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Li Y, Deng X, Hu Q, Chen Y, Zhang W, Qin X, Wei F, Lu X, Ma X, Zeng J, Efferth T. Paeonia lactiflora Pall. ameliorates acetaminophen-induced oxidative stress and apoptosis via inhibiting the PKC-ERK pathway. JOURNAL OF ETHNOPHARMACOLOGY 2024; 329:118107. [PMID: 38599475 DOI: 10.1016/j.jep.2024.118107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/14/2024] [Accepted: 03/23/2024] [Indexed: 04/12/2024]
Abstract
ETHNOPHARMACOLOGICAL RELEVANCE Paeonia lactiflora Pall. (PLP), a traditional Chinese medicine, is recognized for its antioxidative and anti-apoptotic properties. Despite its potential medicinal value, the mechanisms underlying its efficacy have been less explored, particularly in alleviating acute liver injury (ALI) caused by excessive intake of acetaminophen (APAP). AIM OF THE STUDY This study aims to elucidate the role and mechanisms of PLP in mitigating oxidative stress and apoptosis induced by APAP. MATERIALS AND METHODS C57BL/6 male mice were pre-treated with PLP for seven consecutive days, followed by the induction of ALI using APAP. Liver pathology was assessed using HE staining. Serum indicators, immunofluorescence (IF), immunohistochemical (IHC), and transmission electron microscopy were employed to evaluate levels of oxidative stress, ferroptosis and apoptosis. Differential expression proteins (DEPs) in the APAP-treated and PLP pre-treated groups were analyzed using quantitative proteomics. Subsequently, the potential mechanisms of PLP pre-treatment in treating ALI were validated using western blotting, molecular docking, molecular dynamics simulations, and surface plasmon resonance (SPR) analysis. RESULTS The UHPLC assay confirmed the presence of three compounds, i.e., albiflorin, paeoniflorin, and oxypaeoniflorin. Pre-treatment with PLP was observed to ameliorate liver tissue pathological damage through HE staining. Further confirmation of efficacy of PLP in alleviating APAP-induced liver injury and oxidative stress was established through liver function serum biochemical indicators, IF of reactive oxygen species (ROS) and IHC of glutathione peroxidase 4 (GPX4) detection. However, PLP did not demonstrate a significant effect in alleviating APAP-induced ferroptosis. Additionally, transmission electron microscopy and TUNEL staining indicated that PLP can mitigate hepatocyte apoptosis. PKC-ERK pathway was identified by proteomics, and subsequent molecular docking, molecular dynamics simulations, and SPR verified binding of the major components of PLP to ERK protein. Western blotting demonstrated that PLP suppressed protein kinase C (PKC) phosphorylation, blocking extracellular signal-regulated kinase (ERK) phosphorylation and inhibiting oxidative stress and cell apoptosis. CONCLUSION This study demonstrates that PLP possesses hepatoprotective abilities against APAP-induced ALI, primarily by inhibiting the PKC-ERK cascade to suppress oxidative stress and cell apoptosis.
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Affiliation(s)
- Yubing Li
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Xinyu Deng
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Qichao Hu
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Yuan Chen
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Wenwen Zhang
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Xuhua Qin
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Feng Wei
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Xiaohua Lu
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, Mainz, Germany.
| | - Xiao Ma
- State Key Laboratory of Southwestern Chinese Medicine Resources, School of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Jinhao Zeng
- TCM Regulating Metabolic Diseases Key Laboratory of Sichuan Province, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China.
| | - Thomas Efferth
- Department of Pharmaceutical Biology, Institute of Pharmaceutical and Biomedical Sciences, Johannes Gutenberg University, Mainz, Germany.
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Orban C, Agapie M, Bratu A, Jafal M, Duțu M, Popescu M. No Significant Beneficial Effects of Intravenous N-Acetylcysteine on Patient Outcome in Non-Paracetamol Acute Liver Failure: A Meta-Analysis of Randomized Controlled Trials. Biomedicines 2024; 12:1462. [PMID: 39062036 PMCID: PMC11274394 DOI: 10.3390/biomedicines12071462] [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: 05/06/2024] [Revised: 06/22/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
Acute liver failure is a life-threatening organ dysfunction with systemic organ involvement and is associated with significant mortality and morbidity unless specific management is undertaken. This meta-analysis aimed to assess the effects of intravenous N-acetylcysteine (NAC) on mortality and the length of hospital stay in patients with non-acetaminophen acute liver failure. Two hundred sixty-six studies from four databases were screened, and four randomized control trials were included in the final analysis. Our results could not demonstrate increased overall survival (OR 0.70, 95% CI [0.34, 1.44], p = 0.33) or transplant-free survival (OR 0.90, 95% CI [0.25, 3.28], p = 0.87) in patients treated with intravenous NAC. We observed an increased overall survival in adult patients treated with NAC (OR 0.59, 95% CI [0.35, 0.99], p = 0.05) compared to pediatric patients, but whether this is attributed to the age group or higher intravenous dose administered remains unclear. We did not observe a decreased length of stay in NAC-treated patients (OR -5.70, 95% CI [-12.44, 1.05], p = 0.10). In conclusion, our meta-analysis could not demonstrate any significant benefits on overall and transplant-free patient survival in non-acetaminophen ALF. Future research should also focus on specific etiologies of ALF that may benefit most from the use of NAC.
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Affiliation(s)
- Carmen Orban
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mihaela Agapie
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Angelica Bratu
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mugurel Jafal
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mădălina Duțu
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesiology and Intensive Care, “Dr. Carol Davila” University Emergency Central Military Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Mihai Popescu
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
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Kim J, Gao C, Guo P, Sheng J, Wang J. A novel approach to alleviate acetaminophen-induced hepatotoxicity with hybrid balloon flower root-derived exosome-like nanoparticles (BDEs) with silymarin via inhibition of hepatocyte MAPK pathway and apoptosis. Cell Commun Signal 2024; 22:334. [PMID: 38890646 PMCID: PMC11184736 DOI: 10.1186/s12964-024-01700-z] [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: 03/08/2024] [Accepted: 06/05/2024] [Indexed: 06/20/2024] Open
Abstract
INTRODUCTION Balloon flower root-derived exosome-like nanoparticles (BDEs) have recently been proposed as physiologically active molecules with no cytotoxicity. However, the therapeutic effects of drug-induced hepatotoxicity of BDEs have not been elucidated. BDEs contain a large amount of platycodin D, which is widely known to be effective in regulating inflammation and ameliorating systemic toxicity. Thus, the main therapeutic activity of BDEs is attributed to inhibiting the inflammatory response and alleviating toxicity. In this study, we fabricated the hybrid BDEs fused with liposomes containing silymarin (SM) to enhance the synergistic effect on inhibition of acetaminophen-induced hepatotoxicity (APAP). OBJECTIVE Considering the potential therapeutic effects of BDEs, and the potential to achieve synergistic effects to improve therapeutic outcomes, we constructed hybrid BDEs with a soy lecithin-based liposome loaded with SM. Since liposomes can provide higher thermal stability and have greater structural integrity, these might be more resistant to clearance and enzymatic degradation of drug molecules. METHODS Hybrid BDEs with liposome-loaded SM (BDEs@lipo-SM) were fabricated by thin-film hydration and extrusion. BDEs@lipo-SM were characterized using dynamic light scattering and high-performance liquid chromatography. After confirmation of the physical properties of BDEs@lipo-SM, various therapeutic properties were evaluated. RESULTS BDEs@lipo-SM were internalized by hepatocytes and immune cells and significantly decreased mRNA expression of apoptosis and inflammation-relevant cytokines by inhibiting the hepatocyte MAPK pathway. BDEs@lipo-SM significantly induced an increase in glutathione levels and inhibited APAP-induced hepatotoxicity. CONCLUSION From this study, we know that BDEs are reliable and safe nanovesicles containing natural metabolites derived from balloon flower, and they can facilitate intercellular communication. BDEs are also easily modified to enhance drug loading capacity, targeting effects, and long-term accumulation in vivo. BDEs@lipo-SM have therapeutic benefits for acute liver injury and can alleviate cell death and toxicity. They can be efficiently delivered to the liver and effectively inhibit APAP-induced hepatotoxicity by inhibiting the MAPK signaling pathway and apoptosis, which accelerates liver recovery in the APAP-induced acute liver injury model. These findings highlight that BDEs represent an attractive delivery vehicle for drug delivery.
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Affiliation(s)
- Jisu Kim
- Department of Pharmaceutics, School of Pharmacy, Fudan University and Key Laboratory of Smart Drug Delivery, Ministry of Education, Shanghai, 201203, People's Republic of China
| | - Chao Gao
- Science and Technology Innovation Center, Guangzhou University of Chinese Medicine, Guangzhou, 510405, China
| | - Pengcheng Guo
- Department of Pharmaceutics, School of Pharmacy, Fudan University and Key Laboratory of Smart Drug Delivery, Ministry of Education, Shanghai, 201203, People's Republic of China
| | - Jianyong Sheng
- Department of Pharmaceutics, School of Pharmacy, Fudan University and Key Laboratory of Smart Drug Delivery, Ministry of Education, Shanghai, 201203, People's Republic of China
| | - Jianxin Wang
- Department of Pharmaceutics, School of Pharmacy, Fudan University and Key Laboratory of Smart Drug Delivery, Ministry of Education, Shanghai, 201203, People's Republic of China.
- Institutes of Integrative Medicine, Fudan University, Shanghai, 201203, People's Republic of China.
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Ouyang S, Zhu J, Cao Q, Liu J, Zhang Z, Zhang Y, Wu J, Sun S, Fu J, Chen Y, Tong J, Liu Y, Zhang J, Shen F, Li D, Wang P. Gasdermin-E-Dependent Non-Canonical Pyroptosis Promotes Drug-Induced Liver Failure by Promoting CPS1 deISGylation and Degradation. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2024; 11:e2305715. [PMID: 38417117 PMCID: PMC11040357 DOI: 10.1002/advs.202305715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Revised: 12/22/2023] [Indexed: 03/01/2024]
Abstract
Drug-induced liver injury (DILI) is a significant global health issue that poses high mortality and morbidity risks. One commonly observed cause of DILI is acetaminophen (APAP) overdose. GSDME is an effector protein that induces non-canonical pyroptosis. In this study, the activation of GSDME, but not GSDMD, in the liver tissue of mice and patients with APAP-DILI is reported. Knockout of GSDME, rather than GSDMD, in mice protected them from APAP-DILI. Mice with hepatocyte-specific rescue of GSDME reproduced APAP-induced liver injury. Furthermore, alterations in the immune cell pools observed in APAP-induced DILI, such as the replacement of TIM4+ resident Kupffer cells (KCs) by monocyte-derived KCs, Ly6C+ monocyte infiltration, MerTk+ macrophages depletion, and neutrophil increase, reappeared in mice with hepatocyte-specific rescue of GSDME. Mechanistically, APAP exposure led to a substantial loss of interferon-stimulated gene 15 (ISG15), resulting in deISGylation of carbamoyl phosphate synthetase-1 (CPS1), promoted its degradation via K48-linked ubiquitination, causing ammonia clearance dysfunction. GSDME deletion prevented these effects. Delayed administration of dimethyl-fumarate inhibited GSDME cleavage and alleviated ammonia accumulation, mitigating liver injury. This findings demonstrated a previously uncharacterized role of GSDME in APAP-DILI by promoting pyroptosis and CPS1 deISGylation, suggesting that inhibiting GSDME can be a promising therapeutic option for APAP-DILI.
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Affiliation(s)
- Shen‐Xi Ouyang
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Jia‐Hui Zhu
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Qi Cao
- The Center for Basic Research and Innovation of Medicine and Pharmacy (MOE), Department of PharmacologySchool of PharmacyNaval Medical University/Second Military Medical UniversityShanghai200433China
- Shanghai Key Laboratory for Pharmaceutical Metabolite ResearchNaval Medical University/Second Military Medical UniversityShanghai200433China
- National Demonstration Center for Experimental Pharmaceutical EducationNaval Medical University/Second Military Medical UniversityShanghai200433China
| | - Jian Liu
- Department of Hepatic SurgeryThe Eastern Hepatobiliary Surgery HospitalNaval Medical University/Second Military Medical UniversityShanghai200438China
| | - Zhen Zhang
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Yan Zhang
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Jing‐Wen Wu
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Si‐Jia Sun
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Jiang‐Tao Fu
- The Center for Basic Research and Innovation of Medicine and Pharmacy (MOE), Department of PharmacologySchool of PharmacyNaval Medical University/Second Military Medical UniversityShanghai200433China
- Shanghai Key Laboratory for Pharmaceutical Metabolite ResearchNaval Medical University/Second Military Medical UniversityShanghai200433China
- National Demonstration Center for Experimental Pharmaceutical EducationNaval Medical University/Second Military Medical UniversityShanghai200433China
| | - Yi‐Ting Chen
- The Center for Basic Research and Innovation of Medicine and Pharmacy (MOE), Department of PharmacologySchool of PharmacyNaval Medical University/Second Military Medical UniversityShanghai200433China
- Shanghai Key Laboratory for Pharmaceutical Metabolite ResearchNaval Medical University/Second Military Medical UniversityShanghai200433China
- National Demonstration Center for Experimental Pharmaceutical EducationNaval Medical University/Second Military Medical UniversityShanghai200433China
| | - Jie Tong
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Yi Liu
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Jia‐Bao Zhang
- The Center for Basic Research and Innovation of Medicine and Pharmacy (MOE), Department of PharmacologySchool of PharmacyNaval Medical University/Second Military Medical UniversityShanghai200433China
- Shanghai Key Laboratory for Pharmaceutical Metabolite ResearchNaval Medical University/Second Military Medical UniversityShanghai200433China
- National Demonstration Center for Experimental Pharmaceutical EducationNaval Medical University/Second Military Medical UniversityShanghai200433China
| | - Fu‐Ming Shen
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Dong‐Jie Li
- Department of PharmacyShanghai Tenth People's HospitalSchool of MedicineTongji UniversityShanghai200092China
| | - Pei Wang
- The Center for Basic Research and Innovation of Medicine and Pharmacy (MOE), Department of PharmacologySchool of PharmacyNaval Medical University/Second Military Medical UniversityShanghai200433China
- Shanghai Key Laboratory for Pharmaceutical Metabolite ResearchNaval Medical University/Second Military Medical UniversityShanghai200433China
- National Demonstration Center for Experimental Pharmaceutical EducationNaval Medical University/Second Military Medical UniversityShanghai200433China
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Popescu M, Bratu A, Agapie M, Borjog T, Jafal M, Sima RM, Orban C. The Use and Potential Benefits of N-Acetylcysteine in Non-Acetaminophen Acute Liver Failure: An Etiology-Based Review. Biomedicines 2024; 12:676. [PMID: 38540289 PMCID: PMC10967777 DOI: 10.3390/biomedicines12030676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Revised: 03/04/2024] [Accepted: 03/15/2024] [Indexed: 08/13/2024] Open
Abstract
Acute liver failure represents a life-threatening organ dysfunction with high mortality rates and an urgent need for liver transplantation. The etiology of the disease varies widely depending on various socio-economic factors and is represented mainly by paracetamol overdose and other drug-induced forms of liver dysfunction in the developed world and by viral hepatitis and mushroom poisoning in less developed countries. Current medical care constitutes either specific antidotes or supportive measures to ensure spontaneous recovery. Although it has been proven to have beneficial effects in paracetamol-induced liver failure, N-acetylcysteine is widely used for all forms of acute liver failure. Despite this, few well-designed studies have been conducted on the assessment of the potential benefits, dose regimens, or route of administration of N-acetylcysteine in non-acetaminophen liver failure. This review aims to summarize the current evidence behind the use of this drug in different forms of liver failure.
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Affiliation(s)
- Mihai Popescu
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Angelica Bratu
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mihaela Agapie
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Tudor Borjog
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mugurel Jafal
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Romina-Marina Sima
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania;
| | - Carmen Orban
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
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Yiew NKH, Vazquez JH, Martino MR, Kennon-McGill S, Price JR, Allard FD, Yee EU, Layman AJ, James LP, McCommis KS, Finck BN, McGill MR. Hepatic pyruvate and alanine metabolism are critical and complementary for maintenance of antioxidant capacity and resistance to oxidative insult. Mol Metab 2023; 77:101808. [PMID: 37716594 PMCID: PMC10561123 DOI: 10.1016/j.molmet.2023.101808] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 08/16/2023] [Accepted: 09/12/2023] [Indexed: 09/18/2023] Open
Abstract
OBJECTIVE Mitochondrial pyruvate is a critical intermediary metabolite in gluconeogenesis, lipogenesis, and NADH production. As a result, the mitochondrial pyruvate carrier (MPC) complex has emerged as a promising therapeutic target in metabolic diseases. Clinical trials are currently underway. However, recent in vitro data indicate that MPC inhibition diverts glutamine/glutamate away from glutathione synthesis and toward glutaminolysis to compensate for loss of pyruvate oxidation, possibly sensitizing cells to oxidative insult. Here, we explored this in vivo using the clinically relevant acetaminophen (APAP) overdose model of acute liver injury, which is driven by oxidative stress. METHODS We used pharmacological and genetic approaches to inhibit MPC2 and alanine aminotransferase 2 (ALT2), individually and concomitantly, in mice and cell culture models and determined the effects on APAP hepatotoxicity. RESULTS We found that MPC inhibition sensitizes the liver to APAP-induced injury in vivo only with concomitant loss of alanine aminotransferase 2 (ALT2). Pharmacological and genetic manipulation of neither MPC2 nor ALT2 alone affected APAP toxicity, but liver-specific double knockout (DKO) significantly worsened APAP-induced liver damage. Further investigation indicated that DKO impaired glutathione synthesis and increased urea cycle flux, consistent with increased glutaminolysis, and these results were reproducible in vitro. Finally, induction of ALT2 and post-treatment with dichloroacetate both reduced APAP-induced liver injury, suggesting new therapeutic avenues. CONCLUSIONS Increased susceptibility to APAP toxicity requires loss of both the MPC and ALT2 in vivo, indicating that MPC inhibition alone is insufficient to disrupt redox balance. Furthermore, the results from ALT2 induction and dichloroacetate in the APAP model suggest new metabolic approaches to the treatment of liver damage.
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Affiliation(s)
- Nicole K H Yiew
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Joel H Vazquez
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael R Martino
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stefanie Kennon-McGill
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jake R Price
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Felicia D Allard
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Eric U Yee
- Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Alexander J Layman
- Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Laura P James
- Department of Pediatrics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kyle S McCommis
- Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Brian N Finck
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mitchell R McGill
- Department of Pharmacology and Toxicology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, 72205, USA; Department of Environmental Health Sciences, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Pathology, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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7
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Hassan GS, Flores Molina M, Shoukry NH. The multifaceted role of macrophages during acute liver injury. Front Immunol 2023; 14:1237042. [PMID: 37736102 PMCID: PMC10510203 DOI: 10.3389/fimmu.2023.1237042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/15/2023] [Indexed: 09/23/2023] Open
Abstract
The liver is situated at the interface of the gut and circulation where it acts as a filter for blood-borne and gut-derived microbes and biological molecules, promoting tolerance of non-invasive antigens while driving immune responses against pathogenic ones. Liver resident immune cells such as Kupffer cells (KCs), a subset of macrophages, maintain homeostasis under physiological conditions. However, upon liver injury, these cells and others recruited from circulation participate in the response to injury and the repair of tissue damage. Such response is thus spatially and temporally regulated and implicates interconnected cells of immune and non-immune nature. This review will describe the hepatic immune environment during acute liver injury and the subsequent wound healing process. In its early stages, the wound healing immune response involves a necroinflammatory process characterized by partial depletion of resident KCs and lymphocytes and a significant infiltration of myeloid cells including monocyte-derived macrophages (MoMFs) complemented by a wave of pro-inflammatory mediators. The subsequent repair stage includes restoring KCs, initiating angiogenesis, renewing extracellular matrix and enhancing proliferation/activation of resident parenchymal and mesenchymal cells. This review will focus on the multifaceted role of hepatic macrophages, including KCs and MoMFs, and their spatial distribution and roles during acute liver injury.
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Affiliation(s)
- Ghada S. Hassan
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
| | - Manuel Flores Molina
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département de microbiologie, infectiologie et immunologie, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
| | - Naglaa H. Shoukry
- Centre de Recherche du Centre hospitalier de l’Université de Montréal (CRCHUM), Montréal, QC, Canada
- Département de médecine, Faculté de médecine, Université de Montréal, Montréal, QC, Canada
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Sharieff S, Idrees A, Rafai W, Bukhari SUS. Use of Oral N-Acetylcysteine (NAC) in Non-Acetaminophen-Induced Acute Hepatic Failure. Cureus 2023; 15:e35852. [PMID: 37033589 PMCID: PMC10077496 DOI: 10.7759/cureus.35852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a syndrome rather than a specific disease with several possible causes, and viral hepatitis is a major cause. The objective of the study was to assess the benefit of N-acetylcysteine (NAC) in non-acetaminophen-induced acute liver failure (NAI-ALF). METHODS A total of six patients with a diagnosis of acute liver failure (ALF) were included in the study. All six patients received oral NAC for 72 hrs. The parameters evaluated were demographic, clinical, biochemical, outcome, and length of ICU and hospital stay. The primary outcome was a reduction in mortality with the use of NAC in NAI-ALF. The secondary outcomes were to evaluate the safety of NAC and assess factors predicting mortality. RESULTS All patients improved and returned to normal or near-normal liver function with the use of NAC. No side effects were noted, and the use of NAC was associated with a shorter hospital stay. CONCLUSION In patients with non-acetaminophen-related acute liver failure, N-acetyl-L-cysteine (NAC) significantly improves overall survival and also decreases the length of hospital stay.
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Treatment of Drug-Induced Liver Injury. Biomedicines 2022; 11:biomedicines11010015. [PMID: 36672522 PMCID: PMC9855719 DOI: 10.3390/biomedicines11010015] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/28/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Current pharmacotherapy options of drug-induced liver injury (DILI) remain under discussion and are now evaluated in this analysis. Needless to say, the use of the offending drug must be stopped as soon as DILI is suspected. Normal dosed drugs may cause idiosyncratic DILI, and drugs taken in overdose commonly lead to intrinsic DILI. Empirically used but not substantiated regarding efficiency by randomized controlled trials (RCTs) is the intravenous antidote treatment with N-acetylcysteine (NAC) in patients with intrinsic DILI by N-acetyl-p-aminophenol (APAP) overdose. Good data recommending pharmacotherapy in idiosyncratic DILI caused by hundreds of different drugs are lacking. Indeed, a recent analysis revealed that just eight RCTs have been published, and in only two out of eight trials were DILI cases evaluated for causality by the worldwide used Roussel Uclaf Causality Assessment Method (RUCAM), representing overall a significant methodology flaw, as results of DILI RCTs lacking RUCAM are misleading since many DILI cases are known to be attributable erroneously to nondrug alternative causes. In line with these major shortcomings and mostly based on anecdotal reports, glucocorticoids (GCs) and other immuno-suppressants may be given empirically in carefully selected patients with idiosyncratic DILI exhibiting autoimmune features or caused by immune checkpoint inhibitors (ICIs), while some patients with cholestatic DILI may benefit from ursodeoxycholic acid use; in other patients with drug-induced hepatic sinusoidal obstruction syndrome (HSOS) and coagulopathy risks, the indication for anticoagulants should be considered. In view of many other mechanistic factors such as the hepatic microsomal cytochrome P450 with a generation of reactive oxygen species (ROS), ferroptosis with toxicity of intracellular iron, and modification of the gut microbiome, additional therapy options may be available in the future. In summation, stopping the offending drug is still the first line of therapy for most instances of acute DILI, while various therapies are applied empirically and not based on good data from RCTs awaiting further trials using the updated RUCAM that asks for strict exclusion and inclusion details like liver injury criteria and provides valid causality rankings of probable and highly probable grades.
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10
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Hepatic ROS Mediated Macrophage Activation Is Responsible for Irinotecan Induced Liver Injury. Cells 2022; 11:cells11233791. [PMID: 36497051 PMCID: PMC9739808 DOI: 10.3390/cells11233791] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Irinotecan is the first line chemotherapy drug used for treatment of metastatic colorectal cancer worldwide. There is increasing evidence suggesting that liver damage, including steatosis and steatohepatitis, can be caused during the treatment involving irinotecan. However, molecular mechanisms by which irinotecan-induced liver injury remain elusive. In this study, we found that irinotecan treatment caused significant elevation of ALT, inflammation, and fat accumulation in the liver, which are associated with hepatic macrophage activation. Depletion of macrophages by clodronate liposome improved irinotecan induced liver injury and inflammatory response in mice. In vitro data indicated that irinotecan induced intracellular ROS production in primary hepatocyte and upregulating of toll-like receptor (TLRs) family expression in macrophages. Supernatant from irinotecan treated hepatocyte triggered macrophage activation and upregulation of TLRs in macrophage, and N-acetylcysteine (NAC) abolished these effects. By using co-culture system, we further revealed that irinotecan activated macrophage induced impairment of lipid metabolism and promoted apoptosis in hepatocyte and NAC prevented macrophage-induced cell death and partially revered impaired lipid metabolism in hepatocytes. By using the irinotecan liver injury model, we demonstrated that combining NAC with irinotecan prevented irinotecan-induced macrophage activation, TLR upregulation, liver injury, and partially prevented the accumulation of triglycerides in liver. Our results thus indicated that macrophages play a critical role in irinotecan-induced liver injury, and targeting ROS provides new options for development of hepatoprotective drugs in clinical practice.
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11
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Niazi B, Ahmed K, Ahmed M, Ali S, Song K, Elias S. Drug-Induced Liver Injury from Herbal Liver Detoxification Tea. Case Rep Gastroenterol 2022; 16:612-617. [PMID: 36636365 PMCID: PMC9830300 DOI: 10.1159/000526311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/26/2022] [Indexed: 11/11/2022] Open
Abstract
The increasing consumption of unregulated herbal and dietary supplements has presented clinicians with new challenges in assessing and managing acute liver injury. Patients may present in various ways ranging from asymptomatic transaminitis to acute liver failure. Several natural products have been found to mitigate drug-induced liver injury, which has led to the creation of numerous registries to outline all its aspects further. We describe the case of a 36-year-old female who developed a clinically significant acute liver injury with a cholestatic pattern due to an over-the-counter herbal liver detox tea. This is the first case reported of a hepatotoxic effect from any of these compounds or ingredients in the detox tea: burdock root, stinging nettle leaf, cleavers herb, dandelion root, lemon peel, and lemon myrtle leaf (Backhousia citriodora). Idiosyncratic drug-induced liver injury (DILI) remains poorly understood; however, recognizing potential toxins is imperative to understanding toxicogenomics and identifying those at risk.
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Affiliation(s)
- Bilal Niazi
- Department of Internal Medicine, HMH-Palisades Medical Center, North Bergen, New Jersey, USA,*Bilal Niazi,
| | - Kareem Ahmed
- Department of Internal Medicine, University of Washington, Seattle, Washington, USA
| | - Mohamed Ahmed
- Department of Internal Medicine, HMH-Palisades Medical Center, North Bergen, New Jersey, USA
| | - Saad Ali
- Department of Gastroenterology, HMH-Palisades Medical Center, North Bergen, New Jersey, USA
| | - Kunchang Song
- Department of Pathology, HMH-Palisades Medical Center, North Bergen, New Jersey, USA
| | - Sameh Elias
- Department of Internal Medicine, HMH-Palisades Medical Center, North Bergen, New Jersey, USA
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12
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Hassanein EHM, Mohamed WR, Ahmed OS, Abdel-Daim MM, Sayed AM. The role of inflammation in cadmium nephrotoxicity: NF-κB comes into view. Life Sci 2022; 308:120971. [PMID: 36130617 DOI: 10.1016/j.lfs.2022.120971] [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: 07/30/2022] [Revised: 09/06/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022]
Abstract
Kidney diseases are major health problem and understanding the underlined mechanisms that lead to kidney diseases are critical research points with a marked potential impact on health. Cadmium (Cd) is a heavy metal that occurs naturally and can be found in contaminated food. Kidneys are the most susceptible organ to heavy metal intoxication as it is the main route of waste excretion. The harmful effects of Cd were previously well proved. Cd induces inflammatory responses, oxidative injury, mitochondrial dysfunction and disturbs Ca2+ homeostasis. The nuclear factor-kappa B (NF-κB) is a cellular transcription factor that regulates inflammation and controls the expression of many inflammatory cytokines. Therefore, great therapeutic benefits can be attained from NF-κB inhibition. In this review we focused on certain compounds including cytochalasin D, mangiferin, N-acetylcysteine, pyrrolidine dithiocarbamate, roflumilast, rosmarinic acid, sildenafil, sinapic acid, telmisartan and wogonin and certain plants as Astragalus Polysaccharide, Ginkgo Biloba and Thymus serrulatus that potently inhibit NF-κB and effectively counteracted Cd-associated renal intoxication. In conclusion, the proposed NF-κB involvement in Cd-renal intoxication clarified the underlined inflammation associated with Cd-nephropathy and the beneficial effects of NF-κB inhibitors that make them the potential to substantially optimize treatment protocols for Cd-renal intoxication.
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Affiliation(s)
- Emad H M Hassanein
- Department of Pharmacology & Toxicology, Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Wafaa R Mohamed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Beni-Suef University, Beni-Suef 62514, Egypt
| | - Osama S Ahmed
- Faculty of Pharmacy, Al-Azhar University, Assiut Branch, Assiut 71524, Egypt
| | - Mohamed M Abdel-Daim
- Department of Pharmaceutical Sciences, Pharmacy Program, Batterjee Medical College, P.O. Box 6231, Jeddah 21442, Saudi Arabia; Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, 41522 Ismailia, Egypt
| | - Ahmed M Sayed
- Biochemistry Laboratory, Chemistry Department, Faculty of Science, Assiut University, Egypt.
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13
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Licata A, Minissale MG, Stankevičiūtė S, Sanabria-Cabrera J, Lucena MI, Andrade RJ, Almasio PL. N-Acetylcysteine for Preventing Acetaminophen-Induced Liver Injury: A Comprehensive Review. Front Pharmacol 2022; 13:828565. [PMID: 36034775 PMCID: PMC9399785 DOI: 10.3389/fphar.2022.828565] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 06/03/2022] [Indexed: 12/28/2022] Open
Abstract
Aims: N-Acetylcysteine (NAC) is used as an antidote in acetaminophen (APAP) overdose to prevent and mitigate drug-induced liver injury (DILI). Our objective was to systematically review evidence of the use of NAC as a therapeutic option for APAP overdose and APAP-related DILI in order to define the optimal treatment schedule and timing to start treatment. Methods: Bibliographic databases (PubMed, Web of Science, Embase, and MEDLINE) were searched for retrospective and prospective cohort studies, case series, and clinical trials. The prespecified primary outcomes were DILI-related mortality, hepatotoxicity, and adverse events (AEs). Results: In total, 34 studies of NAC usage in APAP-related DILI cases with 19,580 patients were identified, of which 2,376 patients developed hepatotoxicities. The mortality rate across different studies ranged from 0 to 52%. Large variability of NAC regimens was found, i.e., intravenous (I.V.) (100–150 mg/kg) and oral (70–140 mg/kg), and length of treatment varied—12, 24, or 48 h for I.V. regimen and 72 h for oral administration. The timing of initiation of NAC treatment showed different results in terms of occurrence of hepatotoxicity and mortality; if started within 8 h and no more than 24 h from APAP overdose, either intravenously or orally, NAC administration was efficacious in terms of mortality. The most frequent AEs reported were anaphylactic reactions, followed by cutaneous AEs for the IV route and intestinal AEs for the oral one. Conclusion: NAC improves hepatotoxicity and reduces mortality. Timing of treatment, ranging from 8 to 24 h from APAP overdose, regardless of the regimen or route of administration, is important to prevent or minimize liver damage, particularly in children and in elderly and obese patients.
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Affiliation(s)
- Anna Licata
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
- *Correspondence: Anna Licata,
| | - Maria Giovanna Minissale
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Simona Stankevičiūtė
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Judith Sanabria-Cabrera
- UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Malaga, Spain
- Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
| | - Maria Isabel Lucena
- UCICEC IBIMA, Plataforma SCReN (Spanish Clinical Research Network), Malaga, Spain
- Centro de Investigación Biomedica en Red de Enfermedades Hepáticas y Digestivas, CIBERehd, Madrid, Spain
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Raul J Andrade
- Servicio de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Piero Luigi Almasio
- Medicina Interna ed Epatologia, Dipartimento di Promozione della Salute, Materno-infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro,” PROMISE, Università degli Studi di Palermo, Palermo, Italy
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14
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Jiang SX, Hussaini T, Yoshida EM. N-acetylcysteine for non-acetaminophen induced acute liver failure: A review. Saudi J Gastroenterol 2022; 28:85-91. [PMID: 35142656 PMCID: PMC9007071 DOI: 10.4103/sjg.sjg_406_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The use of N-acetylcysteine (NAC) for non-acetaminophen-induced acute liver failure (NAI-ALF) has been increasing despite controversy in its efficacy. National guidelines are in disagreement for NAC use as standard of care; however, many healthcare centers continue to adopt the use of NAC outside of acetaminophen poisoning. While NAC may have multiple mechanisms of action in treatment of ALF, this has not translated to clinical benefit. Murine models have reported antioxidant and anti-inflammatory properties, as well as improvement in liver-specific microcirculation. Multiple case studies and series have reported positive outcomes of NAC treatment for ALF of various etiologies. While prospective studies suggested the benefit of NAC treatment, these studies have methodological and statistical shortcomings that affect the validity of the results. In this review, we aimed to summarize the existing literature on the efficacy of NAC for NAI-ALF including mechanism of action, case studies and series demonstrating outcomes, and prospective studies that have led to its current widespread use, along with the reported rate of adverse events.
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Affiliation(s)
- Shirley Xue Jiang
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Trana Hussaini
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Eric M. Yoshida
- Division of Gastroenterology, University of British Columbia, Vancouver General Hospital, Vancouver, BC, Canada,Address for correspondence: Dr. Eric M. Yoshida, Division of Gastroenterology, Faculty of Medicine, 5th Floor-2775 Laurel St., Vancouver, BC, Canada. E-mail:
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15
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Studentova H, Volakova J, Spisarova M, Zemankova A, Aiglova K, Szotkowski T, Melichar B. Severe tyrosine-kinase inhibitor induced liver injury in metastatic renal cell carcinoma patients: two case reports assessed for causality using the updated RUCAM and review of the literature. BMC Gastroenterol 2022; 22:49. [PMID: 35123392 PMCID: PMC8818210 DOI: 10.1186/s12876-022-02121-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 01/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background Sunitinib and pazopanib are both oral small molecule multityrosine kinase inhibitors (MTKI) used in the treatment of renal cell carcinoma (RCC). Hepatotoxicity or “liver injury” is the most important adverse effect of pazopanib administration, but little is known about the underlying mechanism. Liver injury may also occur in patients treated with sunitinib, but severe toxicity is extremely rare. Herein we report two new cases of severe liver injury induced by MTKI. Both cases are unique and exceptional. We assessed both cases for drug-induced liver injury (DILI) using the updated score Roussel Uclaf causality assessment method (RUCAM). The literature on potential pathogenic mechanisms and precautionary measures is reviewed.
Case presentation A case of a metastatic RCC (mRCC) patient treated with pazopanib who had manifestation of severe liver injury is presented. These manifestations consisted of grade 4 alanine aminotransferase (ALT) increase and grade 4 hyperbilirubinemia. Alternate causes of acute or chronic liver disease were excluded. The patient gradually recovered from the liver injury and refused any further therapy for mRCC. The patient was diagnosed with acute myeloid leukemia (AML) two years later and eventually succumbed to the disease. The second case describes a mRCC patient treated with sunitinib for 3,5 years and fatal liver failure after 2 weeks of clarithromycin co-medication for acute bronchitis. Conclusions Liver injury has been commonly observed in TKI-treated patients with unpredictable course. Management requires regular routine liver enzyme-monitoring and the collaboration of medical oncologist and hepatologist. There is an unmet medical need for a risk stratification and definition of predictive biomarkers to identify potential genetic polymorphisms or other factors associated with TKI-induced liver injury. Any potential unrecommended concomitant therapy has to be avoided.
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16
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Shrestha DB, Budhathoki P, Sedhai YR, Adhikari A, Poudel A, Aryal B, Baniya R. N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis. Ann Hepatol 2022; 24:100340. [PMID: 33722689 DOI: 10.1016/j.aohep.2021.100340] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 02/04/2023]
Abstract
The role of N-acetylcysteine (NAC) in the treatment of acetaminophen induced acute liver injury (ALI) is well established but its role in non-acetaminophen induced ALI is still elusive. We conducted this meta-analysis to evaluate the role of NAC in non-acetaminophen induced ALI. We searched electronic databases for studies published till Oct 25, 2020. We used RevMan v5.4 software to analyze the data extracted from selected studies by using Covidence systematic review software. Outcome estimation was done using Odds Ratio (OR) with 95% confidence interval (CI). The heterogeneity in various studies was determined using the I2 test. A total of 11 studies were included in quantitative analysis. Use of NAC in non-acetaminophen induced ALI showed 53% reduction in mortality compared to standard of care (OR, 0.47; CI, 0.29-0.75) and reduced mean duration of hospital stay by 6.52 days (95% CI, -12.91 to -0.13). Similarly, the rate of encephalopathy was 59% lower in the treatment group (OR, 0.41; CI, 0.20-0.83). However, the risk of developing nausea and vomiting (OR, 3.99; CI, 1.42-11.19), and the need for mechanical ventilation (OR 3.88; CI, 1.14-13.29) were significantly higher in the treatment group. These findings conclude use of NAC decreases mortality and hepatic encephalopathy compared to standard of care in patients with non-acetaminophen induced ALI. Although there is an increased risk of nausea and vomiting with the use of NAC, the majority of adverse events are transient and minor.
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Affiliation(s)
| | - Pravash Budhathoki
- Department of Emergency Medicine, Dr. Iwamura Memorial Hospital, Bhaktapur 44800, Nepal
| | - Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
| | - Anurag Adhikari
- Department of Emergency Medicine, Nepal National Hospital, Kathmandu, Nepal
| | - Ayusha Poudel
- Department of Emergency Medicine, Alka Hospital, Kathmandu, Nepal
| | - Barun Aryal
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Ramkaji Baniya
- Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
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17
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Karaarslan U, Çolak M, Topal S, Atakul G, Soydan E, Çağlar A, Ağın H. The association between N-acetylcysteine treatment and hepatic healing in patients with non-acetaminophen-induced liver injury in pediatric intensive care: A single-center retrospective study. Arch Pediatr 2022; 29:140-144. [PMID: 35039188 DOI: 10.1016/j.arcped.2021.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 12/31/2020] [Accepted: 11/28/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The aim of this study was to determine the association between the use of intravenous N-acetylcysteine (NAC) and hepatic healing in pediatric intensive care unit (PICU) patients with non-acetaminophen-induced hepatic injury, except for acute liver failure. METHODS The data of patients who received intravenous NAC as adjuvant therapy for transaminase levels more than sixfold normal values during their PICU stay between 2010 and 2014 were retrospectively collected from the medical records database. The patients who did not receive NAC with elevated transaminase levels during their PICU stay between 2014 and 2018 were also collected as the standard of care (SOC) cohort. RESULTS More than 50% of the liver injuries were secondary to acute hypoxia, hypotension, sepsis, and inflammation. The median number of elevated transaminase period (ETP) days of the NAC and SOC groups were 5 (IQR: 4) and 4 (IQR: 4), respectively (p = 0.17). There was no significant difference between the groups in terms of minimum and maximum laboratory values during ETP. There was no significant difference in terms of ETP and maximum ALT levels between the NAC and SOC groups in the hypoxia-hypotension subgroup. CONCLUSION This study did not show an association between indirect measures of hepatic healing and post-insult use of NAC in pediatric liver injury in the PICU setting.
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Affiliation(s)
- Utku Karaarslan
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey.
| | - Mustafa Çolak
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey
| | - Sevgi Topal
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey
| | - Gülhan Atakul
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey
| | - Ekin Soydan
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey
| | - Aykut Çağlar
- Department of Pediatric Emergency Care, Dr. Behcet Uz Children's Hospital, Izmir, Turkey
| | - Hasan Ağın
- Department of Pediatric Intensive Care, Dr. Behcet Uz Children's Hospital, Konak, Izmir 35210, Turkey
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Praharaj DL, Anand AC, Acharya SK. Dosage of N-Acetyl Cysteine in Acute Liver Failure Not Related to Acetaminophen. J Clin Exp Hepatol 2022; 12:726-728. [PMID: 35535093 PMCID: PMC9077223 DOI: 10.1016/j.jceh.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
| | | | - Subrat K. Acharya
- Address for correspondence: Subrat K. Acharya Emeritus Professor and Pro-chancellor, KIIT University, Bhubaneswar, Odisha, India.
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Drug-Induced Liver Injury: Clinical Evidence of N-Acetyl Cysteine Protective Effects. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:3320325. [PMID: 34912495 PMCID: PMC8668310 DOI: 10.1155/2021/3320325] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 11/12/2021] [Accepted: 11/22/2021] [Indexed: 12/29/2022]
Abstract
Oxidative stress is a key pathological feature implicated in both acute and chronic liver diseases, including drug-induced liver injury (DILI). The latter describes hepatic injury arising as a direct toxic effect of administered drugs or their metabolites. Although still underreported, DILI remains a significant cause of liver failure, especially in developed nations. Currently, it is understood that mitochondrial-generated oxidative stress and abnormalities in phase I/II metabolism, leading to glutathione (GSH) suppression, drive the onset of DILI. N-Acetyl cysteine (NAC) has attracted a lot of interest as a therapeutic agent against DILI because of its strong antioxidant properties, especially in relation to enhancing endogenous GSH content to counteract oxidative stress. Thus, in addition to updating information on the pathophysiological mechanisms implicated in oxidative-induced hepatic injury, the current review critically discusses clinical evidence on the protective effects of NAC against DILI, including the reduction of patient mortality. Besides injury caused by paracetamol, NAC can also improve liver function in relation to other forms of liver injury such as those induced by excessive alcohol intake. The implicated therapeutic mechanisms of NAC extend from enhancing hepatic GSH levels to reducing biomarkers of paracetamol toxicity such as keratin-18 and circulating caspase-cleaved cytokeratin-18. However, there is still lack of evidence confirming the benefits of using NAC in combination with other therapies in patients with DILI.
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20
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Zhang Q, Liu Y, Yuan Y, Yao F, Zhang H, Zhao C, Luo Y. miR-26a-5p protects against drug-induced liver injury via targeting bid. Toxicol Mech Methods 2021; 32:325-332. [PMID: 34749575 DOI: 10.1080/15376516.2021.2003919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUNDS miR-26a-5p is a short noncoding RNA that is abnormally expressed in drug-induced liver injury (DILI), but its pathophysiologic role in the mechanism of disease in DILI is still vague. METHODS The expression of miR-26a-5p, viability of hepatic stellate cells (HSCs) proliferation, and apoptosis were explored via real-time PCR, CCK-8 assay, Tunel fluorescence, and flow cytometry. The expression of Bid was detected via Western blot assays, real-time PCR, and immunofluorescence. The apoptosis-associated proteins were determined through Western blot. The interaction between miR-26a-5p and Bid was measured via Dual luciferase reporter assay. RESULTS miR-26a-5p expression was greatly decreased in HSCs and serum treated with azithromycin, simvastatin and diclofenac sodium, respectively. Hepatocyte viability was largely suppressed while hepatocyte apoptosis was markedly increased in DILI. Correspondingly, the apoptosis-associated proteins including Bid, caspase-8 and cytochrome C in HSCs were significantly upregulated when treated with either of these drugs. Moreover, miR-26a-5p interacted with Bid, and hepatocyte proliferation and apoptosis influenced by miR-26a-5p mimics were obviously reversed when co-treated with overexpressed Bid plasmids. CONCLUSIONS miR-26a-5p played a protective role against DILI via targeting Bid.
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Affiliation(s)
- Qian Zhang
- Department of Geriatrics, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yan Liu
- Department of Geriatrics, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yujie Yuan
- Department of Neurology, The Gucheng County Hospital of Hebei Province, Hebei, China
| | - Feifei Yao
- Department of Geriatrics, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Hongmei Zhang
- Department of Geriatrics, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Caiyan Zhao
- Department of Infectious Diseases, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Yanli Luo
- Department of Geriatrics, the third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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21
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Tenório MCDS, Graciliano NG, Moura FA, de Oliveira ACM, Goulart MOF. N-Acetylcysteine (NAC): Impacts on Human Health. Antioxidants (Basel) 2021; 10:967. [PMID: 34208683 PMCID: PMC8234027 DOI: 10.3390/antiox10060967] [Citation(s) in RCA: 134] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023] Open
Abstract
N-acetylcysteine (NAC) is a medicine widely used to treat paracetamol overdose and as a mucolytic compound. It has a well-established safety profile, and its toxicity is uncommon and dependent on the route of administration and high dosages. Its remarkable antioxidant and anti-inflammatory capacity is the biochemical basis used to treat several diseases related to oxidative stress and inflammation. The primary role of NAC as an antioxidant stems from its ability to increase the intracellular concentration of glutathione (GSH), which is the most crucial biothiol responsible for cellular redox imbalance. As an anti-inflammatory compound, NAC can reduce levels of tumor necrosis factor-alpha (TNF-α) and interleukins (IL-6 and IL-1β) by suppressing the activity of nuclear factor kappa B (NF-κB). Despite NAC's relevant therapeutic potential, in several experimental studies, its effectiveness in clinical trials, addressing different pathological conditions, is still limited. Thus, the purpose of this chapter is to provide an overview of the medicinal effects and applications of NAC to human health based on current therapeutic evidence.
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Affiliation(s)
| | - Nayara Gomes Graciliano
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
| | - Fabiana Andréa Moura
- College of Nutrition, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
- College of Medicine, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil
| | - Alane Cabral Menezes de Oliveira
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
- College of Nutrition, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
| | - Marília Oliveira Fonseca Goulart
- Institute of Chemistry and Biotechnology, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil;
- Institute of Biological and Health Sciences, Federal University of Alagoas, Maceió 57072-970, Alagoas, Brazil; (N.G.G.); (A.C.M.d.O.)
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Becker MW, Schwambach KH, Lunardelli M, Blatt CR. Overview of drug induced liver injury in Brazil: What is the role of public health policy on the evidence? World J Gastrointest Pharmacol Ther 2021; 12:40-55. [PMID: 34046243 PMCID: PMC8134851 DOI: 10.4292/wjgpt.v12.i3.40] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/20/2021] [Accepted: 04/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Adverse drug reactions are responsible for increased costs and morbidity in the health system. Hepatotoxicity can be induced both by non-prescription drugs and by those used for chronic diseases. It is the main cause of safety-related drug marketing withdrawals and could be responsible for irreversible and fatal injuries. AIM To identify and to summarize Brazilian studies reporting the drug-induced liver injury. METHODS A systematic review of Brazilian studies was carried out until June 2020. It was found 32 studies, being 10 retrospective cohorts, 12 prospective cohorts, 5 cross-sectional, 3 case-control, one case series and one randomized clinical trial. In most studies were investigated tuberculosis patients followed by other infectious conditions like human immunodeficiency virus (HIV) and hepatitis C virus. The hepatotoxicity ranged from one to 57%, led by isoniazid, rifampicin, and pyrazinamide. Few studies reported algorithm to assess causality. In most studies, there were moderate outcomes and it was necessary drug interruption. However, few severe outcomes, such as chronic liver damage and liver transplantation were reported. RESULTS Twenty-two different criteria for hepatotoxicity were found. The great heterogeneity did not allow a meta-analysis. Standardization of parameter of drug-induced liver injury and greater effort in pharmacovigilance could contribute to learn more about drug-induced liver injury (DILI)'s epidemiology in Brazil. CONCLUSION The development of strategic public health policies seems to have an influence on the DILI scientific evidence in Brazil due to main studies are in HIV and tuberculosis line care, two strategic health policies in Brazil.
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Affiliation(s)
- Matheus William Becker
- Graduate Program in Medicine-Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, RS, Brazil
| | - Karin Hepp Schwambach
- Graduate Program in Medicine-Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, RS, Brazil
| | - Michele Lunardelli
- Graduate Program in Medicine-Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, RS, Brazil
| | - Carine Raquel Blatt
- Graduate Program in Medicine-Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, RS, Brazil
- Pharmacoscience Department, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90050-170, RS, Brazil
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Prevention and management of idiosyncratic drug-induced liver injury: Systematic review and meta-analysis of randomised clinical trials. Pharmacol Res 2021; 164:105404. [DOI: 10.1016/j.phrs.2020.105404] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/18/2020] [Accepted: 12/18/2020] [Indexed: 02/06/2023]
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Walayat S, Shoaib H, Asghar M, Kim M, Dhillon S. Role of N-acetylcysteine in non-acetaminophen-related acute liver failure: an updated meta-analysis and systematic review. Ann Gastroenterol 2021; 34:235-240. [PMID: 33654365 PMCID: PMC7903568 DOI: 10.20524/aog.2021.0571] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 08/04/2020] [Indexed: 12/11/2022] Open
Abstract
Background The American Association for the Study of Liver Diseases recommends that N-acetylcysteine (NAC) may be beneficial in non-acetaminophen-related drug-induced liver injury. A subsequent review and analysis reported the current evidence to be inconclusive. Herein, we present an updated review and meta-analysis. Methods We evaluated prospective, retrospective and randomized controlled trials that compared outcomes in patients of all ages with acute liver failure (defined as abnormal liver enzymes along with elevated international normalized ratio >1.5, with or without hepatic encephalopathy) receiving NAC with the outcomes in a control group. The primary outcome was to compare the overall survival in the 2 groups. Secondary outcomes included difference in length of hospital stay, transplant-free survival, and post-transplant survival. Results Seven studies (N=883) that met the inclusion criteria were included in this analysis. The mean age of patients in the NAC group was 21.22 years compared with 23.62 years in the control group. The odds of overall survival were significantly higher in the NAC group than in controls (odds ratio [OR] 1.77, 95% confidence interval [CI] 1.3-2.41). Post-transplant survival (OR 2.44, 95%CI 1.11-5.37) and transplant-free survival were also better in the NAC group than in the control group (OR 2.85, 95%CI 2.11-3.85). Patients in the control group had statistically significant odds of a longer inpatient stay (mean difference 7.79, 95%CI 6.93-8.66). Conclusion In patients with non-acetaminophen-related acute liver failure, NAC significantly improves overall survival, post-transplant survival and transplant-free survival while decreasing the overall length of hospital stay.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology and Hepatology (Saqib Walayat, Sonu Dhillon)
| | - Hasan Shoaib
- Department of Internal Medicine (Hasan Shoaib, Muhammad Asghar Minchul Kim), University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Muhammad Asghar
- Department of Internal Medicine (Hasan Shoaib, Muhammad Asghar Minchul Kim), University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Minchul Kim
- Department of Internal Medicine (Hasan Shoaib, Muhammad Asghar Minchul Kim), University of Illinois College of Medicine at Peoria, Peoria, IL, USA
| | - Sonu Dhillon
- Department of Gastroenterology and Hepatology (Saqib Walayat, Sonu Dhillon)
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Neema S, Sinha A, Manrai M, Vasudevan B, Radhakrishnan S. Drug-induced liver injury: What a dermatologist should know? INDIAN JOURNAL OF DRUGS IN DERMATOLOGY 2021. [DOI: 10.4103/ijdd.ijdd_53_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Atefi N, Behrangi E, Mozafarpoor S, Seirafianpour F, Peighambari S, Goodarzi A. N-acetylcysteine and coronavirus disease 2019: May it work as a beneficial preventive and adjuvant therapy? A comprehensive review study. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2020; 25:109. [PMID: 33824674 PMCID: PMC8019127 DOI: 10.4103/jrms.jrms_777_20] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/11/2020] [Accepted: 09/25/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronaviruses are major pathogens of respiratory system causing different disorders, including the common cold, Middle East respiratory syndrome, and severe acute respiratory syndrome. Today's global pandemic coronavirus disease 2019 (COVID-19) has high mortality rate, with an approximate of 20% in some studies, and is 30-60 times more fatal than the common annual influenza, However, there is still no gold standard treatment for it. N-acetylcysteine (NAC) is a well-known multi-potential drug with hypothetically probable acceptable effect on COVID-related consequences, which we completely focused in this comprehensive review. MATERIALS AND METHODS PubMed, Scopus, Science Direct, and Google Scholar have been searched. Study eligibility criteria: efficacy of NAC in various subclasses of pathogenic events which may occur during COVID-19 infection. Efficacy of NAC for managing inflammatory or any symptoms similar to symptoms of COVID-19 was reviewed and symptom improvements were assessed. RESULTS Randomized clinical trials introduced NAC as an antioxidant glutathione analog and detoxifying agent promoted for different medical conditions and pulmonary disorders to alleviate influenza and reduce mortality by 50% in influenza-infected animals. The beneficial effects of NAC on viral disorders, including Epstein-Barr virus, HIV and hepatitis, and well-known vital organ damages were also exist and reported. CONCLUSION We classified the probable effects of NAC as oxidative-regulatory and apoptotic-regulatory roles, antiviral activities, anti-inflammatory roles, preventive and therapeutic roles in lung disorders and better oxygenation functions, supportive roles in intensive care unit admitted patients and in sepsis, positive role in other comorbidities and nonpulmonary end-organ damages or failures and even in primary COVID-associated cutaneous manifestations. Based on different beneficial effects of NAC, it could be administered as a potential adjuvant therapy for COVID-19 considering patient status, contraindications, and possible drug-related adverse events.
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Affiliation(s)
- Najmolsadat Atefi
- Department of Dermatology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Elham Behrangi
- Department of Dermatology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Samaneh Mozafarpoor
- Department of Dermatology, Skin Disease and Leishmaniasis Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Farnoosh Seirafianpour
- Department of General Medicine, Student Research Committee, School of Medicine, Iran University of Medical Sciences, Tehran
| | - Shadi Peighambari
- Department of Internal Medicine, San Joaquin General Hospital, CA, USA
| | - Azadeh Goodarzi
- Department of Dermatology, Rasoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Eskandarani RM, Alghamdi FS. Naphthalene Toxicity in a Three-Year-Old Child Complicated by Severe Hemolytic Anemia and Mild Methemoglobinemia: A Case Report. J Emerg Med 2020; 59:e113-e117. [PMID: 32682642 DOI: 10.1016/j.jemermed.2020.06.009] [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] [Received: 12/12/2019] [Revised: 05/13/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Exposure to naphthalene, which is widely used in mothballs, does not usually produce adverse effects. However, naphthalene can be toxic, especially in individuals with underlying conditions such as glucose-6-phosphate-dehydrogenase (G6PD) deficiency. CASE REPORT A 3-year-old boy was brought to our Emergency Department after accidentally ingesting naphthalene mothballs 3 days prior to presentation. Laboratory investigations revealed that he had severe hemolytic anemia and mild methemoglobinemia (6%), which were treated with ascorbic acid and N-acetylcysteine. The patient tested positive for G6PD deficiency after stabilization and completion of his treatment. All provided treatments were administered empirically; test results were available only after the patient was discharged. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Naphthalene exposure is a common pediatric presentation with various complications that can occur in certain high-risk individuals, such as those with G6PD deficiency. Emergency physicians should be aware of this to anticipate and be able to treat worsening toxicity.
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Moosa MS, Maartens G, Gunter H, Allie S, Chughlay MF, Setshedi M, Wasserman S, Hickman N, Stewart A, Sonderup M, Spearman CW, Cohen K. A Randomized Controlled Trial of Intravenous N-acetylcysteine in the Management of Anti-tuberculosis Drug-Induced Liver Injury. Clin Infect Dis 2020; 73:e3377-e3383. [PMID: 32845997 DOI: 10.1093/cid/ciaa1255] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Liver injury is a common complication of first-line anti-tuberculosis therapy. N-acetylcysteine (NAC) is widely used in patients with paracetamol toxicity with limited evidence of benefit in liver injury due to other causes. METHODS We conducted a randomized, double-blind, placebo-controlled trial to assess whether intravenous NAC hastens liver recovery in hospitalized adult patients with anti-tuberculosis drug induced liver injury (AT-DILI). The primary endpoint was the time for serum alanine aminotransferase (ALT) to fall below 100 U/L. Secondary endpoints included length of hospital stay, in-hospital mortality and adverse events. RESULTS Fifty-three participants were randomized to NAC and 49 to placebo. Mean age was 38 (SD±10) years, 58 (57%) were female and 89 (87%) were HIV-positive. Median serum ALT and total bilirubin at presentation were 462 U/L (IQR 266-790) and 56 μmol/L (IQR 25-100) respectively. Median time to ALT&100 U/L was 7.5 days (IQR 6 -11) in the NAC arm and 8 days (IQR 5 -13) in the placebo arm. Median time to hospital discharge was shorter in the NAC arm (9 days; IQR 6-15) than in the placebo arm (18 days; IQR 10-25), hazard ratio 1.73 (95% CI 1.13-2.65). Mortality was 14% overall and did not differ by study arm. The study infusion was stopped early due to an adverse reaction in 5 participants receiving NAC [nausea and vomiting (3), anaphylaxis (1), pain at drip site (1)]. CONCLUSION NAC did not shorten time to ALT&100 U/L in participants with AT-DILI, but significantly reduced length of hospital stay. NAC should be considered in management of AT-DILI.
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Affiliation(s)
- Muhammed S Moosa
- Department of Medicine, University of Cape Town, Cape Town, South Africa.,Department of Medicine, New Somerset Hospital, Cape Town, South Africa
| | - Gary Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Hannah Gunter
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Shaazia Allie
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mohamed F Chughlay
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mashiko Setshedi
- Division of Gastroenterology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Nicole Hickman
- Clinical Research Centre, University of Cape Town, Cape Town, South Africa
| | - Annemie Stewart
- Clinical Research Centre, University of Cape Town, Cape Town, South Africa
| | - Mark Sonderup
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Catherine Wendy Spearman
- Division of Hepatology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Maruyama H, Shiina S. Antioxidant therapy on ischemic hepatitis: here we are and where do we go? Hepatol Int 2020; 14:456-459. [PMID: 32347529 DOI: 10.1007/s12072-020-10044-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/07/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Epidemiology of drug-induced liver injury in a University Hospital from Colombia: Updated RUCAM being used for prospective causality assessment. Ann Hepatol 2020; 18:501-507. [PMID: 31053545 DOI: 10.1016/j.aohep.2018.11.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 10/29/2018] [Accepted: 11/27/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Epidemiological information regarding drug-induced liver injury in some Latin American countries remains limited. Therefore, disease prevention and health promotion strategies are imperative to reduce drug-induced liver injuries and its fatal outcomes. This study aimed to collect epidemiological data regarding drug-induced liver injury and identify associated factors in patients admitted to a university hospital in Colombia. METHODS AND PATIENTS A prospective study was conducted for 1 year to assess the incidence of drug-induced liver injury in patients aged >18 years who showed elevated values in liver tests. Data were collected after obtaining informed consent from the patients. The updated Roussel Uclaf Causality Assessment Method was applied to assess the causality of drug-induced liver injury. RESULTS The study included 286 patients with elevated values in liver tests, 18 of whom presented with drug-induced liver injury. The mean age of patients was 54.7±19.1 years. The associated pharmacological groups were anti-infectives and anticonvulsants (isoniazid, rifampicin, nitrofurantoin, phenytoin, and valproic acid), with a total of 15 drugs. The affected patients presented with cytopenia, jaundice, nausea, vomiting, or hepatomegaly. The most common type of liver injury was hepatocellular, and most patients recovered satisfactorily. The number of patients who had highly probable and probable causality grading was 1 and 9, respectively. CONCLUSION The incidence of drug-induced liver injury in a university hospital in Colombia was 6%. Comorbidities and concomitant drugs are risk factors for drug-induced liver injury. TRIAL REGISTRATION Registered in The Cuban Public Registry of Clinical Trials (identifier RPCEC00000242).
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Khaltourina D, Matveyev Y, Alekseev A, Cortese F, Ioviţă A. Aging Fits the Disease Criteria of the International Classification of Diseases. Mech Ageing Dev 2020; 189:111230. [PMID: 32251691 DOI: 10.1016/j.mad.2020.111230] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/04/2020] [Accepted: 03/09/2020] [Indexed: 12/24/2022]
Abstract
The disease criteria used by the World Health Organization (WHO) were applied to human biological aging in order to assess whether aging can be classified as a disease. These criteria were developed for the 11th revision of the International Classification of Diseases (ICD) and included disease diagnostics, mechanisms, course and outcomes, known interventions, and linkage to genetic and environmental factors. RESULTS: Biological aging can be diagnosed with frailty indices, functional, blood-based biomarkers. A number of major causal mechanisms of human aging involved in various organs have been described, such as inflammation, replicative cellular senescence, immune senescence, proteostasis failures, mitochondrial dysfunctions, fibrotic propensity, hormonal aging, body composition changes, etc. We identified a number of clinically proven interventions, as well as genetic and environmental factors of aging. Therefore, aging fits the ICD-11 criteria and can be considered a disease. Our proposal was submitted to the ICD-11 Joint Task force, and this led to the inclusion of the extension code for "Ageing-related" (XT9T) into the "Causality" section of the ICD-11. This might lead to greater focus on biological aging in global health policy and might provide for more opportunities for the new therapy developers.
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Affiliation(s)
- Daria Khaltourina
- Department of Risk Factor Prevention, Federal Research Institute for Health Organization and Informatics of Ministry of Health of the Russian Federation, Dobrolyubova St. 11, Moscow, 127254, Russia; International Longevity Alliance, 19 avenue Jean Jaurès, Sceaux, 92330, France.
| | - Yuri Matveyev
- Research Lab, Moscow Regional Research and Clinical Institute, Schepkina St. 61/2 k.1, Moscow, 129110, Russia
| | - Aleksey Alekseev
- Faculty of Physics, Lomonosov Moscow State University, Leninskie Gory, GSP-1, Moscow, 119991, Russia
| | - Franco Cortese
- Biogerontology Research Foundation, Apt 2354 Chynoweth House, Trevissome Park, Truro, London, TR4 8UN, UK
| | - Anca Ioviţă
- International Longevity Alliance, 19 avenue Jean Jaurès, Sceaux, 92330, France
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Therapeutic effect of N-acetylcysteine on chemotherapy-induced liver injury. Ir J Med Sci 2020; 189:1189-1194. [PMID: 32239424 DOI: 10.1007/s11845-020-02219-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND N-acetylcysteine (NAC) may be useful in the management of chemotherapy-induced liver injury. AIMS The present study evaluates the possible therapeutic effects of NAC on chemotherapy-induced hepatotoxicity. METHODS A total of 102 patients' files who were diagnosed with cancer between 2015 and 2019 were evaluated retrospectively. Two patient groups with and without NAC were selected. NAC was administered in a 3-μg/kg IV dose in a 24-h infusion to 70 patients when any alanine aminotransferase (ALT) or gamma-glutamyl transferase (GGT) values reached three times the normal levels. The other group consisted of 32 patients who were not treated with NAC. Alanine aminotransferase and GGT values were recorded at pretreatment, and on the 1st, 3rd, 5th, and 7th days in both the NAC and non-NAC groups from files. RESULTS In the NAC group, ALT and GGT values on day 1, 3, 5, and 7 differed from each other, decreasing from day 1 to day 7. A statistically significant difference was noted between the values in the NAC group (p < 0.001). In the non-NAC group, the ALT values on day 7 were lower than the ALT values on day 1. A comparison of the ALT and GGT values in the NAC and non-NAC groups found that the values in the NAC group decreased earlier than in the non-NAC group. CONCLUSIONS This study shows that NAC has a therapeutic effect on hepatotoxicity in children being treated with chemotherapeutic agents due to underlying malign diseases. The early reduction in the results of liver function tests is important for the continuation of chemotherapy.
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Acute Fatty Liver of Pregnancy: Pathophysiology, Anesthetic Implications, and Obstetrical Management. Anesthesiology 2020; 130:446-461. [PMID: 30707120 DOI: 10.1097/aln.0000000000002597] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
A narrative review of the pathophysiology, diagnosis, management, delivery implications, obstetric anesthesia care, and potential critical care needs in patients presenting with acute fatty liver of pregnancy.
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Mohamed M, Al-Hillan A, Flores M, Kaunzinger C, Mushtaq A, Asif A, Hossain M. Concomitant Acute Hepatic Failure and Renal Failure Induced by Intravenous Amiodarone: A Case Report and Literature Review. Gastroenterology Res 2020; 13:40-43. [PMID: 32095172 PMCID: PMC7011916 DOI: 10.14740/gr1254] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/17/2020] [Indexed: 12/17/2022] Open
Abstract
Hepatotoxicity caused by chronic oral amiodarone is well documented with around 15-20% incidence rate. However, acute liver failure due to intravenous (IV) amiodarone is rare clinical presentation with 3% incidence rate. Incidence of concomitant renal failure is even rarer. There is no full explanation for the underlying mechanism. Herein, we are presenting a rare case of concomitant acute hepatic failure and acute-on-chronic renal injury induced by use of IV amiodarone. A 67-year-old man with past medical history of coronary artery disease s/p coronary artery bypass graft (CABG), history of alcoholism, and chronic kidney disease stage 3 presented with chest pain for 1 week. In the emergency department (ED), he was found to have atrial flutter. Due to unresponsiveness to IV β-blocker and diltiazem, the patient was loaded with IV amiodarone and continued IV amiodarone drip. His liver function tests (LFTs) and renal functions at the time of administration of IV amiodarone were aspartate transaminase (AST) 176 (10 - 42 IU/L) and alanine transaminase (ALT) 208 (10 - 60 IU/L), international normalized ratio (INR) 1.39 (reference value 2 - 3), blood urea nitrogen (BUN) 37 (5 - 25 mg/dL), and creatinine 1.85. Sixteen hours later patient developed acute hepatic failure with AST 4,250 (reference value 10 - 42 IU/L), ALT 2,422 (10 - 60 IU/L), INR 2.28, and acute renal failure with creatinine of 3.2 mg/dL (0.44 - 1.0 mg/dL), and BUN of 44 mg/d (5 - 25 mg/dL). Patient was intubated due to acute hepatic encephalopathy and sent to intensive care unit (ICU). IV amiodarone was stopped immediately. All workup for other causes of acute hepatic failure came back negative. He was started on IV N-acetylcysteine and required hemodialysis for acute-on-chronic renal failure. LFTs peaked 72 h after discontinuation of amiodarone. Kidney functions started to improve 5 days after discontinuation of amiodarone and patient came off hemodialysis. Acute hepatic failure as result of IV amiodarone is a rare presentation; however, it has a high mortality. Risk factors include low ejection fraction, hepatic congestion and pre-existing hepatic dysfunction. No obvious underlying mechanism to this presentation has been fully explained. Acute renal failure can be associated with this presentation which is even rarer. Stopping IV amiodarone, administering N-acetylcysteine and good supportive care can lead to favorable outcome.
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Affiliation(s)
- Mujtaba Mohamed
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Alsadiq Al-Hillan
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Marcus Flores
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Christian Kaunzinger
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Arman Mushtaq
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Arif Asif
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohammad Hossain
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
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Lee ACW, Aung L. Treatment of hepatic veno-occlusive disease in children with N-acetylcysteine. Pediatr Blood Cancer 2019; 66:e27518. [PMID: 30350914 DOI: 10.1002/pbc.27518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/03/2018] [Indexed: 02/05/2023]
Abstract
In our institution, hepatic veno-occlusive disease/sinusoidal obstruction syndrome (VOD/SOS) has been treated with N-acetylcysteine (NAC) since 2008-a loading dose of 150 mg/kg, followed by 12 doses of 70 mg/kg 6 hourly. Nine children were diagnosed with hepatic VOD/SOS. Hepatic VOD/SOS occurred in seven children after stem cell transplantation and two were receiving chemotherapy for Wilms tumor. Their clinical severity was classified as moderate in two and severe in seven by the European Society for Blood and Marrow Transplantation criteria. All children recovered and were discharged from 4 to 16 days after diagnosis. No side effects were observed. Intravenous NAC is an effective treatment for hepatic VOD/SOS.
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Affiliation(s)
- Anselm Chi-Wai Lee
- Children's Haematology and Cancer Centre, Mount Elizabeth Hospital, Singapore, Singapore
| | - LeLe Aung
- Parkway Cancer Centre, Gleneagles Hospital, Singapore, Singapore
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Gu LL, Shen ZL, Li YL, Bao YQ, Lu H. Oxymatrine Causes Hepatotoxicity by Promoting the Phosphorylation of JNK and Induction of Endoplasmic Reticulum Stress Mediated by ROS in LO2 Cells. Mol Cells 2018; 41:401-412. [PMID: 29754474 PMCID: PMC5974617 DOI: 10.14348/molcells.2018.2180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 12/23/2017] [Accepted: 01/16/2018] [Indexed: 12/11/2022] Open
Abstract
Oxymatrine (OMT) often used in treatment for chronic hepatitis B virus infection in clinic. However, OMT-induced liver injury has been reported. In this study, we aim to investigate the possible mechanism of OMT-induced hepatotoxicity in human normal liver cells (L02). Exposed cells to OMT, the cell viability was decreased and apoptosis rate increased, the intracellular markers of oxidative stress were changed. Simultaneously, OMT altered apoptotic related proteins levels, including Bcl-2, Bax and pro-caspase-8/-9/-3. In addition, OMT enhanced the protein levels of endoplasmic reticulum (ER) stress makers (GRP78/Bip, CHOP, and cleaved-Caspase-4) and phosphorylation of c-Jun N-terminal kinase (p-JNK), as well as the mRNA levels of GRP78/Bip, CHOP, caspase-4, and ER stress sensors (IREI, ATF6, and PERK). Pre-treatment with Z-VAD-fmk, JNK inhibitor SP600125 and N-acetyl-l-cysteine (NAC), a ROS scavenger, partly improved the survival rates and restored OMT-induced cellular damage, and reduced caspase-3 cleavage. SP600125 or NAC reduced OMT-induced p-JNK and NAC significantly lowered caspase-4. Furthermore, 4-PBA, the ER stress inhibitor, weakened inhibitory effect of OMT on cells, on the contrary, TM worsen. 4-PBA also reduced the levels of p-JNK and cleaved-caspase-3 proteins. Therefore, OMT-induced injury in L02 cells was related to ROS mediated p-JNK and ER stress induction. Antioxidant, by inhibition of p-JNK or ER stress, may be a feasible method to alleviate OMT-induced liver injury.
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Affiliation(s)
- Li-li Gu
- College of Pharmaceutical science, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province,
China
| | - Zhe-lun Shen
- College of Pharmaceutical science, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province,
China
| | - Yang-Lei Li
- College of Pharmaceutical science, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province,
China
| | - Yi-Qi Bao
- College of Pharmaceutical science, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province,
China
| | - Hong Lu
- College of Pharmaceutical science, Zhejiang Chinese Medical University, Hangzhou 310053, Zhejiang Province,
China
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Calvo PL, Tandoi F, Haak TB, Brunati A, Pinon M, Olio DD, Romagnoli R, Spada M. NBAS mutations cause acute liver failure: when acetaminophen is not a culprit. Ital J Pediatr 2017; 43:88. [PMID: 28946922 PMCID: PMC5613325 DOI: 10.1186/s13052-017-0406-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/13/2017] [Indexed: 01/25/2023] Open
Abstract
Background Pediatric acute-liver-failure due to acetaminophen (APAP) administration at therapeutic dosage is rare, while viral infections and metabolic defects are the prevalent causes. Yet, as acetaminophen is routinely used in febrile illnesses, it may be mistakenly held responsible for the acute liver damage. Case presentation An 11 month old boy had been on acetaminophen for 10 days (total dose 720 mg = 72 mg/kg) when he developed acute-liver-failure with encephalopathy. As he rapidly improved on N-acetylcysteine (NAC) infusion, it was concluded that chronic acetaminophen administration in an infant had lead to acute-liver-failure even at therapeutic doses, that N-acetylcysteine infusion had been life-saving and should be immediately started in similar circumstances. The child, however, had two further episodes of acute liver damage over a 34-month period, without having been given acetaminophen, as the parents carefully avoided using it. His clinical, laboratory and radiological findings between the acute episodes were unremarkable. His features and skeletal surveys were not suggestive of a syndromic condition. He then went on to suffer another episode of acute-liver-failure with multi-organ failure, necessitating an urgent liver transplant. All efforts to come to a diagnosis for the causes of his recurrent episodes of liver failure had been unsuccessful, until a biallelic mutation in the NBAS gene was reported to be associated with recurrent acute-liver-failure in children. The boy’s DNA analysis revealed compound heterozygous pathogenic mutations in the NBAS gene. Liver failure episodes in these patients are triggered and worsened by fever, most likely due to thermal susceptibility of hepatocytes, hence APAP, rather than being a culprit, is part of the supportive treatment. Conclusions We suggest that, in acute-liver-failure with a history of acetaminophen exposure at therapeutic dosage, clinicians should not be contented with administering NAC, but should consider an alternative etiology, above all if the episodes are recurrent, and actively start supportive and antipyretic treatment while seeking the advice of a specialist unit.
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Affiliation(s)
- Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy.
| | - Francesco Tandoi
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Tobias B Haak
- Institute of Human Genetics, Technische Universität München, 81675, Munich, Germany.,Institute of Human Genetics, Helmholtz Zentrum München, 85764, Neuherberg, Germany
| | - Andrea Brunati
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Michele Pinon
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Piazza Polonia 94, 10126, Torino, Italy
| | - Dominic Dell Olio
- Regional Transplant Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Renato Romagnoli
- Liver Transplantation Center, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
| | - Marco Spada
- Department of Pediatrics, Regina Margherita Children's Hospital, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, University of Turin, Torino, Italy
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Baekdal M, Ytting H, Skalshøi Kjær M. Drug-induced liver injury: a cohort study on patients referred to the Danish transplant center over a five year period. Scand J Gastroenterol 2017; 52:450-454. [PMID: 27973926 DOI: 10.1080/00365521.2016.1267790] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The idiosyncratic subtype of drug-induced liver injury (DILI) is a rare reaction to medical treatment that in severe cases can lead to acute liver failure and death. The aim of this study was to describe the presentation and outcome of DILI and to identify potential predictive factors of poor outcome. MATERIALS AND METHODS We identified all patients diagnosed with DILI at the Department of Hepatology, Rigshospitalet, from March 2007 to November 2012. The following parameters were registered from patient files: drug causing DILI, symptoms, comorbidity, biochemistry, treatment and outcome. RESULTS Of 43 patients, 25 (58%) were female with a mean age of 54 years. The two most frequent causes of DILI were Disulfiram (30%) and antibiotics (19%). The most common symptoms were jaundice, nausea, fatigue and gastrointestinal discomfort. At the time of admission, the most frequent biochemical findings included bilirubin elevated to above 3.2 × ULN, ALT elevated to above 9 × ULN in 86%, INR above 1.4 in 70%. Twenty two patients needed treatment in the liver intensive care unit. Fifteen patients developed acute liver failure with a severe outcome. Six patients were liver transplanted and nine patients died. Jaundice, a moderately elevated bilirubin level or INR at presentation was predictive of severe outcome. CONCLUSION In this retrospective study, 35% of patients with DILI developed severe acute liver failure and were either liver transplanted or died. Our results underline that DILI may be severe and run a fatal course, and that bilirubin and INR levels may predict poor outcome.
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Affiliation(s)
- Mille Baekdal
- a Department of Hepatology , Rigshospitalet, University Hospital of Copenhagen , Copenhagen , Denmark
| | - Henriette Ytting
- a Department of Hepatology , Rigshospitalet, University Hospital of Copenhagen , Copenhagen , Denmark
| | - Mette Skalshøi Kjær
- a Department of Hepatology , Rigshospitalet, University Hospital of Copenhagen , Copenhagen , Denmark
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Yang LX, Liu CY, Zhang LL, Lai LL, Fang M, Zhang C. Clinical Characteristics of Patients with Drug-induced Liver Injury. Chin Med J (Engl) 2017; 130:160-164. [PMID: 28091407 PMCID: PMC5282672 DOI: 10.4103/0366-6999.197995] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background: Drug is an important cause of liver injury and accounts for up to 40% of instances of fulminant hepatic failure. Drug-induced liver injury (DILI) is increasing while the diagnosis becomes more difficult. Though many drugs may cause DILI, Chinese herbal medicines have recently emerged as a major cause due to their extensive use in China. We aimed to provide drug safety information to patients and health carers by analyzing the clinical and pathological characteristics of the DILI and the associated drug types. Methods: A retrospective analysis was conducted in 287 patients diagnosed with DILI enrolled in our hospital from January 2011 to December 2015. The categories of causative drugs, clinical and pathological characteristics were reviewed. Results: Western medicines ranked as the top cause of DILI, accounting for 163 out of the 287 DILI patients (56.79%) in our study. Among the Western medicine, antituberculosis drugs were the highest cause (18.47%, 53 patients) of DILI. Antibiotics (18 patients, 6.27%) and antithyroid (18 patients, 6.27%) drugs also ranked among the major causes of DILI. Chinese herbal medicines are another major cause of DILI, accounting for 36.59% of cases (105 patients). Most of the causative Chinese herbal medicines were those used to treat osteopathy, arthropathy, dermatosis, gastropathy, leukotrichia, alopecia, and gynecologic diseases. Hepatocellular hepatitis was prevalent in DILI, regardless of Chinese herbal medicine or Western medicine-induced DILI. Conclusions: Risks and the rational use of medicines should be made clear to reduce the occurrence of DILI. For patients with liver injury of unknown origin, liver tissue pathological examination is recommended for further diagnosis.
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Affiliation(s)
- Li-Xia Yang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Cheng-Yuan Liu
- Department of Emergency, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Lun-Li Zhang
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Ling-Ling Lai
- Department of Infectious Diseases, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Ming Fang
- Department of Emergency, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Chong Zhang
- Department of Clinical Medicine, Medical College of Nanchang University, Nanchang, Jiangxi 330006, China
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Effect of N-Acetylcysteine on Mortality and Liver Transplantation Rate in Non-Acetaminophen-Induced Acute Liver Failure: A Multicenter Study. Clin Drug Investig 2017; 37:473-482. [DOI: 10.1007/s40261-017-0505-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
Drug-induced acute liver failure (ALF) disproportionately affects women and nonwhites. It is most frequently caused by antimicrobials and to a lesser extent by complementary and alternative medications, antiepileptics, antimetabolites, nonsteroidals, and statins. Most drug-induced liver injury ALF patients have hepatocellular injury pattern. Cerebral edema and intracranial hypertension are the most serious complications of ALF. Other complications include coagulopathy, sepsis, metabolic derangements, and renal, circulatory, and respiratory dysfunction. Although advances in intensive care have improved outcome, ALF has significant mortality without liver transplantation. Liver-assist devices may provide a bridge to transplant or to spontaneous recovery.
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Affiliation(s)
- Shahid Habib
- Department of Medicine, Southern Arizona Veterans Affairs Healthcare System 3601 S 6th Avenue, Tucson, AZ 85723 USA
| | - Obaid S Shaikh
- Section of Gastroenterology, Department of Medicine, Veterans Affairs Pittsburgh Healthcare System, University Drive C, FU #112, Pittsburgh, PA 15240, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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Postoperative Liver Failure. GI SURGERY ANNUAL 2017. [PMCID: PMC7123164 DOI: 10.1007/978-981-10-2678-2_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Technical innovations in surgical techniques, anaesthesia, critical care and a spatial understanding of the intra-hepatic anatomy of the liver, have led to an increasing number of liver resections being performed all over the world. However, the number of complications directly attributed to the procedure and leading to inadequate or poor hepatic functional status in the postoperative period remains a matter of concern. There has always been a problem of arriving at a consensus in the definition of the term: postoperative liver failure (PLF). The burgeoning rate of living donor liver transplants, with lives of perfectly healthy donors involved, has mandated a consensual definition, uniform diagnosis and protocol for management of PLF. The absence of a uniform definition has led to poor comparison among various trials. PLF remains a dreaded complication in resection of the liver, with a reported incidence of up to 8 % [1], and mortality rates of up to 30–70 % have been quoted [2]. Several studies have quoted a lower incidence of PLF in eastern countries, but when it occurs the mortality is as high as in the West [3].
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Chughlay MF, Kramer N, Spearman CW, Werfalli M, Cohen K. N-acetylcysteine for non-paracetamol drug-induced liver injury: a systematic review. Br J Clin Pharmacol 2016; 81:1021-9. [PMID: 26757427 DOI: 10.1111/bcp.12880] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Revised: 11/22/2015] [Accepted: 01/01/2016] [Indexed: 01/08/2023] Open
Abstract
AIMS N-acetylcysteine (NAC) may be useful in the management of non-paracetamol drug-induced liver injury (DILI). Our objective was to review systematically evidence for the use of NAC as a therapeutic option for non-paracetamol DILI. METHODS We searched for randomized controlled trials (RCTs) and prospective cohort studies. We searched several bibliographic databases, grey literature sources, conference proceedings and ongoing trials. Our pre-specified primary outcomes were all cause and DILI related mortality, time to normalization of liver biochemistry and adverse events. Secondary outcomes were proportion receiving liver transplant, time to transplantation, transplant-free survival and hospitalization duration. RESULTS We identified one RCT of NAC vs. placebo in patients with non-paracetamol acute liver failure. There was no difference in the primary outcomes of overall survival at 3 weeks between NAC [70%, 95% confidence interval (CI) = 60%, 81%, n = 81] and placebo (66%, 95% CI = 56%, 77%, n = 92). NAC significantly improved the secondary outcomes of transplant-free survival compared with placebo: 40% NAC (95% CI = 28%, 51%) vs. 27% placebo (95% CI = 18%, 37%). A subgroup analysis according to aetiology found improved transplant-free survival in patients with non-paracetamol DILI, NAC (58%, n = 19) vs. placebo (27%, n = 26), odds ratio (OR) 0.27 (95% CI = 0.076, 0.942). Overall survival was similar, NAC (79%) vs. placebo (65%);, OR 0.50 (95% CI = 0.13, 1.98). CONCLUSION Current available evidence is limited and does not allow for any firm conclusions to be made regarding the role of NAC in non-paracetamol DILI. We therefore highlight the need for further research in this area.
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Affiliation(s)
- Mohamed Farouk Chughlay
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - Nicole Kramer
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - C Wendy Spearman
- Division of Hepatology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
| | - Mahmoud Werfalli
- Division of Endocrinology and Diabetes, Chronic Disease Initiative in Africa (CDIA) Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town, South Africa
| | - Karen Cohen
- Division of Clinical Pharmacology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925, Cape Town
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