Outcomes and Predictors of Mortality in Patients With Drug-Induced Liver Injury at a Tertiary Hospital in South India: A Single-Centre Experience

INTRODUCTION

Drug-induced liver injury (DILI) is an important cause of acute liver failure with significant morbidity and mortality. The outcome of DILI varies widely according to the drug implicated and the type of liver injury. Owing to the heterogeneous nature of liver injury, knowledge on clinical course and prognosis of DILI is limited. We had undertaken this study to determine the clinical characteristics, outcomes, and predictors of mortality in patients with DILI.

MATERIALS AND METHODS

This prospective study was conducted from January 2015 through December 2018. We analyzed the drugs implicated, clinical course, and the outcome. Causality assessment was performed by using Roussel Uclaf Causality Assessment Method scoring. Patients were followed for 6 months until recovery/death or liver transplantation.

RESULTS

There were 133 cases with DILI. The mean age was 47.6 years, and 51.9% of them were men. Drugs causing DILI were antitubercular drugs (37.5%) followed by neuropsychiatric drugs (16.5%), antibiotics/antifungals (12%), complementary and alternative medicine (10.5%), immunomodulatory/chemotherapeutic drugs (10.5%), and nonsteroidal antiinflammatory drugs (7.5%). Eighty-two (61.6%) patients were classified as hepatocellular, 30 (22.5%) as mixed and 21 (15.7%) as cholestatic type of injury. There was no significant difference in the mortality and morbidity between the three types of liver injury. There were 18 deaths (13.5%), of which antitubercular drugs constituted the majority (55.5%) followed by neuropsychiatric drugs (27.7%) and complementary and alternative medicine (16.6%). Based on receiver operating characteristic curve analysis, model for end-stage liver disease (MELD) score >28, mean international normalized ratio (INR) >1.97, mean bilirubin level >15.6 mg/dl, and creatinine level >1.35 mg/dl were associated with mortality.

CONCLUSION

Although DILI is uncommon, it has significant morbidity and mortality. Antitubercular drugs were the most common cause for DILI and DILI-related mortality in our study. Variables such as MELD, INR, bilirubin, albumin, and creatinine help in predicting severity of liver injury and may help in triaging the patient for referral for liver transplantation.

Clinical and biochemical profile of tuberculosis in patients with liver cirrhosis

INTRODUCTION

There is paucity of data on tuberculosis and antituberculous therapy (ATT) induced hepatotoxicity in patients with chronic liver disease.

AIM

To study demographic, clinical characteristics of tuberculosis, pattern of drug induced liver injury and treatment responses to ATT in patients with liver cirrhosis.

MATERIAL AND METHOD

All cases of liver cirrhosis diagnosed with tuberculosis (TB) between January 2010 and June 2013 were enrolled. Drug induced liver injury (DILI) was defined as follows (1) an aspartate aminotransferase (AST)/alanine aminotransferase (ALT) value exceeding 3 times the normal upper limit if the baseline level was normal (<40 IU/L), or an AST/ALT exceeding 2 times the baseline level if the baseline level was abnormal and an absolute increase in serum bilirubin >2 mg/dl from baseline.

RESULTS

Sixty seven patients had confirmed TB with underlying cirrhosis and formed the study group. The mean age was 52 ± 12 years and M:F ratio was 57:10. Mean Child Turcotte Pugh (CTP) score 8.5 ± 1.5 (CTP A:B:C:7:44:16). The sites of TB included: pulmonary (25, 37%); pleural effusion (10, 16%) peritoneal (19, 29%); chest lymph nodes (3, 4%); liver (1, 1.5%); intestines (3, 4%), vertebra (3, 4%), brain (1, 1.5%) and disseminated (2, 3%). Thus, extrapulmonary TB was more common in the cirrhotic patients as compared to pulmonary TB. Patients with Child's status A (n = 7) received 4 drugs (R: rifampicin, H: Isoniazid, E: ethambutol, Z: pyrizinamide) and could tolerate well even during follow up without any drug induced toxicity. In rest of patients commonest regimen followed was combination of drugs (RHEO, n = 32) followed by RHE (n = 11). DILI occurred in 35% started with either RHEO, HEO and REO. Median time of onset of DILI was 12 days (4-34) days. There was no DILI related death during hospital stay or follow up.

CONCLUSIONS

Extrapulmonary TB is common in patients with cirrhosis and DILI is common in Child B and C with combination of rifampicin and isoniazid regimen.