Hepatotoxicity in immune checkpoint inhibitors: A pharmacovigilance study from 2014-2021

Drug Induced Liver Injury: Highlights and Controversies in the 2023 Literature

Drug-induced liver injury (DILI) remains an active field of clinical research and investigation with more than 4700 publications appearing in 2023 relating to hepatotoxicity of all causes and injury patterns. As in years past, we have attempted to identify and summarize highlights and controversies from the past year's literature. Several new and novel therapeutic agents were approved by the US Food and Drug Administration (FDA) in 2023, a number of which were associated with significant hepatotoxicity. Updates in the diagnosis and management of DILI using causality scores as well as newer artificial intelligence-based methods were published. Details of newly established hepatotoxins as well as updated information on previously documented hepatotoxic drugs is presented. Significant updates in treatment of DILI were also included as well as reports related to global DILI registries.

Acetazolamide-Induced Liver Injury: A Case Report and Literature Review

Acetazolamide is a carbonic anhydrase inhibitor, which has been very rarely associated with drug-induced liver injury (DILI). This report presents a case of an elderly male who developed severe but asymptomatic DILI associated with acetazolamide use. Severity was established based on markedly elevated serum transaminases. Subsequent rechallenge of acetazolamide at a higher dose resulted in increased severity of the elevations, further suggesting a causative effect. Liver function tests ultimately improved after acetazolamide discontinuation. This case underscores the need for early recognition and timely discontinuation of acetazolamide to prevent worsening liver injury and optimize clinical outcomes. Only two prior documented cases of acetazolamide-induced DILI are found in the medical literature. A detailed review and comparison of those prior cases have been undertaken in the discussion of this case presentation.

Identification of a senescence-related transcriptional signature to uncover molecular subtypes and key genes in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a cancer caused by abnormal cell growth due to faulty signal transduction. Cells secrete tumor suppressor factors in response to potential carcinogenic signals, inducing cellular senescence (CS) as a countermeasure. However, accurately measuring CS levels in different types of tumors is challenging due to tumor heterogeneity and the lack of universal and specific CS markers. Machine learning has revealed unique molecular traits in HCC patients, leading to clinical advantages. More research is needed to understand senescence-related molecular features in these patients. In this study, the gene expression profile features of patients with HCC were analyzed by integrating single-cell RNA sequencing and bulk RNA-seq datasets from HCC samples. The analysis identified the senescence-related pathways exhibiting HCC specificity. Subsequently, genes from these pathways were used to identify senescence-related molecular subtypes in HCC, showing significant variations in biological and clinical attributes. An HCC-specific CS risk model developed in this study revealed substantial associations between the patients' CS scores and prognosis grouping, clinical staging, immune infiltration levels, immunotherapy response, and drug sensitivity levels. Within the constructed model, G6PD was identified as a key gene, potentially serving as a senescence-related target in liver cancer. Molecular biology experiments demonstrated that overexpression of G6PD effectively promotes the proliferative, invasive, and migration capacities of HepG2 and SK-HEP-1 cells. In conclusion, this analysis offers a valuable framework for understanding senescence in HCC and introduces a new biomarker. These findings improve our understanding of senescence in HCC and have potential for future research.

Hepatobiliary complications of immune checkpoint inhibitors in cancer

Immune checkpoint inhibitors (ICIs) have dramatically changed the landscape of cancer therapy. Over the last decade, both their primary focus in trials and clinical application have exponentially risen, with repeated demonstrations of their efficacy in improving survival in various cancer types. The adverse effects of these drugs on various organ systems were recognised in early phase studies. Given their relatively new emergence on the market, there has been increasing interest into short- and long-term effects and management of ICIs in real-world settings. ICI-related hepatobiliary toxicities are often challenging to diagnose and difficult to distinguish from other causes of deranged liver biochemical tests. The aim of this review is to provide an up-to-date and detailed exploration of the hepatobiliary complications of ICIs, including pathogenesis and approaches to diagnosis and management.

Hepatitis-related adverse events associated with immune checkpoint inhibitors in cancer patients: an observational, retrospective, pharmacovigilance study using the FAERS database

Background: Immune checkpoint inhibitors (ICIs), including anti-PD-1, anti-PD-L1 and anti-CTLA-4 antibodies, have become a standard treatment for multiple cancer types. However, ICIs can induce immune-related adverse events, with hepatitis-related adverse events (HRAEs) being of particular concern. Our objective is to identify and characterize HRAEs that exhibit a significant association with ICIs using real-world data. Methods: In this observational and retrospective pharmacovigilance study, we extracted real-world adverse events reports from the FDA Adverse Event Reporting System database spanning from the first quarter of 2004 to the first quarter of 2023. We conducted both Frequentist and Bayesian methodologies in the framework of disproportionality analysis, which included the reporting odds ratios (ROR) and information components (IC) to explore the intricate relationship between ICIs and HRAEs. Results: Through disproportionality analysis, we identified three categories of HRAEs as being significantly related with ICIs, including autoimmune hepatitis (634 cases, ROR 19.34 [95% CI 17.80-21.02]; IC025 2.43), immune-mediated hepatitis (546 cases, ROR 217.24 [189.95-248.45]; IC025 4.75), and hepatitis fulminant (80 cases, ROR 4.56 [3.65-5.70]; IC025 0.49). The median age of patients who report ICI-related HRAEs was 63 years (interquartile range [IQR] 53.8-72), with a fatal outcome observed in 24.9% (313/1,260) of these reports. Cases pertaining to skin cancer, lung cancer, and kidney cancer constituted the majority of these occurrences. Patients treated with anti-PD-1 or anti-PD-L1 antibodies exhibited a higher frequency of immune-mediated hepatitis in comparison to those undergoing anti-CTLA-4 monotherapy, with a ROR of 3.59 (95% CI 1.78-6.18). Moreover, the dual ICI therapy demonstrated higher reporting rates of ICI-related HRAEs compared to ICI monotherapy. Conclusion: Our findings confirm that ICI treatment carries a significant risk of severe HRAEs, in particular autoimmune hepatitis, immune-mediated hepatitis, and hepatitis fulminant. Healthcare providers should exercise heightened vigilance regarding these risks when managing patients receiving ICIs.

Conversion therapy for initially unresectable hepatocellular carcinoma: Current status and prospects

Research has shown that locoregional and/or systemic treatments can reduce the tumor stage, enabling radical surgical resection in patients with initially unresectable hepatocellular carcinoma. This is referred to as conversion therapy. Patients who undergo conversion therapy followed by curative surgery experience a significant survival benefit compared to those who receive chemotherapy alone, those who are successfully downstaged with conversion therapy but not treated with surgery, or those who are treated with upfront surgery. Several treatments have been studied as conversion therapy. However, the success rate of conversion varies greatly, ranging from 0.8% to 60%. Combined locoregional plus systemic conversion therapy has demonstrated significant clinical advantages, with a conversion rate of up to 60%, an objective remission rate of 96% for patients, and a disease control rate of up to 100%. However, patients who underwent conversion therapy experienced significantly more complications than those who underwent direct LR without conversion therapy. Conversion therapy can cause hepatotoxicity, bone marrow suppression, local adhesions, increased fragility of blood vessels and liver tissues, and hepatic edema, which can increase the difficulty of surgery. In addition, criteria need to be established to evaluate the efficacy of conversion therapy and subsequent treatment. Further clinical evidence in this area is urgently needed.