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Marañón P, Rey E, Isaza SC, Wu H, Rada P, Choya-Foces C, Martínez-Ruiz A, Martín MÁ, Ramos S, García-Monzón C, Cubero FJ, Valverde ÁM, González-Rodríguez Á. Inhibition of ALK3-mediated signalling pathway protects against acetaminophen-induced liver injury. Redox Biol 2024; 71:103088. [PMID: 38401290 PMCID: PMC10902147 DOI: 10.1016/j.redox.2024.103088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024] Open
Abstract
Acetaminophen (APAP)-induced liver injury is one of the most prevalent causes of acute liver failure (ALF). We assessed the role of the bone morphogenetic protein (BMP) type I receptors ALK2 and ALK3 in APAP-induced hepatotoxicity. The molecular mechanisms that regulate the balance between cell death and survival and the response to oxidative stress induced by APAP was assessed in cultured human hepatocyte-derived (Huh7) cells treated with pharmacological inhibitors of ALK receptors and with modulated expression of ALK2 or ALK3 by lentiviral infection, and in a mouse model of APAP-induced hepatotoxicity. Inhibition of ALK3 signalling with the pharmacological inhibitor DMH2, or by silencing of ALK3, showed a decreased cell death both by necrosis and apoptosis after APAP treatment. Also, upon APAP challenge, ROS generation was ameliorated and, thus, ROS-mediated JNK and P38 MAPK phosphorylation was reduced in ALK3-inhibited cells compared to control cells. These results were also observed in an experimental model of APAP-induced ALF in which post-treatment with DMH2 after APAP administration significantly reduced liver tissue damage, apoptosis and oxidative stress. This study shows the protective effect of ALK3 receptor inhibition against APAP-induced hepatotoxicity. Furthermore, findings obtained from the animal model suggest that BMP signalling might be a new pharmacological target for the treatment of ALF.
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Affiliation(s)
- Patricia Marañón
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain.
| | - Esther Rey
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Stephania C Isaza
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Hanghang Wu
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain
| | - Patricia Rada
- Instituto de Investigaciones Biomédicas Sols-Morreale (Centro Mixto CSIC-UAM), Madrid, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Carmen Choya-Foces
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Antonio Martínez-Ruiz
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain; Departamento de Bioquímica y Biología Molecular, Facultad de Farmacia, Universidad Complutense de Madrid, Spain
| | - María Ángeles Martín
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain; Instituto de Ciencia y Tecnología de Alimentos y Nutrición (ICTAN-CSIC), Madrid, Spain
| | - Sonia Ramos
- Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain; Instituto de Ciencia y Tecnología de Alimentos y Nutrición (ICTAN-CSIC), Madrid, Spain
| | - Carmelo García-Monzón
- Unidad de Investigación, Hospital Universitario Santa Cristina, Instituto de Investigación Sanitaria Princesa (IIS-IP), Madrid, Spain
| | - Francisco Javier Cubero
- Department of Immunology, Ophthalmology and ENT, Complutense University School of Medicine, Madrid, Spain; Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Ángela M Valverde
- Instituto de Investigaciones Biomédicas Sols-Morreale (Centro Mixto CSIC-UAM), Madrid, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain
| | - Águeda González-Rodríguez
- Instituto de Investigaciones Biomédicas Sols-Morreale (Centro Mixto CSIC-UAM), Madrid, Spain; Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas Asociadas (CIBERDEM), Madrid, Spain.
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Brilakis L, Theofilogiannakou E, Lykoudis PM. Current remarks and future directions on the interactions between metabolic dysfunction-associated fatty liver disease and COVID-19. World J Gastroenterol 2024; 30:1480-1487. [PMID: 38617460 PMCID: PMC11008415 DOI: 10.3748/wjg.v30.i11.1480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/30/2024] [Accepted: 03/04/2024] [Indexed: 03/21/2024] Open
Abstract
During the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, particular interest rose regarding the interaction between metabolic dysfunction-associated fatty liver disease (MAFLD) and the COVID-19 infection. Several studies highlighted the fact that individuals with MAFLD had higher probability of severe acute respiratory syndrome coronavirus 2 infection and more severe adverse clinical outcomes. One of the proposed mechanisms is the inflammatory response pathway, especially the one involving cytokines, such as interleukin 6, which appeared particularly elevated in those patients and was deemed responsible for additional insult to the already damaged liver. This should increase our vigilance in terms of early detection, close follow up and early treatment for individuals with MAFLD and COVID-19 infection. In the direction of early diagnosis, biomarkers such as cytokeratin-18 and scoring systems such as Fibrosis-4 index score are proposed. COVID-19 is a newly described entity, expected to be of concern for the years to come, and MAFLD is a condition with an ever-increasing impact. Delineating the interaction between these two entities should be brought into the focus of research. Reducing morbidity and mortality of patients with COVID-19 and MAFLD should be the ultimate objective, and the optimal way to achieve this is by designing evidence-based prevention and treatment policies.
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Affiliation(s)
- Leonidas Brilakis
- School of Medicine, National & Kapodistrian University of Athens, Athens 11527, Greece
| | | | - Panagis M Lykoudis
- School of Medicine, National & Kapodistrian University of Athens, Athens 11527, Greece
- Division of Surgery & Interventional Science, University College London, London WC1E 6BT, United Kingdom
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Zhang T, Zhong Y, Shi Y, Feng C, Xu L, Chen Z, Sun X, Zhao Y, Sun X. Multi-omics reveals that 5-O-methylvisammioside prevention acute liver injury in mice by regulating the TNF/MAPK/NF-κB/arachidonic acid pathway. Phytomedicine 2024; 128:155550. [PMID: 38522313 DOI: 10.1016/j.phymed.2024.155550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 03/09/2024] [Accepted: 03/18/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The pathogenesis of acute liver injury (ALI) has been a pressing issue in the medical scientific community. We previously found that 5-O-methylvisammioside (MeV) from Saposhnikovia divaricata (Turcz.) Schischk has excellent anti-inflammatory properties. However, the mechanism by which MeV protects against ALI still needs to be deeply investigated. PURPOSE In the present study, we established an acetaminophen (APAP) -induced ALI mouse model and pre-protected the mice with MeV. METHODS & RESULTS Our findings indicate that MeV (5 and 10 mg/kg) lowered the blood levels of alanine aminotransferase and aspartate aminotransferase and reduced the infiltration of inflammatory cells in the liver. MeV initially showed an inhibitory effect on ALI. We then analyzed the molecular mechanisms underlying the effects of MeV by transcriptomic and metabolomic analyzes. Through transcriptomic analysis, we identified 4675 differentially expressed genes between the APAP+MeV group and the APAP-induced ALI group, which were mainly enriched in the MAPK pathway, the TNF pathway, and the NF-κB pathway. Through metabolomic analysis, we found that 249 metabolites in the liver were differentially regulated between the APAP+MeV group and the APAP- induced ALI group, which were mainly enriched in the arachidonic acid pathway. The mRNA expression levels of key genes (encoding TNF-α, p38, AP-1, RelB, IL-1β, and Ptges), as determined by RT-PCR analysis, were consistent with the RNA-seq data. The ELISA results indicate that MeV markedly decreased the serum levels of TNF-α and IL-1β in mice. Finally, the key proteins in the NF-κB and MAPK pathways were examined using immunoblotting. The results showed that MeV decreased IκB-α phosphorylation and inhibited the nuclear translocation of NF-κB. In addition, MeV reduced the hepatic inflammatory burst mainly by inhibiting the phosphorylation of p38 and JNK in the MAPK pathway. CONCLUSION The present study demonstrated (i) that MeV could ameliorate APAP-induced ALI by inhibiting arachidonic acid metabolism and the TNF, MAPK, and NF-κB pathways, and (ii) that MeV is a promising drug candidate for the prevention of ALI.
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Affiliation(s)
- Tingwen Zhang
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Yue Zhong
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Yan Shi
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Chengcheng Feng
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Lu Xu
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Zheng Chen
- Jilin Hospital of Integrated Traditional Chinese and Western Medicine, No.9 Changchun Road, Chuanying District, Jilin City, Jilin Province, China
| | - Xin Sun
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China
| | - Yan Zhao
- College of Chinese Medicinal Materials, Jilin Agricultural University, No. 2888, Xincheng Street, Nanguan District, Changchun City, Jilin Province, China.
| | - Xialin Sun
- College of Pharmacy, Jilin Medical University, No. 5, Jilin Street, Fengman District, Jilin City, Jilin Province, China.
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Şimşek C, Wahlin S, Efe C. Autoimmune Hepatitis: Mycophenolate mofetil versus azathioprine as first line therapy. J Hepatol 2024:S0168-8278(24)00142-9. [PMID: 38458322 DOI: 10.1016/j.jhep.2024.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 03/10/2024]
Affiliation(s)
- Cem Şimşek
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey
| | - Staffan Wahlin
- Hepatology Division, Department of Upper GI Diseases, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University, Ankara, Turkey; Department of Gastroenterology, Harran University, Şanlıurfa, Turkey.
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Soldera J. Insights into skullcap herb-induced liver injury. World J Hepatol 2024; 16:120-122. [PMID: 38495279 PMCID: PMC10941739 DOI: 10.4254/wjh.v16.i2.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/14/2024] [Accepted: 01/29/2024] [Indexed: 02/27/2024] Open
Abstract
This editorial addresses the growing concern of herb-induced liver injury (HILI), focusing on a unique case of Skullcap-induced HILI report. This editorial underscore the significant mortality rate linked to Skullcap-induced HILI, emphasizing the importance of vigilant monitoring and intervention. As herbal supplement usage rises, collaboration among clinicians and researchers is crucial to comprehend and address the complexities of HILI, particularly those involving Skullcap.
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Affiliation(s)
- Jonathan Soldera
- Post Graduate Program at Acute Medicine and Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom.
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Ahmed T, Ahmad J. Recent advances in the diagnosis of drug-induced liver injury. World J Hepatol 2024; 16:186-192. [PMID: 38495272 PMCID: PMC10941738 DOI: 10.4254/wjh.v16.i2.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/03/2024] [Accepted: 02/03/2024] [Indexed: 02/27/2024] Open
Abstract
Drug-induced liver injury (DILI) is a major problem in the United States, commonly leading to hospital admission. Diagnosing DILI is difficult as it is a diagnosis of exclusion requiring a temporal relationship between drug exposure and liver injury and a thorough work up for other causes. In addition, DILI has a very variable clinical and histologic presentation that can mimic many different etiologies of liver disease. Objective scoring systems can assess the probability that a drug caused the liver injury but liver biopsy findings are not part of the criteria used in these systems. This review will address some of the recent updates to the scoring systems and the role of liver biopsy in the diagnosis of DILI.
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Affiliation(s)
- Taqwa Ahmed
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Department of Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States.
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Giunta DH, Karlsson P, Younus M, Berglind IA, Kieler H, Reutfors J. Validation of diagnoses of liver disorders in users of systemic azole antifungal medication in Sweden. BMC Gastroenterol 2024; 24:21. [PMID: 38182992 PMCID: PMC10770890 DOI: 10.1186/s12876-023-03110-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024] Open
Abstract
BACKGROUND Liver disorders are important adverse effects associated with antifungal drug treatment. However, the accuracy of Clinical International Classification of Diseases (ICD)-10 codes in identifying liver disorders for register based research is not well-established. This study aimed to determine the positive predictive value (PPV) of the ICD-10 codes for identifying patients with toxic liver disease, hepatic failure, and jaundice among patients with systemic antifungal treatment. METHODS Data from the Swedish Prescribed Drug Register and the National Patient Register were utilized to identify adult patients who received systemic azole antifungal drugs and had a recorded diagnosis of toxic liver disease (K71.0, K71.1, K71.2, K71.6, K71.8, K71.9), hepatic failure (K72.0, K72.9), or jaundice (R17) between 2005 and 2016. The medical records of all included patients were reviewed. Prespecified criteria were used to re-evaluate and confirm each diagnosis, serving as the gold standard to calculate PPVs with 95% confidence intervals (95% CI) for each diagnostic group. RESULTS Among the 115 included patients, 26 were diagnosed with toxic liver disease, 58 with hepatic failure, and 31 with jaundice. Toxic liver disease was confirmed in 14 out of 26 patients, yielding a PPV of 53.8% (95% CI 33.4-73.4%). Hepatic failure was confirmed in 26 out of 38 patients, resulting in a PPV of 62.1% (95% CI 48.4-74.5%). The highest PPV was found in jaundice, with 30 confirmed diagnoses out of 31, yielding a PPV of 96.8% (95% CI 83.3-99.9%). CONCLUSION Among patients who received azole antifungal treatment and were subsequently diagnosed with a liver disorder, the PPV for the diagnosis of jaundice was high, while the PPVs for toxic liver disease and hepatic failure were lower.
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Affiliation(s)
- Diego Hernan Giunta
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden.
| | - Pär Karlsson
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
| | - Muhammad Younus
- Safety Surveillance Research, Worldwide Medical and Safety, Pfizer Inc, Collegeville, PA, USA
| | - Ina Anveden Berglind
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
- Center for Occupational and Environmental Medicine, Stockholm Region, Stockholm, Sweden
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
| | - Johan Reutfors
- Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital T2:02, 171 76, Stockholm, Sweden
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Wu HY, Su TH, Liu CJ, Yang HC, Tsai JH, Wei MH, Chen CC, Tung CC, Kao JH, Chen PJ. Hepatitis B reactivation: A possible cause of coronavirus disease 2019 vaccine induced hepatitis. J Formos Med Assoc 2024; 123:88-97. [PMID: 37349170 PMCID: PMC10281508 DOI: 10.1016/j.jfma.2023.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/08/2023] [Accepted: 06/08/2023] [Indexed: 06/24/2023] Open
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19) vaccines were rapidly implemented globally and vaccine-associated immune-related hepatitis was recently reported. We aim to investigate its impact in regions endemic of chronic hepatitis B (CHB). METHODS We retrospectively collected patients who developed hepatitis within 90 days after COVID-19 vaccination in Taiwan. The mechanisms of hepatitis included vaccine induced liver injury (VILI) and immune-related hepatitis, which are direct liver injuries defined as aspartate or alanine aminotransferase (AST or ALT) increased ≥ 5-fold upper limit of normal (ULN) and/or AST or ALT ≥ 3-fold of ULN with concurrent total bilirubin ≥ 2-fold of ULN. Indirect liver injury due to HBV reactivation was defined as HBsAg reverse seroconversion or significant rise in HBV DNA level. The demographics, clinical data, and course of hepatitis were compared statistically. RESULTS Twenty-five patients were included with a median age of 54. The culprit vaccines were ChAdOx1 nCoV-19 (n = 9), mRNA-1273 (n = 12), and BNT162b2 (n = 4). The characteristics of hepatitis were comparable regardless of vaccine subtypes. The median onset of hepatitis was 25 days post vaccination, with a peak of 10-fold ALT-increase. The etiologies included HBV reactivation (n = 10), VILI (n = 10), and immune-related hepatitis (n = 5). HBV reactivation accounts for 90% of vaccine-induced hepatitis in patients of CHB (n = 10), and two patients died. Patients with initial AST levels >500 U/L increased 27-fold risks of liver injury greater than moderate severity compared with those without. CONCLUSION COVID-19 vaccine induced hepatitis is a clinical significant complication, and HBV reactivation may account for a possible mechanism.
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Affiliation(s)
- Hsin-Yun Wu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Tung-Hung Su
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.
| | - Chun-Jen Liu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Hung-Chih Yang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Huei Tsai
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Han Wei
- Division of Gastroenterology, Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, BioMedical Park Hospital, HsinChu, Taiwan
| | - Chieh-Chang Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Chih Tung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Jia-Horng Kao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Pei-Jer Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan.
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Wang Y, She S, Li W, Zhu J, Li X, Yang F, Dai K. Inhibition of cGAS-STING pathway by stress granules after activation of M2 macrophages by human mesenchymal stem cells against drug induced liver injury. Mol Immunol 2024; 165:42-54. [PMID: 38150981 DOI: 10.1016/j.molimm.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 11/05/2023] [Accepted: 12/14/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE Cells can produce stress granules (SGs) to protect itself from damage under stress. The cGAS-STING pathway is one of the important pattern recognition pathways in the natural immune system. This study was investigated whether human mesenchymal stem cells (hMSCs) could protect the liver by inducing M2 macrophages to produce SGs during acute drug induced liver injury (DILI) induced by acetaminophen (APAP). METHODS After intragastric administration of APAP in vivo to induce DILI mice model, hMSCs were injected into the tail vein. The co-culture system of hMSCs and M2 macrophages was established in vitro. It was further use SGs inhibitor anisomicin to intervene M2 macrophages. The liver histopathology, liver function, reactive oxygen species (ROS) level, apoptosis pathway, endoplasmic reticulum stress (ERS) level, SGs markers (G3BP1/TIA-1), cGAS-STING pathway, TNF-α, IL-6, IL-1β mRNA levels in liver tissue and M2 macrophages were observed. RESULTS In vivo experiments, it showed that hMSCs could alleviate liver injury, inhibite the level of ROS, apoptosis and ERS, protect liver function in DILI mice. The mount of M2 was increased in the liver. hMSCs could also induce the production of SGs, inhibit the cGAS-STING pathway and reduce TNF-α, IL-6, IL-1β mRNA expression. The results in vitro showed that hMSCs could induce the production of SGs in macrophages, inhibit the cGAS-STING pathway, promote the secretion of IL-4 and IL-13, and reduce TNF-α, IL-6, IL-1β mRNA level in cells. In the process of IL-4 inducing M2 macrophage activation, anisomycin could inhibit the production of SGs, activate the cGAS-STING pathway, and promote the inflammatory factor TNF-α, IL-6, IL-1β mRNA expression in cells. CONCLUSIONS HMSCs had a protective effect on acute DILI in mice induced by APAP. Its mechanism might involve in activating M2 type macrophages, promoting the production of SGs, inhibiting the cGAS-STING pathway, and reducing the expression of pro-inflammatory factors in macrophages, to reduce hepatocytes damage.
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Affiliation(s)
- Yao Wang
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Sha She
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Wenyuan Li
- Department of Anesthesiology, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Jiling Zhu
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Xun Li
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Fan Yang
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China.
| | - Kai Dai
- Department of Infectious Diseases, Renmin Hospital of Wuhan University, Wuhan 430060, China.
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Thakral N, Konjeti VR, Salama FW. Drug induced autoimmune hepatitis: An unfortunate case of herbal toxicity from Skullcap supplement: A case report. World J Hepatol 2023; 15:1333-1337. [PMID: 38223420 PMCID: PMC10784811 DOI: 10.4254/wjh.v15.i12.1333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/14/2023] [Accepted: 11/24/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND The surge in traditional herbal dietary supplement (HDS) popularity has led to increased drug-induced liver injuries (DILI). Despite lacking evidence of efficacy and being prohibited from making medical claims, their acceptance has risen over sevenfold in the last two decades, with roughly 25% of United States (US) adults using these supplements monthly. An estimated 23000 emergency room visits annually in the US are linked to HDS side effects. NIH-funded research suggests HDS contribute to 7-20% of DILI cases, with similar trends in Europe-Spain reporting 2% and Iceland up to 16%. Patients with acute liver failure from HDS undergo liver transplantation more frequently than those from prescription medicines. Here we describe a case of drug-induced autoimmune hepatitis due to Skullcap supplements, this association appears to be the first documented instance in literature. CASE SUMMARY A middle-aged Caucasian woman, previously healthy, presented with sudden jaundice. Four months earlier, her liver enzymes were normal. She mentioned recent use of Skullcap mushroom supplements. Tests for chronic liver disease were negative. The first liver biopsy indicated severe resolving drug-induced liver injury. Despite treatment, she was readmitted due to worsening jaundice. Follow-up tests raised concerns about autoimmune hepatitis. A subsequent biopsy confirmed this diagnosis. The patient responded as expected to stopping the medication with improvement in liver enzymes. CONCLUSION This scenario highlights an uncommon instance of DILI caused by Skullcap supplements. It's crucial for hepatologists to recognize this connection due to the increasing prevalence of herbal supplements.
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Affiliation(s)
- Nimish Thakral
- Department of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY 40536, United States.
| | - Venkata Rajesh Konjeti
- Department of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY 40536, United States
| | - Fady William Salama
- Department of Digestive Diseases and Nutrition, University of Kentucky, Lexington, KY 40536, United States
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Du Q, Teng M, Yang L, Meng C, Qiu Y, Wang C, Chen J, Wang T, Chen S, Luo Y, Sun J, Dong Y. Metabolic characteristics of voriconazole - Induced liver injury in rats. Chem Biol Interact 2023; 383:110693. [PMID: 37659626 DOI: 10.1016/j.cbi.2023.110693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/14/2023] [Accepted: 08/30/2023] [Indexed: 09/04/2023]
Abstract
Voriconazole (VOR) - induced liver injury is a common adverse reaction, and can lead to serious clinical outcomes. It is of great significance to describe the metabolic characteristics of VOR - induced liver injury and to elucidate the potential mechanisms. This study investigated the changes of plasma metabolic profiles in a rat model of VOR - induced liver injury by non - targeted metabolomics. Correlation analysis was performed between differentially expressed metabolites and plasma liver function indexes. The metabolites with strong correlation were determined for their predictive performance for liver injury using receiver operating characteristic (ROC) curve analysis. Potential biomarkers were then screened combined with liver pathological scores. Finally, the expression level of genes that involved in lipid metabolism were determined in rat liver to verify the mechanism of VOR - induced liver injury we proposed. VOR - induced liver injury in rats was characterized by plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) elevation, the lipid droplets accumulation in liver, as well as inflammation and fibrosis. Significant changes of plasma metabolites were observed, with a decrease in lipid metabolites accounting for over 50% of all changed metabolites, and alterations of cholesterol and bile acids metabolites. The decrease of 3 phosphatidylcholine (PC) in plasma could indicate the occurrence of VOR - induced liver injury. Decreased fatty acids (FA) oxidation and bile acid excretion might be the potential mechanisms of VOR - induced liver injury. This study provided new insights into the molecular characterization of VOR - induced liver injury.
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Affiliation(s)
- Qian Du
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Mengmeng Teng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Luting Yang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Chao Meng
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yulan Qiu
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Chuhui Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Jiaojiao Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Taotao Wang
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Siying Chen
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yu Luo
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Jinyao Sun
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China
| | - Yalin Dong
- Department of Pharmacy, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710061, China.
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12
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Timmery E, Binet Q, Delire B, Horsmans Y. Acute hepatitis induced by Guduchi; Letter to the editor. Clin Res Hepatol Gastroenterol 2023; 47:102151. [PMID: 37269895 DOI: 10.1016/j.clinre.2023.102151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/18/2023] [Accepted: 05/27/2023] [Indexed: 06/05/2023]
Affiliation(s)
- Emilie Timmery
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
| | - Quentin Binet
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Benedicte Delire
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Yves Horsmans
- Department of Gastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
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13
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Monte AA, Vest A, Reisz JA, Berninzoni D, Hart C, Dylla L, D'Alessandro A, Heard KJ, Wood C, Pattee J. A Multi-Omic Mosaic Model of Acetaminophen Induced Alanine Aminotransferase Elevation. J Med Toxicol 2023; 19:255-261. [PMID: 37231244 PMCID: PMC10212224 DOI: 10.1007/s13181-023-00951-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/13/2023] [Accepted: 05/18/2023] [Indexed: 05/27/2023] Open
Abstract
BACKGROUND Acetaminophen (APAP) is the most common cause liver injury following alcohol in US patients. Predicting liver injury and subsequent hepatic regeneration in patients taking therapeutic doses of APAP may be possible using new 'omic methods such as metabolomics and genomics. Multi'omic techniques increase our ability to find new mechanisms of injury and regeneration. METHODS We used metabolomic and genomic data from a randomized controlled trial of patients administered 4 g of APAP per day for 14 days or longer with blood samples obtained at 0 (baseline), 4, 7, 10, 13 and 16 days. We used the highest ALT as the clinical outcome to be predicted in our integrated analysis. We used penalized regression to model the relationship between genetic variants and day 0 metabolite level, and then performed a metabolite-wide colocalization scan to associate the genetically regulated component of metabolite expression with ALT elevation. Genome-wide association study (GWAS) analyses were conducted for ALT elevation and metabolite level using linear regression, with age, sex, and the first five principal components included as covariates. Colocalization was tested via a weighted sum test. RESULTS Out of the 164 metabolites modeled, 120 met the criteria for predictive accuracy and were retained for genetic analyses. After genomic examination, eight metabolites were found to be under genetic control and predictive of ALT elevation due to therapeutic acetaminophen. The metabolites were: 3-oxalomalate, allantoate, diphosphate, L-carnitine, L-proline, maltose, and ornithine. These genes are important in the tricarboxylic acid cycle (TCA), urea breakdown pathway, glutathione production, mitochondrial energy production, and maltose metabolism. CONCLUSIONS This multi'omic approach can be used to integrate metabolomic and genomic data allowing identification of genes that control downstream metabolites. These findings confirm prior work that have identified mitochondrial energy production as critical to APAP induced liver injury and have confirmed our prior work that demonstrate the importance of the urea cycle in therapeutic APAP liver injury.
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Affiliation(s)
- Andrew A Monte
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA.
- Center for Bioinformatics & Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
- Skaggs School of Pharmacy, University of Colorado, Aurora, CO, USA.
- Denver Health and Hospital Authority, Rocky Mountain Poison & Drug Center, Denver, CO, USA.
| | - Alexis Vest
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Julie A Reisz
- Metabolomics Core, Department of Biochemistry and Molecular Genetics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Danielle Berninzoni
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Claire Hart
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
| | - Layne Dylla
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
- Center for Bioinformatics & Personalized Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Angelo D'Alessandro
- Metabolomics Core, Department of Biochemistry and Molecular Genetics, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Kennon J Heard
- Department of Emergency Medicine, University of Colorado School of Medicine, Leprino Building, 7th Floor Campus Box B-215, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
- Denver Health and Hospital Authority, Rocky Mountain Poison & Drug Center, Denver, CO, USA
| | - Cheyret Wood
- Department of Biostatistics & Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
| | - Jack Pattee
- Department of Biostatistics & Informatics, Colorado School of Public Health, University of Colorado-Denver Anschutz Medical Campus, Aurora, CO, USA
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14
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Sukumaran D, Usharani P, Paramjyothi GK, Subbalaxmi MVS, Sireesha K, Abid Ali M. A study to evaluate the hepatoprotective effect of N- acetylcysteine on anti tuberculosis drug induced hepatotoxicity and quality of life. Indian J Tuberc 2023; 70:303-310. [PMID: 37562904 DOI: 10.1016/j.ijtb.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 05/26/2022] [Indexed: 08/12/2023]
Abstract
BACKGROUND Drug induced liver injury (DILI) is a serious adverse effect caused by first-line anti-TB (ATT) drugs, limiting the TB-treatment. The tissue inflammation induced by free radical burst and poor dietary intake in TB induces oxidative stress, which was proposed as one of the mechanisms responsible for ATT induced DILI. N-acetylcysteine (NAC) exerts a hepato-protective effect by enhancing the cellular antioxidant defense mechanism. There are few studies evaluating the effect of NAC on ATT induced DILI in Indian-population. METHODS This is a prospective, randomized, double-blind, placebo-controlled, parallel-group study. Thirty-eight newly diagnosed TB patients on first-line ATT with normal liver function test (LFT) were recruited and randomized to receive either NAC 600 mg tablet or placebo twice daily for 4 weeks and followed-up for next 4 weeks. LFT [AST, ALT, ALP and Total bilirubin] was assessed at baseline, 2, 4 and 8 weeks. Oxidative-stress biomarkers [Malondialdehyde (MDA), Nitric Oxide (NO), Glutathione (GSH)] and quality of life (QOL) by SF-36 questionnaire were assessed at baseline, 4 and 8 weeks. Adverse Drug Reactions (ADRs) were monitored at every visit. Compliance was assessed by pill-count method. RESULTS Baseline characteristics were homogenous among both the groups. In the NAC group, there was significant reduction in ALT (p < 0.01), ALP (p < 0.01), total bilirubin (p < 0.001) at 4 weeks compared to baseline. AST, MDA and NO showed a reduction of 19%, 21.6% and 5.5% respectively from baseline and GSH at showed an increase of 2.6% from baseline at 4 weeks in the NAC group, however these were not statistically significant. These effects in LFT and oxidative biomarkers persisted even at the end of 8 weeks. Significant improvement from baseline in QOL was observed in both the groups (p < 0.05). Between group analysis showed, significant reduction in ALT (p < 0.05) and AST (p < 0.05) in NAC group at 4 weeks, whereas bilirubin, MDA, NO and GSH showed improvement at 4 weeks compared to placebo in NAC group, however it was not statistically significant. This improvement in the LFT and oxidative biomarkers continued even at the end of 8 weeks. Itching and rashes were the most common ADRs, with similar incidence in both the groups. Compliance to treatment was good in both the groups. CONCLUSION Significant improvement in liver function parameters is suggestive of hepatoprotective effect of NAC. This observed effect at 4 weeks was found to be persistent at 8 weeks, which signifies prolonged hepato-protective effect of NAC. Long duration studies with large sample size are required for further confirmation of hepato-protective action of NAC.
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Affiliation(s)
- Deepasree Sukumaran
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad.
| | - P Usharani
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad
| | - G K Paramjyothi
- Department of Pulmonary Medicine, Nizam's Institute of Medical Sciences, Hyderabad
| | - M V S Subbalaxmi
- Department of General Medicine, Nizam's Institute of Medical Sciences, Hyderabad
| | - K Sireesha
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad
| | - Mohammed Abid Ali
- Department of Clinical Pharmacology and Therapeutics, Nizam's Institute of Medical Sciences, Hyderabad
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15
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Juneja D, Nasa P, Jain R. Liver injury from direct oral anticoagulants. World J Hepatol 2023; 15:841-849. [PMID: 37397936 PMCID: PMC10308284 DOI: 10.4254/wjh.v15.i6.841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/23/2023] [Accepted: 05/15/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Drug-induced liver injury (DILI) can be caused by any prescribed drug and is a significant reason for the withdrawal of newly launched drugs. Direct-acting oral anticoagulants (DOACs) are non-vitamin K-based antagonists recently introduced and increasingly used for various clinical conditions. A meta-analysis of 29 randomised controlled trials and 152116 patients reported no increased risk of DILI with DOACs. However, it is challenging to predict the risk factors for DILI in individual patients with exclusion of patients with pre-existing liver disease from these studies.
AIM To determine the risk factors and outcomes of patients who developed DILI secondary to DOACs by systematic review and meta-summary of recent case reports and series.
METHODS A systematic search was conducted on multiple databases including PubMed, Science Direct, Reference Citation Analysis, and Google Scholar. The search terms included “Acute Liver Failure” OR “Acute-On-Chronic Liver Failure” OR “Acute Chemical and Drug Induced Liver Injury” OR “Chronic Chemical and Drug Induced Liver Injury” AND “Factor Xa Inhibitors” OR “Dabigatran” OR “Rivaroxaban” OR “apixaban” OR “betrixaban” OR “edoxaban” OR “Otamixaban”. The results were filtered for literature published in English and on adult patients. Only case reports and case studies reporting cases of DILI secondary to DOACs were included. Data on demographics, comorbidities, medication history, laboratory investigations, imaging, histology, management, and outcomes were extracted.
RESULTS A total of 15 studies (13 case reports and 2 case series) were included in the analysis, comprising 27 patients who developed DILI secondary to DOACs. Rivaroxaban was the most commonly implicated DOAC (n = 20, 74.1%). The mean time to onset of DILI was 40.6 d. The most common symptoms were jaundice (n = 15, 55.6%), malaise (n = 9, 33.3%), and vomiting (n = 9, 33.3%). Laboratory investigations showed elevated liver enzymes and bilirubin levels. Imaging studies and liver biopsies revealed features of acute hepatitis and cholestatic injury. Most patients had a favourable outcome, and only 1 patient (3.7%) died due to liver failure.
CONCLUSION DOACs are increasingly used for various clinical conditions, and DILI secondary to DOACs is a rare but potentially serious complication. Prompt identification and cessation of the offending drug are crucial for the management of DILI. Most patients with DILI secondary to DOACs have a favourable outcome, but a small proportion may progress to liver failure and death. Further research, including post-marketing population-based studies, is needed to better understand the incidence and risk factors for DILI secondary to DOACs.
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Affiliation(s)
- Deven Juneja
- Institute of Critical Care Medicine, Max Super Specialty Hospital, New Delhi 110017, India
| | - Prashant Nasa
- Critical Care Medicine, NMC Specialty Hospital, Dubai 7832, United Arab Emirates
- Internal Medicine, College of Medicine and Health Sciences, Al Ain 15551, United Arab Emirates
| | - Ravi Jain
- Critical Care Medicine, Mahatma Gandhi Medical College and Hospital, Jaipur 302001, Rajasthan, India
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16
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Whitaker LH, Middleton LJ, Daniels JP, Williams AR, Priest L, Odedra S, Cheed V, Stubbs CE, Clark TJ, Lumsden MA, Hapangama DK, Bhattacharya S, Smith PP, Nicholls EP, Roberts N, Semple SI, Saraswat L, Walker J, Chodankar RR, Critchley HO. Ulipristal acetate versus levonorgestrel-releasing intrauterine system for heavy menstrual bleeding (UCON): a randomised controlled phase III trial. EClinicalMedicine 2023; 60:101995. [PMID: 37251622 PMCID: PMC10209678 DOI: 10.1016/j.eclinm.2023.101995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/16/2023] [Accepted: 04/19/2023] [Indexed: 05/31/2023] Open
Abstract
Background Heavy menstrual bleeding affects one in four women and negatively impacts quality of life. Ulipristal acetate is prescribed to treat symptoms associated with uterine fibroids. We compared the effectiveness of ulipristal acetate and the levonorgestrel-releasing intrauterine system at reducing the burden of heavy menstrual bleeding, irrespective of the presence of fibroids. Methods This randomised, open-label, parallel group phase III trial enrolled women over 18 years with heavy menstrual bleeding from 10 UK hospitals. Participants were centrally randomised, in a 1:1 ratio, to either three, 12-week treatment cycles of 5 mg ulipristal acetate daily, separated by 4-week treatment-free intervals, or a levonorgestrel-releasing intrauterine system. The primary outcome, analysed by intention-to-treat, was quality of life measured by the Menorrhagia Multi-Attribute Scale at 12 months. Secondary outcomes included menstrual bleeding and liver function. The trial is registered with ISRCTN, 20426843. Findings Between June 5th, 2015 and February 26th, 2020, 236 women were randomised, either side of a recruitment suspension due to concerns of ulipristal acetate hepatoxicity. Subsequent withdrawal of ulipristal acetate led to early cessation of recruitment but the trial continued in follow-up. The primary outcome substantially improved in both groups, and was 89, (interquartile range [IQR] 65 to 100, n = 53) and 94, (IQR 70 to 100, n = 50; adjusted odds ratio 0.55, 95% confidence interval [CI] 0.26-1.17; p = 0.12) in the ulipristal and levonorgestrel-releasing intrauterine system groups. Rates of amenorrhoea at 12 months were higher in those allocated ulipristal acetate compared to levonorgestrel-releasing intrauterine system (64% versus 25%, adjusted odds ratio 7.12, 95% CI 2.29-22.2). Other outcomes were similar between the two groups and there were no cases of endometrial malignancy or hepatotoxicity due to ulipristal acetate use. Interpretation Our findings suggested that both treatments improved quality of life. Ulipristal was more effective at inducing amenorrhoea. Ulipristal has been demonstrated to be an effective medical therapeutic option but currently its use has restrictions and requires liver function monitoring. Funding UK Medical Research Council and National Institute of Health Research EME Programme (12/206/52).
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Affiliation(s)
- Lucy H.R. Whitaker
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Lee J. Middleton
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Jane P. Daniels
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
| | | | - Lee Priest
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Smita Odedra
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Versha Cheed
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Clive E. Stubbs
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | | | - Mary-Ann Lumsden
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
| | - Dharani K. Hapangama
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
| | | | - Paul P. Smith
- Birmingham Women's and Children's Hospital, Birmingham, UK
| | | | - Neil Roberts
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Scott I. Semple
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Jane Walker
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rohan R. Chodankar
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | | | - UCON Collaborative
- MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
- Nottingham Clinical Trials Unit, University of Nottingham, Nottingham, UK
- Division of Pathology, University of Edinburgh, Edinburgh, UK
- Birmingham Women's and Children's Hospital, Birmingham, UK
- Reproductive & Maternal Medicine, University of Glasgow, Glasgow, UK
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- University of Aberdeen, Aberdeen, UK
- Adcal H.R. Consultancy, UK (PPI representative)
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Clinical Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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17
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Ferronato M, Lenzi M, Muratori L. Liver injury with autoimmune features after vaccination against SARS-CoV-2: The verdict is still open. Eur J Intern Med 2023; 108:108-110. [PMID: 36261309 PMCID: PMC9534794 DOI: 10.1016/j.ejim.2022.09.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 09/18/2022] [Accepted: 09/20/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Marco Ferronato
- DIMEC Università di Bologna, IRCCS Policlinico di Sant'Orsola, Italy.
| | - Marco Lenzi
- DIMEC Università di Bologna, IRCCS Policlinico di Sant'Orsola, Italy
| | - Luigi Muratori
- DIMEC Università di Bologna, IRCCS Policlinico di Sant'Orsola, Italy
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18
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Milionis C, Ilias I, Koukkou E. Liver function in transgender persons: Challenges in the COVID-19 era. World J Clin Cases 2023; 11:299-307. [PMID: 36686345 PMCID: PMC9850971 DOI: 10.12998/wjcc.v11.i2.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/23/2022] [Accepted: 12/27/2022] [Indexed: 01/12/2023] Open
Abstract
Transgender persons constitute a non-negligible percentage of the general population. Physical gender-transitioning in trans persons is mainly achieved with hormonal cross-sex therapy and sex reassignment surgeries that aim to align bodily appearance with gender identity. Hormonal treatment acts via suppressing the secretion of the endogenous sex hormones and replacing them with the hormones of the desired sex. The administration of testosterone is the typical masculinizing treatment in trans men, whilst trans women are routinely treated with estradiol agents in combination with anti-androgens or gonadotrophin-releasing hormone agonists if testes are present. Exogenous androgenic steroids, estradiol agents, and anti-androgens have been implicated in a series of hepatotoxic effects. Thus, liver integrity is a major concern with the long-term administration of cross-sex therapy. Hepatic tissue is susceptible to coronavirus disease 19 (COVID-19) through various pathophysiological mechanisms. Special consideration should be paid to minimize the risk of hepatic damage from the potential cumulative effect of COVID-19 and gender-affirming treatment in transgender patients. Appropriate care is significant, with continuous laboratory monitoring, clinical observation and, if needed, specific treatment, especially in severe cases of infection and in persons with additional liver pathologies. The pandemic can be an opportunity to provide equal access to care for all and increase the resilience of the transgender population.
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Affiliation(s)
- Charalampos Milionis
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Ioannis Ilias
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
| | - Eftychia Koukkou
- Department of Endocrinology, Diabetes and Metabolism, Elena Venizelou Hospital, Athens GR-11521, Greece
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19
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Oscanoa TJ, Vidal X, Luque J, Julca DI, Romero-Ortuno R. Hepatotoxicity induced by isoniazid in patients with latent tuberculosis infection: a meta-analysis. Gastroenterol Hepatol Bed Bench 2023; 16:448-457. [PMID: 37070117 PMCID: PMC10105504 DOI: 10.22037/ghfbb.v16i1.2685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/26/2022] [Indexed: 04/19/2023]
Abstract
Aim The aim of the present study was to conduct a meta-analysis of the frequency of isoniazid-induced liver injury (INH-ILI) in patients receiving isoniazid (INH) preventative therapy (IPT). Background The frequency of hepatotoxicity (drug-induced liver injury: DILI) of antituberculosis drugs has been studied, especially when INH, rifampin, and pyrazinamide are co-administered. However, little is known about the frequency of DILI in patients with latent tuberculosis infection (LTBI), where IPT is indicated. Methods We searched PubMed, Google Scholar, and the Cochrane Database of Systematic Reviews for studies reporting the frequency of INH-ILI in patients with IPT using one or more diagnostic indicators included in the criteria of the DILI Expert Working Group. Results Thirty-five studies comprising a total of 22,193 participants were included. The overall average frequency of INH-ILI was 2.6% (95% CI, 1.7-3.7%). The mortality associated with INH-DILI was 0.02% (4/22193). Subgroup analysis revealed no significant differences in the frequency of INH-ILI in patients older or younger than 50 years, children, patients with HIV, candidates for liver, kidney, or lung transplant, or according to the type of study design. Conclusion The frequency of INH-ILI in patients receiving IPT is low. Studies on INH-ILI are needed where the current DILI criteria are used.
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Affiliation(s)
- Teodoro J. Oscanoa
- Universidad Nacional Mayor de San Marcos. Facultad de Medicina, Lima, Perú
- Universidad de San Martín de Porres. Facultad de Medicina Humana. Drug Safety Research Center, Lima, Perú
- Servicio de Geriatría del Hospital Almenara, ESSALUD, Lima, Peru
| | - Xavier Vidal
- Vall d'Hebron University Hospital, Clinical Pharmacology, Barcelona, Spain
| | - Julio Luque
- Universidad de San Martín de Porres. Facultad de Medicina Humana. Drug Safety Research Center, Lima, Perú
| | - Dante I. Julca
- Universidad Nacional Mayor de San Marcos. Facultad de Medicina, Lima, Perú
| | - Roman Romero-Ortuno
- Discipline of Medical Gerontology, Mercer’s Institute for Successful Ageing, St James’s Hospital, Dublin, Ireland
- Global Brain Health Institute, Trinity College Dublin, Ireland
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20
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Tabrizi N, Sharifi-Razavi A. Potential risk of liver injury in epileptic patients during COVID-19 pandemic. World J Virol 2022; 11:467-476. [PMID: 36483103 PMCID: PMC9724200 DOI: 10.5501/wjv.v11.i6.467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/08/2022] [Accepted: 10/28/2022] [Indexed: 11/23/2022] Open
Abstract
Most of the antiseizure medications (ASMs) are metabolized in liver and many of them particularly first-generation ASMs have the potential to increase liver enzymes or induce liver injury. Hence, treatment of new onset seizures or epilepsy by ASMs during the course of coronavirus disease 2019 (COVID-19), which could potentially be complicated by hepatic dysfunction, is a challenging clinical issue. Intravenous form of levetiracetam which has no significant hepatic metabolism or drug-drug interaction is often a favorable option to control seizures in acute phase of COVID-19. Administration of enzyme inducer ASMs and valproate with the well-known hepatotoxicity and common drug interactions is not generally recommended. In patients with epilepsy who are under control with potentially hepatotoxic ASMs, close observation and cautious dose reduction or drug switch should be considered if any evidence of hepatic impairment exists. However, risks of possible breakthrough seizures should be weighed against benefits of lowering the hazard of liver injury. In patients with epilepsy who receive polytherapy with ASMs, transient dose modification with the tendency to increase the dose of ASMs with more favorable safety profile and less drug interaction and decrease the dose of drugs with main hepatic metabolism, high protein binding, potential to cause liver injury and known drug-drug reaction should be considered. Finally, decision making should be individualized based on patients’ conditions and course of illness.
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Affiliation(s)
- Nasim Tabrizi
- Department of Neurology, Mazandaran University of Medical Sciences, Sari 4815838477, Iran
| | - Athena Sharifi-Razavi
- Department of Neurology, Mazandaran University of Medical Sciences, Sari 4815838477, Iran
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21
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Ezhilarasan D, Mani U. Valproic acid induced liver injury: An insight into molecular toxicological mechanism. Environ Toxicol Pharmacol 2022; 95:103967. [PMID: 36058508 DOI: 10.1016/j.etap.2022.103967] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/22/2022] [Accepted: 08/29/2022] [Indexed: 06/15/2023]
Abstract
Valproic acid (VPA) is an anti-seizure drug that causes idiosyncratic liver injury. 2-propyl-4-pentenoic acid (Δ4VPA), a metabolite of VPA, has been implicated in VPA-induced hepatotoxicity. This review summarizes the pathogenesis involved in VPA-induced liver injury. The VPA induce liver injury mainly by i) liberation of Δ4VPA metabolites; ii) decrease in glutathione stores and antioxidants, resulting in oxidative stress; iii) inhibition of fatty acid β-oxidation, inducing mitochondrial DNA depletion and hypermethylation; a decrease in proton leak; oxidative phosphorylation impairment and ATP synthesis decrease; iv) induction of fatty liver via inhibition of carnitine palmitoyltransferase I, enhancing nuclear receptor peroxisome proliferator-activated receptor-gamma and acyl-CoA thioesterase 1, and inducing long-chain fatty acid uptake and triglyceride synthesis. VPA administration aggravates liver injury in individuals with metabolic syndromes. Therapeutic drug monitoring, routine serum levels of transaminases, ammonia, and lipid parameters during VPA therapy may thus be beneficial in improving the safety profile or preventing the progression of DILI.
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Affiliation(s)
- Devaraj Ezhilarasan
- Department of Pharmacology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu 600 077, India.
| | - Uthirappan Mani
- Animal House Division, CSIR-Central Leather Research Institute, Adyar, Chennai 600 020, India
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22
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Cui J, Chasman DI, Raychaudhuri S, Xu C, Ridker PM, Solomon DH, Karlson EW. Genetics are not likely to offer clinically useful predictions for elevated liver enzyme levels in patients using low dose methotrexate. Semin Arthritis Rheum 2022; 55:152036. [PMID: 35671649 PMCID: PMC10782828 DOI: 10.1016/j.semarthrit.2022.152036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/25/2022] [Accepted: 05/27/2022] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To examine genetic influence on the risk of elevations in liver function tests (AST and ALT) among patients using low-dose methotrexate (LD-MTX). METHODS We examined data from the LD-MTX arm of a randomized double-blind placebo-controlled trial conducted among subjects without rheumatic disease. Genome wide association studies (GWAS) were performed in subjects of European ancestry to test the association between single nucleotide polymorphisms (SNPs) and the log transformed maximum values of AST, ALT, and dichotomized outcome with AST or ALT > 2 times upper limit of normal (ULN). The association between variants in MTX metabolism candidate genes and the outcomes was also tested. Furthermore, associations between a drug induced liver injury (DILI) weighted genetic risk score (wGRS) and the outcomes were tested, combining 10 SNPs and 11 classical HLA alleles associated with DILI. RESULTS In genome-wide genetic analyses among 1,429 subjects of European ancestry who were randomized to receive LD-MTX, two SNPs reached genome wide significance for association with log transformed maximum ALT. We observed associations between established candidate genes in MTX pharmacogenetics and log transformed maximum AST and ALT, as well as in dichotomized outcome with AST or ALT > 2 x ULN. There was no association between DILI wGRS or candidate variants and AST, ALT, or DILI response. CONCLUSIONS Modest evidence was observed that common variants affected AST and ALT levels in subjects of European ancestry on LD-MTX, but this genetic effect is not useful as a clinical predictor of MTX toxicity.
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Affiliation(s)
- Jing Cui
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA.
| | - Daniel I Chasman
- Division of Preventive Medicine, Brigham and Women's Hospital USA; Division of Genetics, Brigham and Women's Hospital, Boston, MA USA
| | - Soumya Raychaudhuri
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA; Division of Genetics, Brigham and Women's Hospital, Boston, MA USA
| | - Chang Xu
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
| | - Paul M Ridker
- Division of Preventive Medicine, Brigham and Women's Hospital USA
| | - Daniel H Solomon
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
| | - Elizabeth W Karlson
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital USA
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23
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Zhang H, Zhang HR, Hu ML, Qi HZ. Development of binary classification models for assessment of drug-induced liver injury in humans using a large set of FDA-approved drugs. J Pharmacol Toxicol Methods 2022; 116:107185. [PMID: 35623583 DOI: 10.1016/j.vascn.2022.107185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/13/2022] [Accepted: 05/18/2022] [Indexed: 02/05/2023]
Abstract
Drug-induced liver injury (DILI) has been identified as one of the major causes for drugs withdrawn from the market, and even termination during the late stages of development. Therefore, it is imperative to evaluate the DILI potential of lead compounds during the research and development process. Although various computational models have been developed to predict DILI, most of which applied the DILI data were extracted from preclinical sources. In this investigation, the in silico prediction models for DILI were constructed based on 1140 FDA-approved drugs by using naïve Bayes classifier approach. The genetic algorithm method was applied for the molecular descriptors selection. Among these established prediction models, the NB-11 model based on eight molecular descriptors combined with ECFP_18 showed the best prediction performance for DILI, which gave 91.7% overall prediction accuracy for the training set, and 68.9% concordance for the external test set. Therefore, the established NB-11 prediction model can be used as a reliable virtual screening tool to predict DILI adverse effect in the early stages of drug design. In addition, some new structural alters for DILI were identified, which could be used for structural optimization in the future drug design by medicinal chemists.
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Affiliation(s)
- Hui Zhang
- College of Life Science, Northwest Normal University, Lanzhou, Gansu 730070, PR China; State Key Laboratory of Biotherapy and Cancer Center, West China Hospital, West China Medical School, Sichuan University, Chengdu, Sichuan 610041, PR China.
| | - Hong-Rui Zhang
- College of Life Science, Northwest Normal University, Lanzhou, Gansu 730070, PR China
| | - Mei-Ling Hu
- College of Life Science, Northwest Normal University, Lanzhou, Gansu 730070, PR China
| | - Hua-Zhao Qi
- College of Life Science, Northwest Normal University, Lanzhou, Gansu 730070, PR China
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24
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Santos G, Figueira ERR, D'Albuquerque LAC, Lisboa PB, de Almeida MD, Filgueira NA, Boin I, Porta G, da Silva RDCMA, Viana CFG, Faria LC, Alvares-da-Silva MR, de Moraes ACP, Morsoletto DBG, Codes L, Paraná R. Evaluation of drug-induced liver injury as etiology for acute liver failure in Brazil. Ann Hepatol 2022; 23:100310. [PMID: 33508520 DOI: 10.1016/j.aohep.2021.100310] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/10/2020] [Accepted: 12/11/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Little is known about the etiology of acute liver failure (ALF) in Latin America. The objective of this paper is to investigate the main etiologies of ALF in Brazil, including Drug Induced Liver Injury (DILI) using stringent causality criteria. PATIENTS OR MATERIAL AND METHODS All the cases of individuals who underwent liver transplantation (LT) in 12 centers in Brazil for ALF were reviewed. When DILI was stated as the cause of ALF, causality criteria were applied on site by the main investigator in order to rule out other etiologies. RESULTS 325 individuals had ALF mainly for unknown reasons (34%), DILI (27%) and AIH (18%). Reassessment of the 89 cases of DILI, using stringent causality criteria, revealed that in only 42 subjects could DILI be confirmed as the cause of ALF. Acetaminophen (APAP) toxicity (n = 3) or DILI due to herbal and dietary supplements (HDS) (n = 2) were not commonly observed. CONCLUSIONS Undetermined etiology and DILI are the main causes of ALF in Brazil. However, APAP toxicity and DILI due to HDS are mostly uncommon.
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Affiliation(s)
- Genario Santos
- Health Science Postgraduation, Faculty of Medicine, University Federal of Bahia, Brazil.
| | - Estela Regina Ramos Figueira
- Department of Gastroenterology, Division of Digestive Surgery, Hospital das Clinicas of University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | - Luiz Augusto Carneiro D'Albuquerque
- Department of Gastroenterology, Division of Digestive Surgery, Hospital das Clinicas of University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | | | | | | | - Ilka Boin
- Medical Sciences Faculty of Campinas State University, Campinas, São Paulo, Brazil.
| | - Gilda Porta
- Department of Pediatrics, Children's Institute, Medical School of the University of São Paulo, São Paulo, Brazil.
| | | | | | - Luciana Costa Faria
- Department of Internal Medicine, Federal University of Minas Gerais, School of Medicine, Belo Horizonte-MG, Brazil.
| | | | | | | | - Liana Codes
- Unit of Gastroenterology and Hepatology, Portuguese Hospital, Salvador-BA, Brazil..
| | - Raymundo Paraná
- Health Science Postgraduation, Faculty of Medicine, University Federal of Bahia, Brazil.
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25
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Gaspar R, Branco CC, Macedo G. Liver manifestations and complications in inflammatory bowel disease: A review. World J Hepatol 2021; 13:1956-1967. [PMID: 35070000 PMCID: PMC8727205 DOI: 10.4254/wjh.v13.i12.1956] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/27/2021] [Accepted: 11/15/2021] [Indexed: 02/06/2023] Open
Abstract
Hepatobiliary manifestations are common in inflammatory bowel disease (IBD), with 30% of patients presenting abnormal liver tests and 5% developing chronic liver disease. They range from asymptomatic elevated liver tests to life-threatening disease and usually follow an independent course from IBD. The pathogenesis of liver manifestations or complications and IBD can be closely related by sharing a common auto-immune background (in primary sclerosing cholangitis, IgG4-related cholangitis, and autoimmune hepatitis), intestinal inflammation (in portal vein thrombosis and granulomatous hepatitis), metabolic impairment (in non-alcoholic fatty liver disease or cholelithiasis), or drug toxicity (in drug induced liver injury or hepatitis B virus infection reactivation). Their evaluation should prompt a full diagnostic workup to identify and readily treat all complications, improving management and outcome.
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Affiliation(s)
- Rui Gaspar
- Department of Gastroenterology and Hepatology, Centro Hospitalar de São João, Porto 4200, Portugal
| | - Catarina Castelo Branco
- Internal Medicine Department, Centro Hospitalar e Universitário do Porto, Porto 4200, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology and Hepatology, Centro Hospitalar de São João, Porto 4200, Portugal
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26
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Abstract
Drug use during pregnancy is not common. Drug-induced liver injury (DILI) is a potential complication that is rare but can adversely affect both the mother and the fetus. Although many drugs can directly cause hepatotoxicity, idiosyncratic liver injury is common in pregnancy. Underreporting of adverse drug reactions, lack of adequate literature regarding drug safety in pregnancy, and the inherent difficulty in diagnosing DILI during pregnancy make the management of this condition challenging. This review attempts to describe the existing literature regarding DILI in pregnancy, which is mainly in the form of case reports; several studies have looked at the safety of antithyroid drugs, antiretroviral drugs, and paracetamol, which have an indication for use in pregnancy; the relevant data from these studies with regard to DILI has been presented. In addition, the review describes the diagnosis of DILI, grading the disease severity, assessment of causality linking the drug to the adverse event, regulatory guidelines for evaluating the potential of drugs to cause liver injury, efforts to ensure better participation of women in clinical trials and studies in pregnant women population in particular, and the challenges involved in generating adequate research evidence. The establishment of DILI registries in various countries is an encouraging development; however, there is a need for promoting active, spontaneous reporting of adverse events during pregnancy to ensure rapid generation of evidence regarding the safety of a drug in pregnant women.
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Affiliation(s)
- Priyanka Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Ashwin Kamath
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
| | - Sheetal D Ullal
- Department of Pharmacology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India - 575001
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27
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Ballotin VR, Bigarella LG, Brandão ABDM, Balbinot RA, Balbinot SS, Soldera J. Herb-induced liver injury: Systematic review and meta-analysis. World J Clin Cases 2021; 9:5490-5513. [PMID: 34307603 PMCID: PMC8281430 DOI: 10.12998/wjcc.v9.i20.5490] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/03/2021] [Accepted: 05/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The use of herbal supplements and alternative medicines has been increasing in the last decades. Despite popular belief that the consumption of natural products is harmless, herbs might cause injury to various organs, particularly to the liver, which is responsible for their metabolism in the form of herb-induced liver injury (HILI).
AIM To identify herbal products associated with HILI and describe the type of lesion associated with each product.
METHODS Studies were retrieved using Medical Subject Headings Descriptors combined with Boolean operators. Searches were run on the electronic databases Scopus, Web of Science, MEDLINE, BIREME, LILACS, Cochrane Library for Systematic Reviews, SciELO, Embase, and Opengray.eu. Languages were restricted to English, Spanish, and Portuguese. There was no date of publication restrictions. The reference lists of the studies retrieved were searched manually. To access causality, the Maria and Victorino System of Causality Assessment in Drug Induced Liver Injury was used. Simple descriptive analysis were used to summarize the results.
RESULTS The search strategy retrieved 5918 references. In the final analysis, 446 references were included, with a total of 936 cases reported. We found 79 types of herbs or herbal compounds related to HILI. He-Shou-Wu, Green tea extract, Herbalife, kava kava, Greater celandine, multiple herbs, germander, hydroxycut, skullcap, kratom, Gynura segetum, garcinia cambogia, ma huang, chaparral, senna, and aloe vera were the most common supplements with HILI reported. Most of these patients had complete clinical recovery (82.8%). However, liver transplantation was necessary for 6.6% of these cases. Also, chronic liver disease and death were observed in 1.5% and 10.4% of the cases, respectively.
CONCLUSION HILI is normally associated with a good prognosis, once the implied product is withdrawn. Nevertheless, it is paramount to raise awareness in the medical and non-medical community of the risks of the indiscriminate use of herbal products.
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Affiliation(s)
| | | | - Ajacio Bandeira de Mello Brandão
- Post-Graduate Program in Medicine, Division of Hepatology, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre 90050-110, RS, Brazil
| | - Raul Angelo Balbinot
- Department of Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95070-560, RS, Brazil
| | - Silvana Sartori Balbinot
- Department of Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95070-560, RS, Brazil
| | - Jonathan Soldera
- Department of Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95070-560, RS, Brazil
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28
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Ronca V, Bozward AG, Oo YH. Use of immunosuppression in non-transplant hepatology. Best Pract Res Clin Gastroenterol 2021; 54-55:101760. [PMID: 34874849 DOI: 10.1016/j.bpg.2021.101760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 06/29/2021] [Accepted: 07/01/2021] [Indexed: 01/31/2023]
Abstract
Human liver possesses a persistent and tightly regulated immune response. Maintaining this homeostatic state is the key to prevent pathological processes, as a failure in clearing dangerous stimuli, is associated with tissue damage. A dysregulation of the liver immune homeostasis is involved in many disease processes and the use of the immunosuppression aims to control the inflammatory response, where the physiologic mechanisms failed. The use of steroids which targets broadly the inflammatory cascade and the immune system activation have been extensively employed in both acute and chronic liver diseases. They currently are the backbone of the treatment of autoimmune diseases such as autoimmune hepatitis or IgG4 sclerosing cholangitis. The steroid use in acute liver injury, especially alcohol mediated and drug induced liver injury (DILI), have been debated, despite the biological rationale. The immunosuppression molecules currently employed in liver diseases target the immune system broadly, causing multiple side effects either intrinsic in the mechanisms of the drug or secondary to off-target toxicity. The future of immunosuppressant treatment is moving towards more selective strategies, targeting disease specific pathways. This review aims to explore the rationale of use of immunosuppression in non-transplant hepatology. A broad summary of the immune biology of liver immune mediated diseases will be provided to the readers in order to highlight the potential therapeutic targets. An extensive description of the molecules employed in liver diseases will follow and the clinical evidences in AIH, IgG4 related cholangitis, alcoholic hepatitis and DILI will be reviewed.
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Affiliation(s)
- Vincenzo Ronca
- Centre for Liver and Gastro Research and NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, UK; Centre for Rare Diseases, European Reference Network Centre- Rare Liver, Birmingham, UK; Liver Transplant and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, UK.
| | - Amber G Bozward
- Centre for Liver and Gastro Research and NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, UK; Centre for Rare Diseases, European Reference Network Centre- Rare Liver, Birmingham, UK
| | - Ye Htun Oo
- Centre for Liver and Gastro Research and NIHR Biomedical Research Centre, Institute of Immunology and Immunotherapy, University of Birmingham, UK; Centre for Rare Diseases, European Reference Network Centre- Rare Liver, Birmingham, UK; Liver Transplant and Hepatobiliary Unit, Queen Elizabeth Hospital, University Hospital of Birmingham NHS Foundation Trust, UK.
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29
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Jiang F, Yan H, Liang L, Du J, Jin S, Yang S, Wang H, Hu T, Zhu Y, Wang G, Hu Y, Cai T, Aithal GP. Incidence and risk factors of anti-tuberculosis drug induced liver injury (DILI): Large cohort study involving 4652 Chinese adult tuberculosis patients. Liver Int 2021; 41:1565-1575. [PMID: 33866661 DOI: 10.1111/liv.14896] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/10/2021] [Accepted: 03/24/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Anti-tuberculosis drugs remain as an important cause of drug-induced liver injury (DILI) worldwide. Adverse drug reactions reduce the effectiveness of treatment. We aimed to determine the incidence and risk factors associated with anti-tuberculosis DILI (ATDILI). METHODS Using established criteria and causality assessment methods, risk factors for ATDILI were identified in a contemporary cohort and validated in another cohort prospectively. Independent determinants of ATDILI were identified using Cox regression analysis. RESULTS In the derivation cohort (n = 3155), 170 (5.4%) developed ATDILI of which 27 (15.9%) developed jaundice; 9(5.3%) developed acute liver failure (ALF) and 3 died. Among HBsAg positive patients, 11/27 (40.7%) of ATDILI developed after 3 months of starting treatment. In addition, of 218 (6.9%) who developed raised alanine transferase (ALT) levels ≥3 times upper limit normal, 193 (88.5%) resolved and 25 (11.4%) progressed to DILI. Age (HR = 1.014, 95% CI: 1.005-1.023), baseline ALT (HR = 1.014, 95% CI: 1.003-1.024), haemoglobin (HR = 1.011, 95% CI: 1.002-1.020) and HBsAg positivity (HR = 1.516, 95% CI: 1.004-2.290) were independent risk factors for DILI. In the second cohort (n = 1497) of which 85 (5.7%) developed ATDILI. Age (HR = 1.029, 95% CI: 1.003-1.056), baseline AST (HR = 1.036, 95% CI: 1.010-1.062), previous TB treatment (HR = 3.894, 95% CI: 1.304-11.625) and active drinking (HR = 3.624, 95% CI: 1.147-11.454) were risk factors for developing jaundice. CONCLUSION Elevation of ALT of ≥3 × ULN during anti-TB treatment resolves in the vast majority without developing serious consequences. In two cohorts involving 4652 patients, incidence of ALF and death because of ATDILI are low. Age, baseline ALT, haemoglobin and HBsAg positivity are risk factors for the development of DILI and these inform monitoring and management of these patients.
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Affiliation(s)
- Fanrong Jiang
- Department of Pharmacy, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China
| | - Huadong Yan
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Lili Liang
- Department of Infectious Diseases, Wenling Hospital, University of Wenzhou School of Medicine, Taizhou, China
| | - Jingyuan Du
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Susu Jin
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Shiqing Yang
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Hongxia Wang
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Infectious Diseases, Ninghai No.1 Hospital, Ningbo, China
| | - Ting Hu
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Yuying Zhu
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China
| | - Guangming Wang
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China
| | - Yaoren Hu
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China.,Department of Hepatology, Hwamei Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Ting Cai
- Department of Infectious Diseases, Key Laboratory of Diagnosis and Treatment of Digestive System Tumors of Zhejiang Province, Hwamei Hospital, University of Chinese Academy of Sciences, Ningbo Institute of Life and Health Industry, Ningbo, China
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, School of Medicine, University of Nottingham, Nottingham, UK
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30
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Ezhilarasan D. Hepatotoxic potentials of methotrexate: Understanding the possible toxicological molecular mechanisms. Toxicology 2021; 458:152840. [PMID: 34175381 DOI: 10.1016/j.tox.2021.152840] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/10/2021] [Accepted: 06/22/2021] [Indexed: 12/12/2022]
Abstract
Methotrexate (MTX) is one of the most effective and widely used drugs in the management of autoimmune and dermatological diseases. Rheumatoid arthritis and psoriasis patients who are under long term MTX-therapy are at high risk of developing a liver injury. Accumulation of intracellular MTX-polyglutamate (MTX-PG), a metabolite of MTX triggers oxidative stress, inflammation, steatosis, fibrosis, and apoptosis in hepatocytes. MTX-PG causes oxidative stress in the liver by inducing lipid peroxidation thereby releasing reactive oxygen species and suppressing antioxidant response elements. MTX-PG induces several pro-inflammatory signaling pathways and cytokines such as tumor necrosis factor-α, nuclear factor kappa B and interleukin 6 (IL-6), IL- β1, IL-12. MTX-PG depletes hepatic folate level and decreases RNA and DNA synthesis leading to hepatocyte death. MTX-PG inhibits 5-aminoimidazole-4-carboxamide ribonucleotide transformylase enzyme and thereby causes accumulation of intracellular adenosine, which causes activation of hepatic stellate cells, extracellular matrix accumulation and hepatic fibrosis. MTX-PG induces hepatocytes apoptosis by activation of caspase 3 via the intrinsic pathway. Clinically, aggravation of underlying fatty liver to non-alcoholic steatohepatitis with fibrosis seems to be an important mechanism of liver injury in MTX-treated RA patients. Therefore, there is a need for monitoring liver injury in RA, psoriatic and cancer patients with NAFLD and fibrosis risk factors during MTX treatment. This review summarizes the possible molecular mechanism of MTX-induced hepatotoxicity. It may pave the way for early detection of liver injury and develop novel strategies for treating MTX mediated hepatotoxicity.
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Rogalewski A, Zuhorn F, Wilkens L, Krüger M, Klingebiel R, Schäbitz WR. Severe drug-induced liver injury caused by levetiracetam - A case report and review of the literature. Epilepsy Behav Rep 2021; 16:100464. [PMID: 34235418 PMCID: PMC8246146 DOI: 10.1016/j.ebr.2021.100464] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/02/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
Levetiracetam (LEV) is a broad-spectrum, second-generation anti-seizure medication, which has quickly become one of the most commonly prescribed drugs for people with epielpsy due to its good tolerability, rapid up-dosing capability, with both parenteral and enteral routes of administration. Considering the frequent prescriptions and predominant excretion by the kidney with minimal hepatic metabolism, severe liver injury is very rarely a complication associated with LEV. An analysis of this reported case and further published cases was performed with respect to indication, relevant previous liver diseases, concomitant medication, and both the dosage as well as the duration of LEV when drug-induced liver injury (DILI) was noted. DILI occurs after a few days to a maximum of five months after initiation of therapy with LEV and, in the worst case, may require liver transplantation or result in death. Monitoring of serum transaminase values may be helpful. Discontinuing LEV is the first therapeutic measure. In addition, immunosuppression with cortisone can be considered for serious cases.
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Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Frédéric Zuhorn
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | | | - Martin Krüger
- Department of Internal Medicine and Gastroenterology, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Department of Neuroradiology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
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Koller T, Vrbova P, Meciarova I, Molcan P, Smitka M, Adamcova Selcanova S, Skladany L. Liver injury associated with the use of selective androgen receptor modulators and post-cycle therapy: Two case reports and literature review. World J Clin Cases 2021; 9:4062-4071. [PMID: 34141767 PMCID: PMC8180234 DOI: 10.12998/wjcc.v9.i16.4062] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 02/28/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Muscle growth promoters are being developed for the treatment of disease-induced loss of muscle mass. Ligandrol and ostarine are selective androgen receptor modulators (SARMs) with a non-steroidal structure and a presumably more favorable side effect profile. In recent years, these substances with or without “post-cycle therapy” (PCT) are often misused by amateur athletes aiming to promote muscle growth. At the same time, reports on their toxic effects on organ systems are emerging.
CASE SUMMARY We report two cases of liver injury in young men who used ligandrol and/or ostarine for a few weeks followed by the use of substances for PCT. Acute liver injury occurred in both cases after stopping SARMs while on PCT. The clinical picture was dominated by jaundice and fatigue. The biochemical pattern showed a mixed type of injury with normal alkaline phosphatase and high concentrations of bilirubin and serum bile acids. Histological evidence showed predominantly cholestatic injury with canalicular bile plugs, ductopenia, and mild hepatocellular damage without significant fibrosis. The patients recovered from the condition after 3 mo. The off target effects of SARMs were likely idiosyncratic, but our report highlights the yet unrecognized effects of other toxic substances used for PCT, supra-therapeutic doses, and the complete absence of monitoring for adverse effects.
CONCLUSION Among muscle-building amateur athletes, SARMs (ligandrol or ostarine) and/or substances in PCT may cause cholestatic liver injury with prolonged recovery.
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Affiliation(s)
- Tomas Koller
- Gastroenterology and Hepatology Subdiv. 5th Department of Internal Medicine, Comenius University Faculty of Medicine, University Hospital Bratislava, 82606, Slovakia
| | - Petra Vrbova
- Gastroenterology and Hepatology Subdiv. 5th Department of Internal Medicine, Comenius University Faculty of Medicine, University Hospital Bratislava, 82606, Slovakia
| | - Iveta Meciarova
- Department of Pathology, Alpha medical Patológia s.r.o., Bratislava 82606, Slovakia
| | - Pavol Molcan
- HEGITO (Division of Hepatology, Gastroenterology and Liver Transplantation), Department of Internal Medicine II of Slovak Medical University, F.D. Roosevelt University Hospital, Banska Bystrica 97517, Slovakia
| | - Michal Smitka
- Department of Pathology, FD Roosevelt Hospital, Banska Bystrica 97517, Slovakia
| | - Svetlana Adamcova Selcanova
- HEGITO (Division of Hepatology, Gastroenterology and Liver Transplantation), Department of Internal Medicine II of Slovak Medical University, F.D. Roosevelt University Hospital, Banska Bystrica 97517, Slovakia
| | - Lubomir Skladany
- HEGITO (Division of Hepatology, Gastroenterology and Liver Transplantation), Department of Internal Medicine II of Slovak Medical University, F.D. Roosevelt University Hospital, Banska Bystrica 97517, Slovakia
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Sung S, Al-Karaghouli M, Kalainy S, Cabrera Garcia L, Abraldes JG. A systematic review on pharmacokinetics, cardiovascular outcomes and safety profiles of statins in cirrhosis. BMC Gastroenterol 2021; 21:120. [PMID: 33726685 PMCID: PMC7967963 DOI: 10.1186/s12876-021-01704-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/02/2021] [Indexed: 12/24/2022] Open
Abstract
Background/Aims There is increased interest in the therapeutic use of statins in cirrhosis, but preferred statin and safety outcomes are still not well known. In this systematic review we aimed to address pharmacokinetics (PK), safety, and effects on cardiovascular (CV) outcomes of statins in cirrhosis. Methods Our systematic search in several electronic databases and repositories of two regulatory bodies up to 2020-06-11 yielded 22 articles and 2 drug monographs with relevant data. Results Rosuvastatin and pitavastatin showed minimal PK changes in Child–Pugh A cirrhosis. Only rosuvastatin was assessed in a repeated dosing PK study. Atorvastatin showed pronounced PK changes in cirrhosis. No PK data was found for simvastatin, the most commonly used statin in cirrhosis trials. There was insufficient data to assess CV effects of statins in cirrhosis. Clinical trials in cirrhosis were limited to simvastatin, atorvastatin, and pravastatin. In patients taking simvastatin 40 mg, pooled frequency of rhabdomyolysis was 2%, an incidence 40-fold higher than that reported in non-cirrhosis patients, while this was no rhabdomyolysis observed in patients on simvastatin 20 mg, atorvastatin 20 mg, or pravastatin 40 mg. Drug-induced liver injury was of difficult interpretation due to co-existence of muscle damage. No overt liver failure was reported. Conclusions Simvastatin 40 mg should be avoided in decompensated cirrhosis. Safety data on simvastatin 20 mg or other statins are based on small study sample size. This rarity of evidence combined with lack of data in dose adjustment methods in cirrhosis is a barrier for using statins for CV indications or for investigational use for liver indications. Supplementary information The online version contains supplementary material available at 10.1186/s12876-021-01704-w.
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Affiliation(s)
- Shuen Sung
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada.
| | | | | | | | - Juan G Abraldes
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. .,Division of Gastroenterology, 1-38 Zeidler Ledcor Centre, University of Alberta, 8540 112 St NW, Edmonton, AB, T6G 2X8, Canada.
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Chen F, Chen W, Chen J, Xu D, Xie W, Wang X, Xie Y. Clinical features and risk factors of COVID-19-associated liver injury and function: A retrospective analysis of 830 cases. Ann Hepatol 2021; 21:100267. [PMID: 33053426 PMCID: PMC7548062 DOI: 10.1016/j.aohep.2020.09.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/26/2020] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION AND OBJECTIVES The incidence of liver injury (LI) in hospitalized COVID-19 patients ranged from 14% to 53% based on sole or multiple elevated indexes for LI. The aims of our study were to investigate the changes of parameters (ALT, AST) in LI and determine the risk factors for LI in a cohort of 830 COVID-19 patients. METHODS Demographic information, clinical features, and laboratory testing outcomes on admission were compared between patients with and without liver biochemistry abnormality (LBA). The same comparisons were performed between the LBA and LI groups. The updated RUCAM was used to determine the causality between drugs application and LI. Univariable and multivariable logistic regression analyses were used to explore the potential risk factors associated with LBA and LI. RESULTS A total of 227 (27.3%) patients exhibited LBA and 32 (3.9%) patients were categorized as having LI based on the diagnostic criteria. 32.6% (74/227) of the LBA patients had RUCAM score >3, whereas the non-LBA patients had a slight lower at rate of 24.2% (146/603) (P?=?0.047). Multivariable regression showed that a higher incidence of LBA was associated with hepatic hypoattenuation on computed tomography (CT) (odds ratio: 2.243, 95% confidence interval: 1.410-3.592, p?=?0.001), lymphocyte proportion <20% (2.088, 1.476-2.954, p?0.001), C-reactive protein (CRP) >1?mg/dL (2.650, 1.845-3.806, p?0.001) and aspartate transaminase to alanine transaminase (AST/ALT) ratio >1 (2.558, 1.820-3.596, p?0.001). CONCLUSIONS CRP levels >1.0?mg/dL, lymphocyte proportion <20%, AST/ALT ratio <1, and triglyceride levels >1.7?mol/L are potential risk factors for LI.
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Affiliation(s)
- Faxiang Chen
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Wei Chen
- Department of Otolaryngology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Jianpu Chen
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Dan Xu
- Department of Gastroenterology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Wei Xie
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Xiang Wang
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
| | - Yuanliang Xie
- Department of Radiology, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430014, China.
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Abstract
Rooibos is consumed worldwide and its use considered safe. It contains scavengers of free radicals and is so is deemed to be a liver protector. Nevertheless, hepatic toxicity exists even if rare. It is probably underdiagnosed and clinicians should think about it in case of acute hepatitis. We report a case of liver injury attributed to Rooibos.
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Affiliation(s)
- Paul Carrier
- Hepatology Unit, Limoges Dupuytren Teaching Hospital, Avenue Martin Luther King, 87042 Limoges, France.
| | - Marilyne Debette-Gratien
- Hepatology Unit, Limoges Dupuytren Teaching Hospital, Avenue Martin Luther King, 87042 Limoges, France; INSERM U-1248, Faculté de Médecine et de Pharmacie, Rue du Docteur Marcland, 87042 Limoges, France
| | - Jérémie Jacques
- Hepatology Unit, Limoges Dupuytren Teaching Hospital, Avenue Martin Luther King, 87042 Limoges, France
| | - Muriel Grau
- Pharmacology Unit, Limoges Dupuytren Teaching Hospital, Limoges 87042, France
| | - Véronique Loustaud-Ratti
- Hepatology Unit, Limoges Dupuytren Teaching Hospital, Avenue Martin Luther King, 87042 Limoges, France; INSERM U-1248, Faculté de Médecine et de Pharmacie, Rue du Docteur Marcland, 87042 Limoges, France
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Greca RD, Cunha-Silva M, Costa LBE, Costa JGF, Mazo DFC, Sevá-Pereira T, Nascimento MMC, Pereira IE, Oliveira FC, Faria GAS, Neto FLP, Almeida JRS. Vanishing bile duct syndrome related to DILI and Hodgkin lymphoma overlap: A rare and severe case. Ann Hepatol 2021; 19:107-112. [PMID: 31537508 DOI: 10.1016/j.aohep.2019.06.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 06/03/2019] [Accepted: 06/10/2019] [Indexed: 02/04/2023]
Abstract
Vanishing bile duct syndrome is a rare acquired condition, characterized by progressive loss of intrahepatic bile ducts leading to ductopenia and cholestasis. It can be associated with infections, ischemia, drug adverse reactions, neoplasms, autoimmune disease, and allograft rejection. Prognosis is variable and depends on the etiology of bile duct injury. We report the case of a 25-year-old female with cholestatic hepatitis and concomitant intakes of hepatotoxic substances, such as garcinia, field horsetail, and ketoprofen. On suspicion of a drug-induced liver injury, the drugs were promptly withdrawn and ursodeoxycholic acid was started with initial clinical and laboratory improvement, and the patient was discharged from the hospital. One month later, she had a new increase in bilirubin levels and canalicular enzymes, requiring a liver biopsy that showed significant loss of intrahepatic bile ducts, which was compatible with vanishing bile duct syndrome. This was confirmed by using cytokeratin 19 on immunohistochemistry. There was subsequent lymph node enlargement in several chains, and relevant weight loss. Histological analysis of a cervical lymph node revealed nodular sclerosis-subtype classic Hodgkin lymphoma. In this setting, vanishing bile duct syndrome was related to Hodgkin lymphoma and a drug-induced liver injury overlap, leading to progressive cholestasis with a worse prognosis. The patient's response to chemotherapy was poor, requiring biological therapy with brentuximab vedotin. It is crucial for physicians to create a broad differential diagnosis in suspected vanishing bile duct syndrome patients, especially to rule out malignancies.
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Affiliation(s)
- Raquel D Greca
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil.
| | - Marlone Cunha-Silva
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Larissa B E Costa
- Department of Pathology, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Júlia G F Costa
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Daniel F C Mazo
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil; Division of Clinical Gastroenterology and Hepatology, Department of Gastroenterology, University of São Paulo, School of Medicine, São Paulo, Brazil
| | - Tiago Sevá-Pereira
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Marlla M C Nascimento
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Isadora E Pereira
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Flávia C Oliveira
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Guilherme A S Faria
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Fernando L P Neto
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
| | - Jazon R S Almeida
- Division of Gastroenterology (Gastrocentro), School of Medical Sciences, University of Campinas (Unicamp), Campinas, São Paulo, Brazil
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Monte AA, Sonn B, Saben J, Rumack BH, Reynolds KM, Dart RC, Heard KJ. The Genomics of Elevated ALT and Adducts in Therapeutic Acetaminophen Treatment: a Pilot Study. J Med Toxicol 2021; 17:160-7. [PMID: 33051802 DOI: 10.1007/s13181-020-00815-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/22/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Therapeutic acetaminophen (APAP) ingestion causes asymptomatic drug-induced liver injury in some patients. In most cases, elevations in alanine aminotransferase (ALT) are transient and return to the normal range, even with continued APAP ingestion, though ALT elevation persists in some patients unpredictably. The etiology of this liver injury or adaption is unclear. Our objective was to identify new pharmacogenomic variants associated with elevated ALT or elevated protein adduct concentrations in patients receiving therapeutic acetaminophen. METHODS We performed genome-wide sequencing analysis on eight patients using leftover blood samples from an observational study that administered four grams of acetaminophen for up to 16 days to all patients. Two patients with ALT elevations > two times the upper limit of normal, two patients with no adduct formation, and four control patients were sequenced. The genomes were aligned with the GRCh38 reference sequence, and variants with predicted low, moderate, or high impact on the subsequent proteins were first manually curated for biologic plausibility, then organized and examined in the REACTOME pathway analysis program. RESULTS We found 394 variants in 107 genes associated with elevated ALT. Variants associated with ALT elevation predominantly involved genes in the immune system (MHC class II complex genes), endoplasmic reticulum stress response (SEC23B and XBP1), oxidative phosphorylation (NDUFB9), and WNT/beta-catenin signaling (FZD5). Variants associated with elevated adducts were primarily in signal transduction (MUC20) and DNA repair mechanisms (P53). CONCLUSIONS While underpowered, genetic variants in immune system genes may be associated with drug-induced liver injury at therapeutic doses of acetaminophen.
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Milani L, Galindo CM, Turin de Oliveira NM, Corso CR, Adami ER, Stipp MC, Beltrame OC, Acco A. The GLP-1 analog liraglutide attenuates acute liver injury in mice. Ann Hepatol 2020; 18:918-928. [PMID: 31151874 DOI: 10.1016/j.aohep.2019.04.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Acute liver injury is a current health problem with few effective treatments. The present study investigated the hepatoprotective and curative potential of the glucagon-like peptide-1 analog liraglutide against carbon tetrachloride (CCl4)-induced hepatotoxicity. MATERIALS AND METHODS Male Swiss mice were subjected to two protocols. The first protocol (Pretreatment) consisted of intraperitoneal (i.p.) treatment with liraglutide (0.057 and 0.118mgkg-1) or vehicle (distilled water) once daily for 7 days. On days 6 and 7, the animals were challenged with 2% CCl4 (5mgkg-1, i.p.). The second protocol (Late treatment) began with an injection of 5% CCl4 (5mgkg-1, i.p.) and subsequent treatment with liraglutide (0.057mgkg-1) or vehicle (distilled water) for 1 day. In both protocols, 24h after the last administration, blood and bile were collected from anesthetized animals, followed by euthanasia and liver collection. Plasma and bile underwent biochemical analyses, and histological, oxidative stress, and metabolic parameters were evaluated in the liver. RESULTS Both liraglutide treatment protocols attenuated hepatotoxicity that was induced by CCl4, decreasing plasma levels of hepatic enzymes, stimulating the hepatic antioxidant system, and decreasing centrilobular necrosis, hepatic glycogen, and lipid accumulation. CCl4 tended to reduce bile lipid excretion, but liraglutide did not influence this parameter. CONCLUSIONS The present results demonstrated the hepatoprotective and therapeutic effects of liraglutide, which may be attributable to a decrease in liver oxidative stress and the preservation of metabolism. Liraglutide may have potential as a complementary therapy for acute liver injury.
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Affiliation(s)
- Letícia Milani
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil
| | - Claudia M Galindo
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil
| | | | - Claudia Rita Corso
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil
| | | | | | - Olair Carlos Beltrame
- Department of Veterinary Medicine, Federal University of Paraná, Curitiba, PR, Brazil
| | - Alexandra Acco
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil.
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Comprehensive review of hepatotoxicity associated with traditional Indian Ayurvedic herbs. World J Hepatol 2020; 12:574-595. [PMID: 33033566 PMCID: PMC7522561 DOI: 10.4254/wjh.v12.i9.574] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/16/2020] [Accepted: 08/15/2020] [Indexed: 02/06/2023] Open
Abstract
With growing antipathy toward conventional prescription drugs due to the fear of adverse events, the general and patient populations have been increasingly using complementary and alternative medications (CAMs) for managing acute and chronic diseases. The general misconception is that natural herbal-based preparations are devoid of toxicity, and hence short- and long-term use remain justified among people as well as the CAM practitioners who prescribe these medicines. In this regard, Ayurvedic herbal medications have become one of the most utilized in the East, specifically the Indian sub-continent, with increasing use in the West. Recent well-performed observational studies have confirmed the hepatotoxic potential of Ayurvedic drugs. Toxicity stems from direct effects or from indirect effects through herbal metabolites, unknown herb-herb and herb-drug interactions, adulteration of Ayurvedic drugs with other prescription medicines, and contamination due to poor manufacturing practices. In this exhaustive review, we present details on their hepatotoxic potential, discuss the mechanisms, clinical presentation, liver histology and patient outcomes of certain commonly used Ayurvedic herbs which will serve as a knowledge bank for physicians caring for liver disease patients, to support early identification and treatment of those who present with CAM-induced liver injury.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India.
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Brito CA, Barros FM, Lopes EP. Mechanisms and consequences of COVID-19 associated liver injury: What can we affirm? World J Hepatol 2020; 12:413-422. [PMID: 32952870 PMCID: PMC7475779 DOI: 10.4254/wjh.v12.i8.413] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/05/2020] [Accepted: 08/01/2020] [Indexed: 02/06/2023] Open
Abstract
Since the first reports of coronavirus disease 2019 (COVID-19) cases in December 2019 in China, numerous papers have been published describing a high frequency of liver injury associated with severe acute respiratory syndrome coronavirus 2 infection, many of them proposing a link between these findings and patient outcomes. Increases in serum aminotransferase levels (ranging from 16% to 62%) and bilirubin levels (ranging from 5% to 21%) have been reported and seem to be more often observed in patients with severe forms of COVID-19. Although absolute changes in these parameters are frequently seen, other variables, such as the ratio above the upper limit of normal, the onset of liver injury as a complication in severe cases and histopathological findings, reinforce that liver changes are of dubious clinical relevance in the course of this disease. Other factors must also be considered in these analyses, such as the repercussions of hemodynamic changes, the presence of thrombotic events, and, mainly, the possible drug-induced liver injury with the current, yet off-label, treatment. This paper aimed to analyze the currently available data on liver injury in patients with COVID-19.
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Affiliation(s)
- Carlos Antunes Brito
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Recife, Pernambuco 50740600, Brazil
- Clinical Hospital of Federal University of Pernambuco, Recife, Pernambuco 50740900, Brazil
- Post-graduation Program of Tropical Medicine of Federal University of Pernambuco, Recife, Pernambuco 50670901, Brazil
- Autoimmune Research Institute, Recife, Pernambuco 52011010, Brazil
| | | | - Edmundo Pessoa Lopes
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Recife, Pernambuco 50740600, Brazil
- Clinical Hospital of Federal University of Pernambuco, Recife, Pernambuco 50740900, Brazil
- Post-graduation Program of Tropical Medicine of Federal University of Pernambuco, Recife, Pernambuco 50670901, Brazil
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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42
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Curtis JR, Owensby JK, Xie F. Comparative safety of flavocoxid vs prescription NSAIDs among osteoarthritis patients. Osteoarthritis Cartilage 2020; 28:917-923. [PMID: 32305527 PMCID: PMC9704801 DOI: 10.1016/j.joca.2020.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 03/01/2020] [Accepted: 03/31/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Flavocoxid is a prescription medical food used to manage osteoarthritis (OA) symptoms. Safety concerns based on case reports raised an association with acute liver injury and hypersensitivity pneumonitis. We determined incidence rates (IR) of these safety events in a cohort of new users of flavocoxid and prescription non-steroidal anti-inflammatory drugs (NSAIDs). METHOD MarketScan® claims data (2006-2017) was used to identify patients initiating flavocoxid or NSAIDs. Propensity score matching (1:2 ratio) was used to balance patient characteristics. Outcomes included hospitalization for hypersensitivity pneumonitis, liver injury, gastrointestinal bleeding, myocardial infarction, and acute kidney injury. Poisson regression was used to calculate IRs and Cox regression for calculating adjusted hazard ratios (aHR). RESULTS 3,337 flavocoxid and 6,674 NSAID users met eligibility criteria. Before matching, flavocoxid users were older (mean 57 vs 51 years), had more polypharmacy (68% vs 29% taking ≥11 medications). After matching, characteristics were well balanced. The rate of hypersensitivity pneumonitis was 1.1 (95% CI 0.0-5.9) per 1,000 PY for flavocoxid and 0.0 (95% CI 0.0-2.2) for NSAIDs. For hospitalized liver injury, it was 3.2 (95% CI 0.7-9.3) for flavocoxid and 2.4 (95% CI 0.7-6.1) for NSAIDs, aHR = 1.16, 95% CI 0.23-6.01. A lower rate of GI bleed was observed, IR: 5.3 (1.7-12.3) for flavocoxid and 10.2 (5.9-16.3) for NSAIDs, aHR 0.49 (0.18-1.68). There were no significant differences for MI or AKI. CONCLUSION The rate of hypersensitivity pneumonitis and liver injury associated with flavocoxid was low and minimally elevated compared to NSAIDs. Flavocoxid users had a significantly lower risk for hospitalized GI bleeding. The risk-benefit profile of flavocoxid may warrant reevaluation in light of these findings.
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Affiliation(s)
- J R Curtis
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - J K Owensby
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - F Xie
- Division of Clinical Immunology & Rheumatology, University of Alabama at Birmingham, Birmingham, AL, USA
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43
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Teschke R, Zhu Y, Jing J. Herb-induced Liver Injury in Asia and Current Role of RUCAM for Causality Assessment in 11,160 Published Cases. J Clin Transl Hepatol 2020; 8:200-214. [PMID: 32832401 PMCID: PMC7438347 DOI: 10.14218/jcth.2020.00009] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/05/2020] [Accepted: 03/31/2020] [Indexed: 12/13/2022] Open
Abstract
Herb-induced liver injuries (HILI) by traditional herbal medicines are particular challenges in Asian countries, with issues over the best approach to establish causality. The aim of the current analysis was to provide an overview on how causality was assessed in HILI cases from Asian countries and whether the Roussel Uclaf Causality Assessment Method (RUCAM) was the preferred diagnostic algorithm, as shown before in worldwide evaluated cases of drug-induced liver injury (DILI). Using the PubMed database, publications in English language were preferred to allow for reevaluation by peers. Overall 11,160 HILI cases have assessed causality using RUCAM and were published by first authors working in Asian countries. With 21 evaluable reports, most publications came from mainland China, with Hong Kong and Taiwan, followed by Korea (n=15), Singapore (n=2), and Japan (n=1), while other Asian countries were not contributory. Most publications provided case and RUCAM data of good quality. For better presentation of future cases, however, the following recommendations are given: (1) preference of prospective study design with use of the updated RUCAM version; (2) clear separation of HILI cohorts from those of other herbal products or DILI; (3) case series for epidemiology studies should contain many essential data, possibly also as supplementary material; (4) otherwise, preference of single case reports providing individual case data and RUCAM-based causality gradings, and applying liver test threshold values; and (5) publication in English language journals. In conclusion, China and Korea are top in presenting RUCAM-based HILI cases, other Asian countries are encouraged to follow.
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Affiliation(s)
- Rolf Teschke
- Department of Internal Medicine II, Division of Gastroenterology and Hepatology, Klinikum Hanau, Hanau, Academic Teaching Hospital of the Medical Faculty, Goethe University Frankfurt/ Main, Frankfurt/Main, Germany
- Correspondence to: Rolf Teschke, Department of Internal Medicine II, Klinikum Hanau, Teaching Hospital of the Goethe University of Frankfurt/Main, Leimenstrasse 20, D-63450 Hanau, Germany. Tel: +49-6181-21859, Fax: +49-6181-2964211, E-mail:
| | - Yun Zhu
- The Fifth Medical Center, General Hospital of PLA, Beijing, China
| | - Jing Jing
- The Fifth Medical Center, General Hospital of PLA, Beijing, China
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44
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Lai RT, Chen CW, Yu YC. [Several issues worthy of reference and discussion of 2019 edition of the European Association for the Study of the Liver guideline for drug-induced liver injury]. Zhonghua Gan Zang Bing Za Zhi 2020; 27:910-912. [PMID: 31941250 DOI: 10.3760/cma.j.issn.1007-3418.2019.11.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The 2019 European Association for the Study of the Liver (EASL) Clinical Practice Guidelines (hereinafter referred to as the EASL Guidelines) extracted the required evidence from detailed research materials, and rigorously graded and condensed the varying strengths of evidence into 32 recommendations and 14 statements (recommendations and reminders) for drug-induced Liver Injury (DILI). This guideline has important reference values for helping clinicians to further improve their understanding of DILI and the level of clinical diagnosis, treatment and prevention; however, there are still several issues worthy of further discussion.
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Affiliation(s)
- R T Lai
- Department of Infectious Diseases, Ruijin Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai 200025, China
| | - C W Chen
- Shanghai Liver Diseases Research Center, 905 Hospital, Nanjing Military Command, Shanghai 200235, China
| | - Y C Yu
- Liver Diseases Center of PLA, General Hospital of Eastern Theater Command, and Bayi Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing 210002, China
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45
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Moon SY, Baek YH, Lee SW. [ Drug Induced Liver Injury by Prophylactic Administration of Albendazole]. Korean J Gastroenterol 2019; 73:360-364. [PMID: 31234627 DOI: 10.4166/kjg.2019.73.6.360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/07/2019] [Accepted: 02/08/2019] [Indexed: 12/19/2022]
Abstract
Albendazole is used as a typical antiparasitic agent worldwide. The side effects of albendazole may include nausea, vomiting, abdominal pain, dizziness, headache, alopecia, and increased liver enzymes. Mild elevation of the liver enzyme has been reported in more than 10% of cases, but drug induced liver injury was reported to be very rare. A 30-year-old woman visited the Dong-A University Hospital with anorexia, nausea, jaundice, and elevated liver enzyme. For diagnosis, other acute hepatitis etiologies were excluded, but the prophylactic administration of albendazole was verified. This paper introduces a case of drug-induced liver injury through the prophylactic administration of albendazole. Physicians should be aware of severe liver injury as one of the side effects of albendazole.
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Affiliation(s)
- Sang Yi Moon
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Yang Hyun Baek
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Sung Wook Lee
- Division of Gastroenterology, Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
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46
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Grewal P, Ahmad J. Severe liver injury due to herbal and dietary supplements and the role of liver transplantation. World J Gastroenterol 2019; 25:6704-6712. [PMID: 31857773 PMCID: PMC6920659 DOI: 10.3748/wjg.v25.i46.6704] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/26/2019] [Accepted: 11/29/2019] [Indexed: 02/06/2023] Open
Abstract
Herbal and dietary supplements (HDS) are increasingly used worldwide for numerous, mainly unproven health benefits. The HDS industry is poorly regulated compared to prescription medicines and most products are easily obtainable. Drug induced liver injury (DILI) is a well-recognized entity associated with prescription and over the counter medications and many reports have emerged of potential HDS-related DILI. There is considerable geographic variability in the risk and severity of DILI associated with HDS but the presentation of severe liver injury is similar with a hepatocellular pattern accompanied by jaundice. This type of injury can lead to acute liver failure and the need for liver transplantation. Patients will often fail to mention their use of HDS, considering it natural and therefore harmless. Hence physicians should understand that these products can be associated with DILI and explicitly ask about HDS use in any patient with otherwise unexplained acute liver injury.
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Affiliation(s)
- Priya Grewal
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Jawad Ahmad
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
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47
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Yousaf MN, Chaudhary FS, Hodanazari SM, Sittambalam CD. Hepatotoxicity associated with Garcinia cambogia: A case report. World J Hepatol 2019; 11:735-742. [PMID: 31772720 PMCID: PMC6856022 DOI: 10.4254/wjh.v11.i11.735] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 09/28/2019] [Accepted: 10/15/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Herbal supplements (HS) for weight loss are perceived to be “safe” and “natural”, as advertised in ads, however, hepatotoxicity can be associated with consumption of some HS. Use of HS may be missed, as the patient may not report these unless specifically asked about these products, since they are often not thought of as medications with potential side effects or interaction potential.
CASE SUMMARY We reported a case of a 21-year-old female with morbid obesity who presented with abdominal pain for 1 wk associated with nausea, vomiting, anorexia and myalgias. She denied smoking tobacco, drinking alcohol, usage of illicit drugs, hormonal contraceptives, or energy drinks. There was no significant past medical or family illnesses. Her laboratory workup revealed acute liver failure. The workup for possible etiologies of acute liver failure was unremarkable. She was using a weight loss herbal supplement “Garcinia cambogia” for 4 wks. This case demonstrates the association of acute liver failure with Garcinia cambogia.
CONCLUSION Medical reconciliation of HS should be performed in patients with suspected acute liver failure and early discontinuation of HS can prevent further progression of drug induced hepatoxicity.
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Affiliation(s)
- Muhammad Nadeem Yousaf
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21137, United States
| | - Fizah S Chaudhary
- Department of Internal Medicine, American University of Barbados, Wildey 11100, Barbados
| | - Seyed Mohammad Hodanazari
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
| | - Charmian D Sittambalam
- Department of Medicine, Medstar Union Memorial Hospital, Baltimore, MD 21218, United States
- Department of Medicine, MedStar Good Samaritan Hospital, Baltimore, MD 21239, United States
- Department of Medicine, Medstar Franklin Square Medical Center, Baltimore, MD 21137, United States
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48
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An Z, Hu T, Lv Y, Li P, Liu L. Targeted amino acid and related amines analysis based on iTRAQ®-LC-MS/MS for discovering potential hepatotoxicity biomarkers. J Pharm Biomed Anal 2019; 178:112812. [PMID: 31639596 DOI: 10.1016/j.jpba.2019.112812] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 08/12/2019] [Accepted: 08/13/2019] [Indexed: 12/13/2022]
Abstract
Drug induced liver injury (DILI) is a diverse set of liver injury occurring after exposure to any manufactured or naturally occurring chemical compounds. DILI has already become the leading cause of acute liver failure in developed countries. Early diagnosis is of great significance for the prevention and treatment of DILI, which can effectively avoid its progress to acute liver failure. In this paper, a novel targeted metabolomics method based on isobaric tagging reagent iTRAQ®-LC-MS/MS was developed for the exploring of 42 common amino acids and related amines alterations in rats treated with hydrazine, aiming to discover the potential biomarkers for early diagnosis of DILI. Forty-two amino acids and related amines were covered in this new method. Through derivatization by iTRAQ reagent, all derivatized amino acids and related amines can be separated and quantified in 16 min with excellent peak shape and good separation efficiency. Fragments related to reporter group (m/z 113 or 121) of iTRAQ reagents could be generated from all derivatized amino acids and related amines under general multiple reaction monitoring (MRM) parameters. Isotope dilution method was established for the quantification of amino acid, which significantly reduced the interference of matrix effect on quantitative accuracy. Using this iTRAQ®-LC-MS/MS method, the changes of amino acid metabolism were comprehensively investigated in rat serum and urine samples after DILI modeling by hydrazine. More significant changes of amino acids were observed in serum and urine samples with fold changes ranging from 0.5 to 193.7. Six significantly increased amino acids in serum, including L-citrulline, L-α-amino-adipic acid, L-tyrosine, L-glutamic acid, glycine and L-lysine, and ten amino acids and related amines in urine including L-citrulline, L-α-amino-adipic acid, L-tyrosine, taurine, β-alanine, ethanolamine, argininosuccinic acid, D,L-β-amino-isobutyric acid, γ-amino-n-butyric acid and L-glutamine, 3 of which were detected in both serum and urine. Except for L-lysine all these significantly increased amino acids and related amines possessed 92.5% to 100% specificity and sensitivity calculated at best cut-off points of their ROC curves in distinguishing control and DILI model group.
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Affiliation(s)
- Zhuoling An
- Pharmacy Department of Beijing Chao-Yang Hospital affiliated with Beijing Capital Medical University, Beijing, 100020, PR China
| | - Ting Hu
- Pharmacy Department of Beijing Chao-Yang Hospital affiliated with Beijing Capital Medical University, Beijing, 100020, PR China
| | - Yali Lv
- Pharmacy Department of Beijing Chao-Yang Hospital affiliated with Beijing Capital Medical University, Beijing, 100020, PR China
| | - Pengfei Li
- Pharmacy Department of Beijing Chao-Yang Hospital affiliated with Beijing Capital Medical University, Beijing, 100020, PR China
| | - Lihong Liu
- Pharmacy Department of Beijing Chao-Yang Hospital affiliated with Beijing Capital Medical University, Beijing, 100020, PR China.
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Jian M, Yang XF, Zhou S, Pi YY, Lei XY. Etiology, diagnosis, and treatment of drug induced liver injury. Shijie Huaren Xiaohua Zazhi 2019; 27:715-720. [DOI: 10.11569/wcjd.v27.i11.715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Drug induced liver injury (DILI) is a common adverse effect in clinical practice, which can cause acute liver failure and even threaten the life. Currently, there are over 1000 commonly used drugs that are clearly capable of causing DILI, which has become a world medical safety issue of great concern. This article reviews the etiology, pathogenesis, diagnosis, and treatment of DILI, with an aim to provide a reference for prevention and prognosis and further research of this disease.
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Affiliation(s)
- Ming Jian
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang 421001, Hunan Province, China
| | - Xue-Feng Yang
- Department of Gastroenterology, Nanhua Hospital, Nanhua University, Hengyang 421002, Hunan Province, China
| | - Shuang Zhou
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang 421001, Hunan Province, China
| | - Yi-Yuan Pi
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang 421001, Hunan Province, China
| | - Xiao-Yong Lei
- Institute of Pharmacy and Pharmacology, University of South China, Hengyang 421001, Hunan Province, China
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50
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Seo KI, Kang SB. [Hepatobiliary Manifestation of Inflammatory Bowel Disease]. Korean J Gastroenterol 2019; 73:248-259. [PMID: 31132831 DOI: 10.4166/kjg.2019.73.5.248] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 05/05/2019] [Accepted: 05/12/2019] [Indexed: 12/13/2022]
Abstract
The hepatobiliary system is one of the most common sites of extraintestinal manifestation in patients with inflammatory bowel disease (IBD). The progression of IBD can lead to a primary hepatobiliary manifestation and can occur secondary to multiple drugs or accompanying viral infections. Primary sclerosing cholangitis is the representative hepatobiliary manifestation of IBD, particularly in ulcerative colitis. Although most agents used in the treatment of IBD are potentially hepatotoxic, the risk of serious hepatitis or liver failure is low. The prevalence of HBV and HCV in IBD is similar to the general population, but the clinical concern is HBV reactivation associated with immunosuppressive therapy. Patients undergoing cytotoxic chemotherapy or immunosuppressive therapy with a moderate to high risk of HBV reactivation require prophylactic antiviral therapy. On the other hand, HCV has little risk of reactivation. Patients with IBD are more likely to have nonalcoholic fatty liver disease than the general population and tend to occur at younger ages. IBD and cholelithiasis are closely related, especially in Crohn's disease.
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Affiliation(s)
- Kwang Il Seo
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sang-Bum Kang
- Division of Gastroenterology, Department of Internal Medicine, Daejeon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Daejeon, Korea
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