine, Einstein Healthcare Network, Philadelphia, Pennsylvania, USA
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14
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Vuppalanchi R, Ghabril M. Review article: clinical assessment of suspected drug-induced liver injury and its management. Aliment Pharmacol Ther 2022; 56:1516-1531. [PMID: 36282208 DOI: 10.1111/apt.17246] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/10/2022] [Accepted: 09/25/2022] [Indexed: 01/30/2023]
Abstract
BACKGROUND Idisyncratic drug-induced liver injury (DILI) is a rare instance of liver injury after exposure to an otherwise safe drug or herbal or dietary supplement. DILI can be associated with significant morbidity and mortality. Furthermore, it is an important consideration in drug development due to safety concerns. AIMS AND METHODS To highlight pearls and pitfalls to aid clinicians in diagnosing DILI and surmising the management options. We also share the best practices from personal insights developed from decades long participation in the causality assessment committee meetings of the DILI Network. RESULTS DILI lacks a diagnostic test and is currently diagnosed through a process of exclusion of competing aetiologies of liver injury. This requires a high degree of suspicion to consider the possibility of DILI, skill in ruling out the obvious and less obvious competing liver insults, and an understanding of the expected phenotypes of DILI. The facets of DILI cover multiple aspects, including the latency, liver injury pattern, course of injury, and associated autoimmune or immuno-allergic features. Care for patients with DILI is geared towards stopping the offending drug and symptom management that include the use of corticosteroids in select cases. CONCLUSION The diagnosis of DILI is challenging and is primarily made through a carefully crafted patient interview, temporal relationship with the implicated drug or supplement, and exclusion of competing aetiology. LiverTox is a useful resource for clinicians to review the literature and recognise the likelihood of the implicated agent in causing DILI.
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Affiliation(s)
- Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, Indiana, USA
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15
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Comparison of the prognostic models for mortality in idiosyncratic drug-induced liver injury. Hepatol Int 2022; 17:488-498. [PMID: 36327052 DOI: 10.1007/s12072-022-10405-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 08/08/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Several models have been proposed to predict acute liver failure/death in patients with drug-induced liver injury (DILI), but the predictive performances of them have not been systematically compared. We aim to compare the current models for their predictive potency of mortality at DILI onset. METHODS DILI patients hospitalized at both Beijing Friendship Hospital and the Fifth Medical Center of PLA General Hospital were categorized into death/liver transplantation (LT) or survival without LT group. Predictive potency of 28-day, 90-day, 6-month and 12-month death/LT outcomes of Hy's Law, nHy's Law, Robles-Diaz Model, drug-induced liver toxicity (DrILTox ALF) Score, Model for End-stage Liver Disease (MELD) Score, and Ghabril Model was compared by Delong method. RESULTS A total of 6.3% (83/1314) patients died or received LT within 12 months after DILI onset. The area under receiver operating characteristic of Hy's Law, nHy's Law, and Robles-Diaz Model was all lower than 0.750 for the prediction of within 12 months' mortality. DrILTox ALF Score, MELD Score and Ghabril Model showed better predictive potency of 28-day [0.896 (0.878-0.912), 0.934 (0.919-0.947), 0.935 (0.921-0.948), respectively], 90-day [0.883 (0.864-0.899), 0.951 (0.938-0.962), 0.952 (0.939-0.963), respectively], 6-month [0.820 (0.799-0.841), 0.905 (0.888-0.921) and 0.908 (0.891-0.923), respectively] and 12-month [0.801 (0.779-0.823), 0.882 (0.863-0.899) and 0.885 (0.866-0.902), respectively] mortality. CONCLUSION Despite the difference of clinical characteristics and implicated-drug categories between China and industrialized countries, we demonstrate that MELD Score and Ghabril Model have the best predictive performance in the prediction of mortality within 12 months after DILI onset.
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16
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Thi Thu PN, Quynh MNT, Van HN, Thanh HN, Minh KP. A logistic regression model based on inpatient health records to predict drug-induced liver injury caused by ramipril—An angiotensin-converting enzyme inhibitor. PLoS One 2022; 17:e0272786. [PMID: 35976917 PMCID: PMC9384991 DOI: 10.1371/journal.pone.0272786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/26/2022] [Indexed: 11/18/2022] Open
Abstract
Drug-induced liver injury (DILI) is a rare side effect of angiotensin-converting enzyme inhibitors (ACEIs). Ramipril is a widely used ACE compound because of its effectiveness in the treatment of hypertension and heart failure, as well as its low risk of adverse effects. However, the clinical features of ramipril, and the risk of DILI, have not been adequately studied. A retrospective cohort study was performed based on data from 3909 inpatients to compare the risk of DILI conferred by ramipril and other ACEIs. A logistic regression model was then constructed and validated against data from 1686 patients using ramipril, of which 117 patients were diagnosed with DILI. The use of ramipril increased the risk of DILI by 2.68 times (odds ratio = 2.68; 95% confident interval (CI):1.96–3.71) compared with the group using other ACEIs. The clinical features of DILI in the ramipril group were similar to those from the ACEI group (P>0.05), except that the ALT level was higher (P<0.05). A logistic regression model including Body mass index (BMI), comorbidity, liver disease, daily dose, alanine aminotransferase (ALT), and alkaline phosphatase (ALP) was built and successfully validated for DILI risk prediction, with the area under the receiver operating characteristic curve of the model of 0.82 (95% CI: 0.752–0.888). We recommend that clinicians should be aware of the levels of ALT and ALP as well as BMI, comorbidities, and liver disease before prescribing ramipril to avoid the risk of DILI in patients.
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Affiliation(s)
- Phuong Nguyen Thi Thu
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
- Hai Phong International Hospital, Hai Phong, Vietnam
- * E-mail:
| | | | - Hung Nguyen Van
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
| | | | - Khue Pham Minh
- Hai Phong University of Medicine and Pharmacy, Hai Phong, Vietnam
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17
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Li X, Tang J, Mao Y. Incidence and risk factors of drug-induced liver injury. Liver Int 2022; 42:1999-2014. [PMID: 35353431 DOI: 10.1111/liv.15262] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 03/08/2022] [Accepted: 03/26/2022] [Indexed: 12/17/2022]
Abstract
The epidemiology and aetiology of drug-induced liver injury (DILI) vary across different countries and populations. Overall, DILI is rare in the general population but has become more prevalent in hospitalized patients, especially among patients with unexplained liver conditions. In addition, drugs implicated in DILI differ between Western and Eastern countries. Antibiotics are the leading drugs implicated in DILI in the West, whereas traditional Chinese medicine is the primary cause implicated in DILI in the East. The incidence of herbal and dietary supplements-induced hepatotoxicity is increasing globally. Several genetic and nongenetic risk factors associated with DILI have been described in the literature; however, there are no confirmed risk factors for all-cause DILI. Some factors may contribute to the risk of DILI in a drug-specific manner.
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Affiliation(s)
- Xiaoyun Li
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Jieting Tang
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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18
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Tang J, Gu J, Chu N, Chen Y, Wang Y, Xue D, Xie Q, Li L, Mei Z, Wang X, Li J, Chen J, Li Y, Yang C, Wang Y, Shang J, Xie W, Hu P, Li D, Zhao L, Lan P, Wang C, Chen C, Mao Y. Efficacy and safety of bicyclol for treating patients with idiosyncratic acute drug-induced liver injury: A multicenter, randomized, phase II trial. Liver Int 2022; 42:1803-1813. [PMID: 35567757 DOI: 10.1111/liv.15290] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/27/2022] [Accepted: 05/12/2022] [Indexed: 02/13/2023]
Abstract
BACKGROUND AND AIMS Evidence for using bicyclol in drug-induced liver injury (DILI) is limited. This study aimed to explore the efficacy and safety of bicyclol in acute DILI. METHODS This was a multicenter, randomized, double-blinded, double-dummy, active-controlled, superiority and phase II trial. Patients with idiosyncratic acute DILI were randomized 1: 1:1 to low-dose bicyclol (25 mg times a day [TID]), high-dose bicyclol (50 mg TID) and polyene phosphatidylcholine (control) groups. The primary endpoint was the decrease from baseline in serum alanine aminotransferase (ALT) levels at post-treatment for 4 weeks. RESULTS Overall, 241 patients were included in the full analysis set, with 81, 82 and 78 patients in the low-dose bicyclol, high-dose bicyclol, and control groups respectively. ALT levels decreased across groups (-249.2 ± 151.1, -273.6 ± 203.1, and -180.8 ± 218.2 U/L in the low-dose bicyclol, high-dose bicyclol and control groups, respectively; both p < .001, the bicyclol-dependent groups vs. control group). The ALT normalization rates at weeks 1, 2, 4, 6 and 8 were higher in the bicyclol-dependent groups than in the control group (p = .002 at week 1 and all p < .001 at weeks 2, 4, 6 and 8 respectively). The median times to ALT normalization in the low-dose bicyclol, high-dose bicyclol and control groups were 29, 16 and 43 days respectively. Adverse events, serious adverse events and adverse drug reactions were similar across groups. CONCLUSIONS Bicyclol (25 and 50 mg TID) appeared efficacious and safe for treating idiosyncratic acute DILI, while bicyclol 50 mg TID showed higher efficacy. TRIAL REGISTRATION NUMBER www. CLINICALTRIALS gov (registration no. NCT02944552).
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Affiliation(s)
- Jieting Tang
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jin Gu
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Shanghai, China
| | - Naihui Chu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Tuberculosis, Henan Infectious Diseases Hospital (The Sixth People's Hospital of Zhengzhou), Zhengzhou, Henan, China
| | - Yongliang Wang
- Department of Tuberculosis, The First Affiliated Hospital of Xinxiang Medical University, Weihui, Henan, China
| | - Dongying Xue
- Department of Infectious Diseases, Shanghai Putuo District Central Hospital, Shanghai, China
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Lei Li
- Department of Infectious Disease, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Zaoxian Mei
- Department of Tuberculosis, Tianjin Haihe Hospital, Tianjin, China
| | - Xiaojin Wang
- Liver Disease Center of Naval 905 Hospital, Shanghai, China
| | - Jun Li
- Department of Infectious Diseases, Jiangsu Province Hospital, Nanjing, China
| | - Jun Chen
- Department of Liver Diseases, The Third People's Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
| | - Yi Li
- Department of Infectious Diseases, The Second Xiangya Hospital of Central South University, Changshang, China
| | - Changqing Yang
- Department of Gastroenterology, Tongji Hospital of Tongji University, Shanghai, China
| | - Yingxin Wang
- Department of Gastroenterology, Tongji Hospital of Tongji University, Shanghai, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Wen Xie
- Center of Liver Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Peng Hu
- Department of Infectious Diseases, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dongliang Li
- Department of Hepatobiliary Disease, 900th Hospital of PLA's Joint Logistics Support Force, Fujian, China
| | - Limin Zhao
- Beijing Union Pharmaceutical Factory, Beijing, China
| | - Pei Lan
- Beijing Union Pharmaceutical Factory, Beijing, China
| | - Chen Wang
- Beijing Union Pharmaceutical Factory, Beijing, China
| | - Chengwei Chen
- Liver Disease Center of Naval 905 Hospital, Shanghai, China
| | - Yimin Mao
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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19
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Contreras Omaña R, Moreno Alcántar R, Cerda Reyes E. Drug-Induced Liver Injury: A Mexican View. Clin Liver Dis (Hoboken) 2022; 19:78-81. [PMID: 35308476 PMCID: PMC8912224 DOI: 10.1002/cld.1206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Audio Recording.
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Affiliation(s)
- Raúl Contreras Omaña
- Centro de Estudio e Investigación en Enfermedades Hepáticas y ToxicológicasHidalgoMéxico
| | - Rosalba Moreno Alcántar
- Jefe del Servicio de GastroenterologíaCentro Médico Nacional Siglo XXIIMSSCiudad de MéxicoMéxico
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20
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Reike-Kunze M, Zenouzi R, Hartel J, Krech T, Weidemann S, Sterneck M, Weiler-Normann C, Lohse AW, Schramm C, Sebode M. Drug-induced liver injury at a tertiary care centre in Germany: Model for end-stage liver disease is the best predictor of outcome. Liver Int 2021; 41:2383-2395. [PMID: 34152686 DOI: 10.1111/liv.14985] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/24/2021] [Accepted: 06/05/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Agents most frequently inducing idiosyncratic drug-induced liver injury (DILI) differ between countries worldwide. Besides, there is no consistent data on the best model predicting mortality or the need for liver transplantation in DILI. We here analysed the DILI cohort of our centre with regard to causative drugs and clinical outcome. METHODS A retrospective analysis of 157 consecutive severe DILI patients presenting to our tertiary care centre in Hamburg, Germany, from 2008 to 2018, was performed. RESULTS The most frequent putatively causative drugs were phenprocoumon (n = 21), metamizole (n = 17) and flupirtine (n = 6). The mean values of ALT, bilirubin and Model for End-stage Liver Disease (MELD) score at the time of hospitalisation were 1201 U/L (SD: 1169 U/L), 6.8 mg/dL (SD: 7 mg/dL) and 17 (SD: 8). About 71% of all cases were treated with steroids or steroids combined with n-acetylcysteine. About 12.1% of all DILI cases had a poor outcome (liver transplantation and/or death). At the time of admission, MELD score performed better than Hy's law, the ratio (R) or the new ratio (nR) on their own or combined with bilirubin, regarding sensitivity or specificity for poor outcome. MELD score had a c-statistic of 0.847 (95% CI: 0.731-0.964). Furthermore, the cut-off of 18 MELD points had a sensitivity of 88% and a specificity of 72% for poor outcome. CONCLUSION Phenprocoumon and metamizole are frequent causative drugs for DILI in Germany. In comparison to other prognostic scores, MELD score ≥18 at the time of admission performed best in our cohort for the prediction of poor outcome in DILI.
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Affiliation(s)
- Martin Reike-Kunze
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Roman Zenouzi
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Johannes Hartel
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Till Krech
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Sören Weidemann
- Department of Pathology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Martina Sterneck
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,University Transplant Centre, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Christina Weiler-Normann
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W Lohse
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Christoph Schramm
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,Martin Zeitz Centre for Rare Diseases, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Marcial Sebode
- I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.,European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
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21
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Stephens C, Robles-Diaz M, Medina-Caliz I, Garcia-Cortes M, Ortega-Alonso A, Sanabria-Cabrera J, Gonzalez-Jimenez A, Alvarez-Alvarez I, Slim M, Jimenez-Perez M, Gonzalez-Grande R, Fernández MC, Casado M, Soriano G, Román E, Hallal H, Romero-Gomez M, Castiella A, Conde I, Prieto M, Moreno-Planas JM, Giraldez A, Moreno-Sanfiel JM, Kaplowitz N, Lucena MI, Andrade RJ. Comprehensive analysis and insights gained from long-term experience of the Spanish DILI Registry. J Hepatol 2021; 75:86-97. [PMID: 33539847 DOI: 10.1016/j.jhep.2021.01.029] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Prospective drug-induced liver injury (DILI) registries are important sources of information on idiosyncratic DILI. We aimed to present a comprehensive analysis of 843 patients with DILI enrolled into the Spanish DILI Registry over a 20-year time period. METHODS Cases were identified, diagnosed and followed prospectively. Clinical features, drug information and outcome data were collected. RESULTS A total of 843 patients, with a mean age of 54 years (48% females), were enrolled up to 2018. Hepatocellular injury was associated with younger age (adjusted odds ratio [aOR] per year 0.983; 95% CI 0.974-0.991) and lower platelet count (aOR per unit 0.996; 95% CI 0.994-0.998). Anti-infectives were the most common causative drug class (40%). Liver-related mortality was more frequent in patients with hepatocellular damage aged ≥65 years (p = 0.0083) and in patients with underlying liver disease (p = 0.0221). Independent predictors of liver-related death/transplantation included nR-based hepatocellular injury, female sex, higher onset aspartate aminotransferase (AST) and bilirubin values. nR-based hepatocellular injury was not associated with 6-month overall mortality, for which comorbidity burden played a more important role. The prognostic capacity of Hy's law varied between causative agents. Empirical therapy (corticosteroids, ursodeoxycholic acid and MARS) was prescribed to 20% of patients. Drug-induced autoimmune hepatitis patients (26 cases) were mainly females (62%) with hepatocellular damage (92%), who more frequently received immunosuppressive therapy (58%). CONCLUSIONS AST elevation at onset is a strong predictor of poor outcome and should be routinely assessed in DILI evaluation. Mortality is higher in older patients with hepatocellular damage and patients with underlying hepatic conditions. The Spanish DILI Registry is a valuable tool in the identification of causative drugs, clinical signatures and prognostic risk factors in DILI and can aid physicians in DILI characterisation and management. LAY SUMMARY Clinical information on drug-induced liver injury (DILI) collected from enrolled patients in the Spanish DILI Registry can guide physicians in the decision-making process. We have found that older patients with hepatocellular type liver injury and patients with additional liver conditions are at a higher risk of mortality. The type of liver injury, patient sex and analytical values of aspartate aminotransferase and total bilirubin can also help predict clinical outcomes.
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Affiliation(s)
- Camilla Stephens
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mercedes Robles-Diaz
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Inmaculada Medina-Caliz
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miren Garcia-Cortes
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Aida Ortega-Alonso
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Judith Sanabria-Cabrera
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Platform ISCiii for Clinical Research and Clinical Trials UICEC- IBIMA, Málaga, Spain
| | - Andres Gonzalez-Jimenez
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Ismael Alvarez-Alvarez
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Mahmoud Slim
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miguel Jimenez-Perez
- UGC Aparato Digestivo, Complejo Hospitalario Regional de Málaga, IBIMA, Málaga, Spain
| | - Rocio Gonzalez-Grande
- UGC Aparato Digestivo, Complejo Hospitalario Regional de Málaga, IBIMA, Málaga, Spain
| | | | - Marta Casado
- UGC Farmacia, Hospital Universitario Torrecárdenas, Almeria, Spain
| | - German Soriano
- Servicio de Gastroenterología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Eva Román
- Servicio de Gastroenterología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Escola Universitària d'Infermeria EUI-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Hacibe Hallal
- Servicio Aparato Digestivo, Hospital General Universitario J.M. Morales Meseguer, Murcia, Spain
| | - Manuel Romero-Gomez
- UGC Aparato Digestivo, SeLiver Group IBIS, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agustin Castiella
- Servicio de Aparato Digestivo, Hospital Universitario de Donostia, San Sebastian, Spain
| | - Isabel Conde
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Martin Prieto
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Alvaro Giraldez
- Servicio de Aparato Digestivo. Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Neil Kaplowitz
- University of Southern California Research Center for Liver Diseases, Keck School of Medicine, Los Angeles, California, USA
| | - M Isabel Lucena
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Platform ISCiii for Clinical Research and Clinical Trials UICEC- IBIMA, Málaga, Spain.
| | - Raúl J Andrade
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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22
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Weng J, Han X, Zeng F, Zhang Y, Feng L, Cai L, Liang K, Liu S, Li S, Fu G, Zeng M, Gao Y. Fiber scaffold bioartificial liver therapy relieves acute liver failure and extrahepatic organ injury in pigs. Theranostics 2021; 11:7620-7639. [PMID: 34335954 PMCID: PMC8315066 DOI: 10.7150/thno.58515] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023] Open
Abstract
Rationale: Acute liver failure (ALF) causes severe liver injury and a systemic inflammatory response, leading to multiorgan failure with a high short-term mortality. Bioartificial liver (BAL) therapy is a promising approach that is hampered by the lack of appropriate bioreactors and carriers to retain hepatic cell function and poor understanding of BAL treatment mechanisms in ALF and extrahepatic organ injury. Recently, we used a fiber scaffold bioreactor (FSB) for the high-density, three-dimensional (3D) culture of primary porcine hepatocytes (PPHs) combined with an absorption component to construct a BAL and verified its function in a D-galactosamine (D-gal)-induced ALF porcine model to evaluate its protective effects on the liver and extrahepatic organs. Methods: Male pigs were randomized into standard/supportive therapy (ST), ST+no-cell BAL (ST+Sham BAL) and ST+BAL groups and received treatment 48 h after receiving a D-gal injection. Changes in blood chemistry and clinical symptoms were monitored for 120 h. Tissues and plasma were collected for analysis by pathological examination, immunoblotting, quantitative PCR and immunoassays. Results: PPHs cultured in the FSB obtained sufficient aeration and nutrition for high-density, 3D culture and maintained superior viability and functionality (biosynthesis and detoxification) compared with those cultured in flasks. All the animals developed ALF, acute kidney injury (AKI) and hepatic encephalopathy (HE) 48 h after D-gal infusion and received corresponding therapies. Animals in the BAL group showed markedly improved survival (4/5; 80%) compared with those in the ST+Sham BAL (0/5; p < 0.001) and ST (0/5; p < 0.001) groups. The levels of blood ammonia and biochemical and inflammatory indices were alleviated after BAL treatment. Increased liver regeneration and attenuations in the occurrence and severity of ALF, AKI and HE were observed in the ST+BAL group compared with the ST (p = 0.0009; p = 0.038) and ST+Sham BAL (p = 0.011; p = 0.031) groups. Gut leakage, the plasma endotoxin level, bacterial translocation, and peripheral and neuroinflammation were alleviated in the ST+BAL group compared with those in the other groups. Conclusions: BAL treatment enhanced liver regeneration and alleviated the systemic inflammatory response and extrahepatic organ injury to prolong survival in the ALF model and has potential as a therapeutic approach for ALF patients.
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Affiliation(s)
- Jun Weng
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Xu Han
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Fanhong Zeng
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Yue Zhang
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Lei Feng
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Lei Cai
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Kangyan Liang
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Shusong Liu
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Shao Li
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
| | - Gongbo Fu
- Department of Medical Oncology, Jinling Hospital, First School of Clinical Medicine, Southern Medical University, Nanjing 210000, China
| | - Min Zeng
- Guangdong Qianhui Biotechnology Co., Ltd., Guangzhou 510285, China
| | - Yi Gao
- Department of Hepatobiliary Surgery II, Guangdong Provincial Research Center for Artificial Organ and Tissue Engineering, Guangzhou Clinical Research and Transformation Center for Artificial Liver, Institute of Regenerative Medicine, Zhujiang Hospital of Southern Medical University, Guangzhou 510515, China
- State Key Laboratory of Organ Failure Research, Southern Medical University, Guangzhou 510515, China
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23
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Hey-Hadavi J, Seekins D, Palmer M, Coffey D, Caminis J, Abdullaev S, Patwardhan M, Tyler H, Raheja R, Stanley AM, Pineda-Salgado L, Bourdet DL, Andrade RJ, Hayashi PH, Dimick-Santos L, Rockey DC, Estilo A. Overview of Causality Assessment for Drug-Induced Liver Injury (DILI) in Clinical Trials. Drug Saf 2021; 44:619-634. [PMID: 33725335 PMCID: PMC8184702 DOI: 10.1007/s40264-021-01051-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 02/08/2023]
Abstract
Causality assessment for suspected drug-induced liver injury (DILI) during drug development and following approval is challenging. The IQ DILI Causality Working Group (CWG), in collaboration with academic and regulatory subject matter experts (SMEs), developed this manuscript with the following objectives: (1) understand and describe current practices; (2) evaluate the utility of new tools/methods/practice guidelines; (3) propose a minimal data set needed to assess causality; (4) define best practices; and (5) promote a more structured and universal approach to DILI causality assessment for clinical development. To better understand current practices, the CWG performed a literature review, took a survey of member companies, and collaborated with SMEs. Areas of focus included best practices for causality assessment during clinical development, utility of adjudication committees, and proposals for potential new avenues to improve causality assessment. The survey and literature review provided renewed understanding of the complexity and challenges of DILI causality assessment as well as the use of non-standardized approaches. Potential areas identified for consistency and standardization included role and membership of adjudication committees, standardized minimum dataset, updated assessment tools, and best practices for liver biopsy and rechallenge in the setting of DILI. Adjudication committees comprised of SMEs (i.e., utilizing expert opinion) remain the standard for DILI causality assessment. A variety of working groups continue to make progress in pursuing new tools to assist with DILI causality assessment. The minimum dataset deemed adequate for causality assessment provides a path forward for standardization of data collection in the setting of DILI. Continued progress is necessary to optimize and advance innovative tools necessary for the scientific, pharmaceutical, and regulatory community.
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Affiliation(s)
| | | | - Melissa Palmer
- Takeda, Cambridge, MA, USA
- Liver Consulting LLC, New York City, USA
| | | | | | | | | | - Haifa Tyler
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | | | - Liliam Pineda-Salgado
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA
| | | | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Málaga, Spain
| | | | | | - Don C Rockey
- Medical University of South Carolina, Charleston, SC, USA
| | - Alvin Estilo
- Otsuka Pharmaceutical Development and Commercialization, Inc., 508 Carnegie Center Dr, Princeton, NJ, 08540, USA.
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ACG Clinical Guideline: Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury. Am J Gastroenterol 2021; 116:878-898. [PMID: 33929376 DOI: 10.14309/ajg.0000000000001259] [Citation(s) in RCA: 137] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/25/2021] [Indexed: 12/11/2022]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is common in gastroenterology and hepatology practices, and it can have multiple presentations, ranging from asymptomatic elevations in liver biochemistries to hepatocellular or cholestatic jaundice, liver failure, or chronic hepatitis. Antimicrobials, herbal and dietary supplements, and anticancer therapeutics (e.g., tyrosine kinase inhibitors or immune-checkpoint inhibitors) are the most common classes of agents to cause DILI in the Western world. DILI is a diagnosis of exclusion, and thus, careful assessment for other etiologies of liver disease should be undertaken before establishing a diagnosis of DILI. Model for end-stage liver disease score and comorbidity burden are important determinants of mortality in patients presenting with suspected DILI. DILI carries a mortality rate up to 10% when hepatocellular jaundice is present. Patients with DILI who develop progressive jaundice with or without coagulopathy should be referred to a tertiary care center for specialized care, including consideration for potential liver transplantation. The role of systemic corticosteroids is controversial, but they may be administered when a liver injury event cannot be distinguished between autoimmune hepatitis or DILI or when a DILI event presents with prominent autoimmune hepatitis features.
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Weersink RA, Alvarez-Alvarez I, Medina-Cáliz I, Sanabria-Cabrera J, Robles-Díaz M, Ortega-Alonso A, García-Cortés M, Bonilla E, Niu H, Soriano G, Jimenez-Perez M, Hallal H, Blanco S, Kaplowitz N, Lucena MI, Andrade RJ. Clinical Characteristics and Outcome of Drug-Induced Liver Injury in the Older Patients: From the Young-Old to the Oldest-Old. Clin Pharmacol Ther 2021; 109:1147-1158. [PMID: 33179256 DOI: 10.1002/cpt.2108] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 11/02/2020] [Indexed: 02/05/2023]
Abstract
Older patients with hepatotoxicity have been scarcely studied in idiosyncratic drug-induced liver injury (DILI) cohorts. We sought the distinctive characteristics of DILI in older patients across age groups. A total of 882 DILI patients included in the Spanish DILI Registry (33% ≥ 65 years) were categorized according to age: "young" (< 65 years); "young-old" (65-74 years); "middle-old" (75-84 years); and "oldest-old" (≥ 85 years). All elderly groups had an increasingly higher comorbidity burden (P < 0.001) and polypharmacy (P < 0.001). There was a relationship between jaundice and hospitalization (P < 0.001), and both were more prevalent in the older age groups, especially in the oldest-old (88% and 69%, respectively), and the DILI episode was more severe (P = 0.029). The proportion of females decreased across age groups from the young to the middle-old, yet in the oldest-old there was a distinct female predominance. Pattern of liver injury shifted towards cholestatic with increasing age among top culprit drugs amoxicillin-clavulanate, atorvastatin, levofloxacin, ibuprofen, and ticlopidine. The best cutoff point for increased odds of cholestatic DILI was 65 years. Older patients had increased non-liver-related mortality (P = 0.030) as shown by the predictive capacity of the Model for End-Stage Liver Disease score (odds ratio (OR) = 1.116; P < 0.001), and comorbidity burden (OR = 4.188; P = 0.001) in the 6-month mortality. Older patients with DILI exhibited an increasingly predominant cholestatic phenotype across a range of culprit drugs, other than amoxicillin-clavulanate, with increased non-liver-related mortality and require a different approach to predict outcome. The oldest DILI patients exhibited a particular phenotype with more severe DILI episodes and need to be considered when stratifying older DILI populations.
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Affiliation(s)
- Rianne A Weersink
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Department of Clinical Pharmacy, Deventer Hospital, Deventer, The Netherlands
| | - Ismael Alvarez-Alvarez
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Inmaculada Medina-Cáliz
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Judith Sanabria-Cabrera
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Platform for Clinical Research and Clinical Trials IBIMA, SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Mercedes Robles-Díaz
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
| | - Aida Ortega-Alonso
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Miren García-Cortés
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Elvira Bonilla
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - Hao Niu
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
| | - German Soriano
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio Aparato Digestivo, Hospital Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Hacibe Hallal
- Servicio Aparato Digestivo, Hospital General Universitario J.M. Morales Meseguer, Murcia, Spain
| | - Sonia Blanco
- Servicio de Aparato Digestivo, Hospital Universitario Basurto, Bilbao, Spain
| | - Neil Kaplowitz
- Keck School of Medicine, University of Southern California Research Center for Liver Diseases, Los Angeles, California, USA
| | - M Isabel Lucena
- Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Platform for Clinical Research and Clinical Trials IBIMA, SCReN (Spanish Clinical Research Network), Madrid, Spain
| | - Raúl J Andrade
- Biomedical Research Network Center for Hepatic and Digestive Diseases (CIBERehd), Carlos III Health Institute, Madrid, Spain
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga-IBIMA, Universidad de Málaga, Málaga, Spain
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Pedraza L, Laosa O, Rodríguez-Mañas L, Gutiérrez-Romero DF, Frías J, Carnicero JA, Ramírez E. Drug Induced Liver Injury in Geriatric Patients Detected by a Two-Hospital Prospective Pharmacovigilance Program: A Comprehensive Analysis Using the Roussel Uclaf Causality Assessment Method. Front Pharmacol 2021; 11:600255. [PMID: 33613279 PMCID: PMC7892439 DOI: 10.3389/fphar.2020.600255] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 11/11/2020] [Indexed: 01/10/2023] Open
Abstract
Background/aim: A prospective evaluation of drug-induced liver injury (DILI) in two tertiary hospitals was conducted through a pharmacovigilance program from laboratory signals at hospital (PPLSH) to determine the principal characteristics of DILI in patients older than 65 years, a growing age group worldwide, which is underrepresented in the literature on DILI. Methods: All DILI in patients older than 65 years detected by PPLSH in two hospitals were followed up for 8 years in the La Paz Hospital and 2 years in the Getafe Hospital. A descriptive analysis was conducted that determined the causality of DILI and suspected drugs, the incidence of DILI morbidities, DILI characteristics, laboratory patterns, evolution and outcomes. Results: 458 DILI cases in 441 patients were identified, 31.0% resulting in hospitalisation and 69.0% developing during hospitalisation. The mean age was 76.61 years old (SD, 7.9), and 54.4% were women. The DILI incidence was 76.33/10,000 admissions (95%CI 60.78–95.13). Polypharmacy (taking >4 drugs) was present in 86.84% of patients, 39.68% of whom took >10 drugs. The hepatocellular phenotype was the most frequent type of DILI (53.29%), a higher proportion (65%) had a mild severity index, and, in 55.2% of the evaluated drugs the RUCAM indicated that the causal relationship was highly probable. The most frequently employed drugs were paracetamol (50-cases), amoxicillin-clavulanate (42-cases) and atorvastatin (37-cases). The incidence rate of in-hospital DILI per 10,000 DDDs was highest for piperacillin-tazobactam (66.96/10,000 DDDs). A higher risk of in-hospital DILI was associated with the therapeutic chemical group-J (antiinfectives for systemic use) (OR, 2.65; 95%CI 1.58–4.46) and group-N (central nervous system drugs) (OR, 2.33; 95%CI 1.26–4.31). The patients taking >4 medications presented higher maximum creatinine level (OR, 2.01; 95%CI 1.28–3.15), and the patients taking >10 medications had a higher use of group J drugs (OR, 2.08; 95%IC 1.31–3.32). Conclusion: The incidence rate of DILI in the patients older than 65 years was higher than expected. DILI in elderly patients is mild, has a good outcome, has a hepatocellular pattern, develops during hospitalisation, and prolongs the hospital stay. Knowing the DILI incidence and explanatory factors will help improve the therapy of the elderly population.
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Affiliation(s)
- Laura Pedraza
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain
| | - Olga Laosa
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain.,Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain
| | - Leocadio Rodríguez-Mañas
- Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain.,Division of Geriatrics, University Hospital of Getafe, Getafe, Spain
| | | | - Jesús Frías
- Clinical Pharmacology departments, La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain
| | - José Antonio Carnicero
- Geriatric Research Group, Biomedical Research Foundation at Getafe University Hospital, Getafe, Spain.,Centre of Network Biomedical Research on Frailty and Healthy Ageing (CIBERFES), Institute of Health Carlos III., Madrid, Spain
| | - Elena Ramírez
- Clinical Pharmacology departments, La Paz University Hospital, IdiPAZ, School of Medicine, Autonomous University of Madrid, Madrid, Spain.,Clinical pharmacology department, University Hospital La Paz, La Paz, Spain
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Steiner-Temnykh L, Dakhoul L, Slaven J, Nephew L, Patidar KR, Orman E, Desai AP, Vilar-Gomez E, Kubal C, Ekser B, Chalasani N, Ghabril M. Comorbidity Burden May Be Associated with Increased Mortality in Patients with Severe Acute Liver Injury Referred for Liver Transplantation. Ann Transplant 2020; 25:e926453. [PMID: 33139688 PMCID: PMC7648405 DOI: 10.12659/aot.926453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Severe acute liver injury (S-ALI) can lead to acute liver and multisystem failure, with high mortality and need for liver transplantation (LT); however, the burden and impact of liver disease and comorbid conditions are unknown. MATERIAL AND METHODS We assessed liver disease and Charlson Comorbidity Index (CCI) in adults without cirrhosis evaluated for LT at our center for S-ALI between 2004 and 2017. The study endpoints were 30-day death or LT and 90-day mortality (with LT as a competing risk). RESULTS A total of 136 patients with S-ALI were included; 13% had underlying liver disease and a higher Model for End-stage Liver Disease score than those without liver disease. Sixty patients (41%) died or underwent LT within 30 days. They were older and more frequently female and had disease of autoimmune, viral, or indeterminate etiology. Transplant-free survival was associated with acetaminophen injury. The mean CCI was higher in patients with 30-day mortality or LT (1.5±2.4) vs. LT-free survivors (0.8±1.2), (P=0.03). Beyond severity of illness, CCI was associated with increased 90-day mortality (subhazard ratio 1.17, 95% confidence interval, 1.01-1.35) but not 30-day mortality or LT in the risk-adjusted analyses. CONCLUSIONS Comorbidity burden may be an important modifier of transplant-free survival in patients with S-ALI, but further studies are needed to validate these findings.
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Affiliation(s)
| | - Lara Dakhoul
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - James Slaven
- Departmental of Biostatistics, Indiana University, Indianapolis, IN, USA
| | - Lauren Nephew
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Kavish R Patidar
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Eric Orman
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Archita P Desai
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Eduardo Vilar-Gomez
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | | | - Burcin Ekser
- Departmental of Transplant Surgery, Indiana University, Indianapolis, IN, USA
| | - Naga Chalasani
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
| | - Marwan Ghabril
- Departmental of Gastroenterology and Hepatology, Indiana University, Indianapolis, IN, USA
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28
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Coppel S, Mathur K, Ekser B, Patidar KR, Orman E, Desai AP, Vilar-Gomez E, Kubal C, Chalasani N, Nephew L, Ghabril M. Extra-hepatic comorbidity burden significantly increases 90-day mortality in patients with cirrhosis and high model for endstage liver disease. BMC Gastroenterol 2020; 20:302. [PMID: 32938387 PMCID: PMC7493147 DOI: 10.1186/s12876-020-01448-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 09/11/2020] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND We examined how extra-hepatic comorbidity burden impacts mortality in patients with cirrhosis referred for liver transplantation (LT). METHODS Adults with cirrhosis evaluated for their first LT in 2012 were followed through their clinical course with last follow up in 2019. Extra-hepatic comorbidity burden was measured using the Charlson Comorbidity Index (CCI). The endpoints were 90-day transplant free survival (Cox-Proportional Hazard regression), and overall mortality (competing risk analysis). RESULTS The study included 340 patients, mean age 56 ± 11, 63% male and MELD-Na 17.2 ± 6.6. The CCI was 0 (no comorbidities) in 44%, 1-2 in 44% and > 2 (highest decile) in 12%, with no differences based on gender but higher CCI in patients with fatty and cryptogenic liver disease. Thirty-three (10%) of 332 patients not receiving LT within 90 days died. Beyond MELD-Na, the CCI was independently associated with 90-day mortality (hazard ratio (HR), 1.32 (95% confidence interval (CI) 1.02-1.72). Ninety-day mortality was specifically increased with higher CCI category and MELD ≥18 (12% (CCI = 0), 22% (CCI = 1-2) and 33% (CCI > 2), (p = 0.002)) but not MELD-Na ≤17. At last follow-up, 69 patients were alive, 100 underwent LT and 171 died without LT. CCI was associated with increased overall mortality in the competing risk analysis (Sub-HR 1.24, 95%CI 1.1-1.4). CONCLUSIONS Extra-hepatic comorbidity burden significantly impacts short-term mortality in patients with cirrhosis and high MELD-Na. This has implications in determining urgency of LT and mortality models in cirrhosis and LT waitlisting, especially with an ageing population with increasing prevalence of fatty liver disease.
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Affiliation(s)
- Scott Coppel
- Medicine, Indiana University, Indianapolis, IN, USA
| | - Karan Mathur
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Burcin Ekser
- Transplant Surgery, Indiana University, Indianapolis, IN, USA
| | - Kavish R Patidar
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Eric Orman
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Archita P Desai
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Eduardo Vilar-Gomez
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | | | - Naga Chalasani
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Lauren Nephew
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA
| | - Marwan Ghabril
- Gastroenterology and Hepatology, Indiana University, 702 Rotary Circle, suite 225, Indianapolis, IN, 46202, USA.
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29
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Lucena MI, Sanabria J, García-Cortes M, Stephens C, Andrade RJ. Drug-induced liver injury in older people. Lancet Gastroenterol Hepatol 2020; 5:862-874. [DOI: 10.1016/s2468-1253(20)30006-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 01/08/2020] [Accepted: 01/08/2020] [Indexed: 12/12/2022]
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Abstract
Drug induced liver injury (DILI) is a relatively rare hepatic condition in response to the use of medications, illegal drugs, herbal products or dietary supplements. It occurs in susceptible individuals through a combination of genetic and environmental risk factors believed to modify drug metabolism and/or excretion leading to a cascade of cellular events, including oxidative stress formation, apoptosis/necrosis, haptenization, immune response activation and a failure to adapt. The resultant liver damage can present with an array of phenotypes, which mimic almost every other liver disorder, and varies in severity from asymptomatic elevation of liver tests to fulminant hepatic failure. Despite recent research efforts specific biomarkers are not still available for routine use in clinical practice, which makes the diagnosis of DILI uncertain and relying on a high degree of awareness of this condition and the exclusion of other causes of liver disease. Diagnostic scales such as the CIOMS/RUCAM can support the causality assessment of a DILI suspicion, but need refinement as some criteria are not evidence-based. Prospective collection of well-vetted DILI cases in established DILI registries has allowed the identification and validation of a number of clinical variables, and to predict a more severe DILI outcome. DILI is also in need of properly designed clinical trials to evaluate the efficacy of new DILI treatments as well as older drugs such as ursodeoxycholic acid traditionally used to ameliorate cholestasis or corticosteroids now widely tried in the oncology field to manage the emergent type of hepatotoxicity related to immune checkpoint inhibitors.
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Ghabril M, Gu J, Yoder L, Corbito L, Dakhoul L, Ringel A, Beyer CD, Vuppalanchi R, Barnhart H, Hayashi PH, Chalasani N. Significant Medical Comorbidities Are Associated With Lower Causality Scores in Patients Presenting With Suspected Drug-Induced Liver Injury. Clin Transl Gastroenterol 2020; 11:e00141. [PMID: 32251016 PMCID: PMC7263658 DOI: 10.14309/ctg.0000000000000141] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 01/27/2020] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Drug-induced liver injury (DILI) is a diagnosis of exclusion, and it can be challenging to adjudicate when there are multiple comorbidities and concomitant medications. In this study, we tested the hypothesis that comorbidity burden impacts the causality adjudication in patients with suspected DILI. METHODS We studied consecutive patients with suspected DILI enrolled in the Drug-Induced Liver Injury Network Prospective Study at 2 centers between 2003 and 2017. The comorbidity burden at presentation was determined using the Charlson Comorbidity Index (CCI). We analyzed the association between significant comorbidity (CCI > 75th percentile) and (i) the adjudication of DILI by expert consensus as definite, highly likely, or probable (high-confidence DILI) and (ii) the Roussel Uclaf Causality Assessment Method (RUCAM) scores. RESULTS Our cohort consisted of 551 patients who were classified as "no comorbidity" (54%, CCI = 0), "mild comorbidity" (29%, CCI = 1 or 2), and "significant comorbidity" (17%, CCI > 2). The probability of high-confidence DILI was significantly lower in patients with significant comorbidity compared with those with mild or no comorbidities (67% vs 76% vs 87%, respectively, P < 0.001). The mean RUCAM scores decreased with increasing comorbidity (no comorbidity 6.6 ± 2, mild comorbidity 6 ± 2.4, and significant comorbidity 5.6 ± 2.7, P < 0.001). In the multiple logistic regression, significant comorbidity had an independent inverse relationship with DILI (odds ratio: 0.37, 95% confidence interval: 0.2-0.69, P = 0.001). DISCUSSION Higher comorbidity burden impacts the causality assessment in patients with suspected DILI. Further studies are needed to investigate the utility of comorbidity burden as a variable in the DILI causality instruments.
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Affiliation(s)
- Marwan Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Jiezhun Gu
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Lindsay Yoder
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Laura Corbito
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Lara Dakhoul
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Amit Ringel
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Christian D. Beyer
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
| | - Raj Vuppalanchi
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Huiman Barnhart
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Paul H. Hayashi
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Naga Chalasani
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
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