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Cueto-Sanchez A, Niu H, Álvarez-Álvarez I, López-Longarela B, Del Campo-Herrera E, Ortega-Alonso A, Garcia-Cortes M, Pinazo-Bandera J, Sanabria-Cabrera J, Díaz-Mochón JJ, Lucena MI, Andrade RJ, Stephens C, Robles-Diaz M. Evaluation of diagnostic and prognostic candidate biomarkers in drug-induced liver injury versus other forms of acute liver damage. Br J Clin Pharmacol 2023. [PMID: 36965054 DOI: 10.1111/bcp.15724] [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] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/13/2023] [Accepted: 03/15/2023] [Indexed: 03/27/2023] Open
Abstract
AIMS Detection and characterization of idiosyncratic drug-induced liver injury (DILI) currently relies on standard liver tests, which are suboptimal in terms of specificity, sensitivity and prognosis. Therefore, DILI diagnosis can be delayed, with important consequences for the patient. In this study we aimed to evaluate the potential of osteopontin, cytokeratin-18 (caspase-cleaved: ccK18 and total: K18), α-glutathione-S-transferase and microRNA-122 as new DILI biomarkers. METHODS Serial blood samples were collected from 32 DILI and 34 non-DILI acute liver injury (ALI) cases and a single sample from 43 population controls without liver injury (HLC) and analysed using ELISA assays or single-molecule arrays. RESULTS All biomarkers differentiated DILI and ALI from HLC with an area under receiver operator characteristic curve (AUC) value >0.75, but were less efficient in distinguishing DILI from ALI, with ccK18 (0.79) and K18 (0.76) demonstrating highest potential. However, the AUC improved considerably (0.98) for ccK18 when comparing DILI and a subgroup of autoimmune hepatitis cases. Cytokeratin-18, microRNA-122 and α-glutathione-S-transferase correlated well with traditional transaminases, while osteopontin was strongest correlated with INR. CONCLUSION ccK18 appears promising in distinguishing DILI from autoimmune hepatitis, but less so from other forms of acute liver injury. Osteopontin demonstrates prognostic potential with higher levels detected in more severe cases regardless of aetiology.
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Affiliation(s)
- Alejandro Cueto-Sanchez
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Hao Niu
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - Ismael Álvarez-Álvarez
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | | | - Enrique Del Campo-Herrera
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Aida Ortega-Alonso
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - Miren Garcia-Cortes
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - José Pinazo-Bandera
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Judith Sanabria-Cabrera
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Juan José Díaz-Mochón
- Destina Genomica S.L., Granada, Spain
- Pfizer-Universidad de Granada-Junta de Andalucia Centre for Genomics and Oncological Research (GENYO), Granada, Spain
| | - M Isabel Lucena
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - Raúl J Andrade
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - Camilla Stephens
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
| | - Mercedes Robles-Diaz
- Servicio de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en red, Enfermedades Hepáticas y digestivas (Ciberehd), Madrid, Spain
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Cueto-Sanchez A, Niu H, Del Campo-Herrera E, Robles-Díaz M, Sanabria-Cabrera J, Ortega-Alonso A, Garcia-Cortes M, Gonzalez-Grande R, Jimenez-Perez M, Ruiz-Cabello F, Andrade RJ, Lucena MI, Stephens C. Lymphocyte Profile and Immune Checkpoint Expression in Drug-Induced Liver Injury: An Immunophenotyping Study. Clin Pharmacol Ther 2021; 110:1604-1612. [PMID: 34543448 DOI: 10.1002/cpt.2423] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/03/2021] [Indexed: 12/16/2022]
Abstract
The identification of specific HLA risk alleles in drug-induced liver injury (DILI) points toward an important role of the adaptive immune system in DILI development. In this study, we aimed to corroborate the role of an adaptive immune response in DILI through immunophenotyping of leukocyte populations and immune checkpoint expressions. Blood samples were collected from adjudicated DILI (n = 12), acute viral hepatitis (VH; n = 13), acute autoimmune hepatitis (AIH; n = 9), and acute liver injury of unknown etiology (n = 15) at day 1 (recognition), day 7, and day >30. Blood samples from patients with nonalcoholic fatty liver disease (NAFLD; n = 20) and healthy liver controls (HLCs; n = 54) were extracted at one time point. Leukocyte populations and immune checkpoint expressions were determined based on cell surface receptors, except for CTLA-4 that was determined intracellularly, using flow cytometry. At recognition, DILI demonstrated significantly higher levels of activated helper T-cell (P < 0.0001), activated cytotoxic T-cells (P = 0.0003), Th1 (P = 0.0358), intracellular CTLA-4 level in helper T-cells (P = 0.0192), and PD-L1 presenting monocytes (P = 0.0452) than HLC. These levels approached those of HLC over time. No significant differences were found between DILI and VH. However, DILI presented higher level of activated helper T-cells and CTLA-4 than NAFLD and lower PD-L1 level than AIH. Our findings suggest that an adaptive immune response is involved in DILI in which activated CD4+ and CD8+ play an important role. Increased expression of negative immune checkpoints is likely the effect of peripheral tolerance regulation.
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Affiliation(s)
- Alejandro Cueto-Sanchez
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Hao Niu
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Enrique Del Campo-Herrera
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Mercedes Robles-Díaz
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Judith Sanabria-Cabrera
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Platform ISCiii for Clinical Research and Clinical Trials UICEC-IBIMA, Malaga, Spain
| | - Aida Ortega-Alonso
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren Garcia-Cortes
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Rocio Gonzalez-Grande
- Servicio de Aparato Digestivo, IBIMA, Hospital Universitario Regional de Málaga, Málaga, Spain
| | - Miguel Jimenez-Perez
- Servicio de Aparato Digestivo, IBIMA, Hospital Universitario Regional de Málaga, Málaga, Spain
| | - Francisco Ruiz-Cabello
- Servicio de Análisis Clínicos e Inmunología, UGC de Laboratorio Clínico, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Raúl J Andrade
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - M Isabel Lucena
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Platform ISCiii for Clinical Research and Clinical Trials UICEC-IBIMA, Malaga, Spain
| | - Camilla Stephens
- Servicio de Farmacología Clínica and UGC Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red en el Área Temática de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Stephens C, Robles-Diaz M, Medina-Caliz I, Garcia-Cortes M, Ortega-Alonso A, Sanabria-Cabrera J, Gonzalez-Jimenez A, Alvarez-Alvarez I, Slim M, Jimenez-Perez M, Gonzalez-Grande R, Fernández MC, Casado M, Soriano G, Román E, Hallal H, Romero-Gomez M, Castiella A, Conde I, Prieto M, Moreno-Planas JM, Giraldez A, Moreno-Sanfiel JM, Kaplowitz N, Lucena MI, Andrade RJ. Comprehensive analysis and insights gained from long-term experience of the Spanish DILI Registry. J Hepatol 2021; 75:86-97. [PMID: 33539847 DOI: 10.1016/j.jhep.2021.01.029] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [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: 09/16/2020] [Revised: 01/13/2021] [Accepted: 01/15/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Prospective drug-induced liver injury (DILI) registries are important sources of information on idiosyncratic DILI. We aimed to present a comprehensive analysis of 843 patients with DILI enrolled into the Spanish DILI Registry over a 20-year time period. METHODS Cases were identified, diagnosed and followed prospectively. Clinical features, drug information and outcome data were collected. RESULTS A total of 843 patients, with a mean age of 54 years (48% females), were enrolled up to 2018. Hepatocellular injury was associated with younger age (adjusted odds ratio [aOR] per year 0.983; 95% CI 0.974-0.991) and lower platelet count (aOR per unit 0.996; 95% CI 0.994-0.998). Anti-infectives were the most common causative drug class (40%). Liver-related mortality was more frequent in patients with hepatocellular damage aged ≥65 years (p = 0.0083) and in patients with underlying liver disease (p = 0.0221). Independent predictors of liver-related death/transplantation included nR-based hepatocellular injury, female sex, higher onset aspartate aminotransferase (AST) and bilirubin values. nR-based hepatocellular injury was not associated with 6-month overall mortality, for which comorbidity burden played a more important role. The prognostic capacity of Hy's law varied between causative agents. Empirical therapy (corticosteroids, ursodeoxycholic acid and MARS) was prescribed to 20% of patients. Drug-induced autoimmune hepatitis patients (26 cases) were mainly females (62%) with hepatocellular damage (92%), who more frequently received immunosuppressive therapy (58%). CONCLUSIONS AST elevation at onset is a strong predictor of poor outcome and should be routinely assessed in DILI evaluation. Mortality is higher in older patients with hepatocellular damage and patients with underlying hepatic conditions. The Spanish DILI Registry is a valuable tool in the identification of causative drugs, clinical signatures and prognostic risk factors in DILI and can aid physicians in DILI characterisation and management. LAY SUMMARY Clinical information on drug-induced liver injury (DILI) collected from enrolled patients in the Spanish DILI Registry can guide physicians in the decision-making process. We have found that older patients with hepatocellular type liver injury and patients with additional liver conditions are at a higher risk of mortality. The type of liver injury, patient sex and analytical values of aspartate aminotransferase and total bilirubin can also help predict clinical outcomes.
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Affiliation(s)
- Camilla Stephens
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mercedes Robles-Diaz
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Inmaculada Medina-Caliz
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miren Garcia-Cortes
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Aida Ortega-Alonso
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Judith Sanabria-Cabrera
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Platform ISCiii for Clinical Research and Clinical Trials UICEC- IBIMA, Málaga, Spain
| | - Andres Gonzalez-Jimenez
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Ismael Alvarez-Alvarez
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Mahmoud Slim
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miguel Jimenez-Perez
- UGC Aparato Digestivo, Complejo Hospitalario Regional de Málaga, IBIMA, Málaga, Spain
| | - Rocio Gonzalez-Grande
- UGC Aparato Digestivo, Complejo Hospitalario Regional de Málaga, IBIMA, Málaga, Spain
| | | | - Marta Casado
- UGC Farmacia, Hospital Universitario Torrecárdenas, Almeria, Spain
| | - German Soriano
- Servicio de Gastroenterología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Eva Román
- Servicio de Gastroenterología, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Spain; Escola Universitària d'Infermeria EUI-Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Hacibe Hallal
- Servicio Aparato Digestivo, Hospital General Universitario J.M. Morales Meseguer, Murcia, Spain
| | - Manuel Romero-Gomez
- UGC Aparato Digestivo, SeLiver Group IBIS, Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Agustin Castiella
- Servicio de Aparato Digestivo, Hospital Universitario de Donostia, San Sebastian, Spain
| | - Isabel Conde
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Martin Prieto
- Unidad de Hepatología, Servicio de Aparato Digestivo, Hospital Universitari i Politècnic La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | | | - Alvaro Giraldez
- Servicio de Aparato Digestivo. Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Neil Kaplowitz
- University of Southern California Research Center for Liver Diseases, Keck School of Medicine, Los Angeles, California, USA
| | - M Isabel Lucena
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Platform ISCiii for Clinical Research and Clinical Trials UICEC- IBIMA, Málaga, Spain.
| | - Raúl J Andrade
- UGC Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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Medina-Caliz I, Garcia-Cortes M, Gonzalez-Jimenez A, Cabello MR, Robles-Diaz M, Sanabria-Cabrera J, Sanjuan-Jimenez R, Ortega-Alonso A, García-Muñoz B, Moreno I, Jimenez-Perez M, Fernandez MC, Ginés P, Prieto M, Conde I, Hallal H, Soriano G, Roman E, Castiella A, Blanco-Reina E, Montes MR, Quiros-Cano M, Martin-Reyes F, Lucena MI, Andrade RJ. Herbal and Dietary Supplement-Induced Liver Injuries in the Spanish DILI Registry. Clin Gastroenterol Hepatol 2018; 16:1495-1502. [PMID: 29307848 DOI: 10.1016/j.cgh.2017.12.051] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [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: 08/23/2017] [Revised: 11/29/2017] [Accepted: 12/21/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There have been increasing reports of liver injury associated with use of herbal and dietary supplements, likely due to easy access to these products and beliefs among consumers that they are safer or more effective than conventional medications. We aimed to evaluate clinical features and outcomes of patients with herbal and dietary supplement-induced liver injuries included in the Spanish DILI Registry. METHODS We collected and analyzed data on demographic and clinical features, along with biochemical parameters, of 32 patients with herbal and dietary supplement-associated liver injury reported to the Spanish DILI registry from 1994 through 2016. We used analysis of variance to compare these data with those from cases of liver injury induced by conventional drugs or anabolic androgenic steroid-containing products. RESULTS Herbal and dietary supplements were responsible for 4% (32 cases) of the 856 DILI cases in the registry; 20 cases of DILI (2%) were caused by anabolic androgenic steroids. Patients with herbal and dietary supplement-induced liver injury were a mean age of 48 years and 63% were female; they presented a mean level of alanine aminotransferase 37-fold the upper limit of normal, 28% had hypersensitivity features, and 78% had jaundice. Herbal and dietary supplement-induced liver injury progressed to acute liver failure in 6% of patients, compared with none of the cases of anabolic androgenic steroid-induced injury and 4% of cases of conventional drugs. Liver injury after repeat exposure to the same product that caused the first DILI episode occurred in 9% of patients with herbal and dietary supplement-induced liver injury vs none of the patients with anabolic androgenic steroid-induced injury and 6% of patients with liver injury from conventional drugs. CONCLUSION In an analysis of cases of herbal and dietary supplement-induced liver injury in Spain, we found cases to be more frequent among young women than older patients or men, and to associate with hepatocellular injury and high levels of transaminases. Herbal and dietary supplement-induced liver injury is more severe than other types of DILI and re-exposure is more likely. Increasing awareness of the hepatoxic effects of herbal and dietary supplements could help physicians make earlier diagnoses and reduce the risk of serious liver damage.
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Affiliation(s)
- Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Miren Garcia-Cortes
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain.
| | - Andres Gonzalez-Jimenez
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Maria R Cabello
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Mercedes Robles-Diaz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Judith Sanabria-Cabrera
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain; UICEC Instituto de Investigación Biomédica de Málaga, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Rocio Sanjuan-Jimenez
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain; UICEC Instituto de Investigación Biomédica de Málaga, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - Aida Ortega-Alonso
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Beatriz García-Muñoz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Inmaculada Moreno
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Miguel Jimenez-Perez
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Regional de Málaga, Málaga, Spain
| | | | - Pere Ginés
- Liver Unit, Hospital Clínic, University of Barcelona, Institut d'Investigaciones Biomèdiques August Pi Sunyer, CIBERehd, Barcelona, Spain
| | - Martin Prieto
- Unidad de Gestión Clínica de Enfermedades Digestivas, IISLaFe, Hospital La Fe, CIBERehd, Valencia, Spain
| | - Isabel Conde
- Unidad de Gestión Clínica de Enfermedades Digestivas, IISLaFe, Hospital La Fe, CIBERehd, Valencia, Spain
| | - Hacibe Hallal
- Servicio de Aparato Digestivo, Hospital Morales Meseguer, Murcia, Spain
| | - German Soriano
- Servicio de Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | - Eva Roman
- Servicio de Aparato Digestivo, Hospital de la Santa Creu i Sant Pau, CIBERehd, Barcelona, Spain
| | | | - Encarnacion Blanco-Reina
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Maria R Montes
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Marta Quiros-Cano
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - Flores Martin-Reyes
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain; UICEC Instituto de Investigación Biomédica de Málaga, Plataforma SCReN (Spanish Clinical Research Network), Servicio de Farmacología Clínica, Hospital Universitario Virgen de la Victoria, Málaga, Spain.
| | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, CIBERehd, Málaga, Spain
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5
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Abstract
The rising burden of herbal and dietary supplement hepatotoxicity (HILI) is a growing concern in Western countries. The estimated incidence of HILI in well-designed prospective studies ranges from less than 1 to 3 individuals per 100,000 inhabitants/year. Herbal hepatotoxicity has a particular signature encompassing female predominance, hepatocellular type of damage with markedly elevated transaminases on presentation, more common unintentional rechallenge, and a greater risk of death/liver transplantation. Herbal hepatotoxicity recognition is particularly challenging for hepatologists because of the often hidden herbal consumption, difficulties in identifying the causative herbal component, and the possibility of contamination, adulteration, and misidentification, which preclude a proper adjudication and lead to inaccurate reporting of cases in scientific journals. Collaborative efforts to retrieve detailed phenotypic data and biological samples of patients with HILI would facilitate genomic and other molecular approaches for a better understanding of host risk factors and, hopefully, for biomarker identification.
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Affiliation(s)
- Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Inmaculada Medina-Caliz
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Andres Gonzalez-Jimenez
- Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miren Garcia-Cortes
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - M Isabel Lucena
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.,Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain.,Unidad Investigación Clínica y Ensayos Clínicos (UICEC)-IBIMA, Plataforma Spanish Clinical Research Network, Spain
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6
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Medina-Caliz I, Robles-Diaz M, Garcia-Muñoz B, Stephens C, Ortega-Alonso A, Garcia-Cortes M, González-Jimenez A, Sanabria-Cabrera JA, Moreno I, Fernandez MC, Romero-Gomez M, Navarro JM, Barriocanal AM, Montane E, Hallal H, Blanco S, Soriano G, Roman EM, Gómez-Dominguez E, Castiella A, Zapata EM, Jimenez-Perez M, Moreno JM, Aldea-Perona A, Hernández-Guerra M, Prieto M, Zoubek ME, Kaplowitz N, Lucena MI, Andrade RJ. Definition and risk factors for chronicity following acute idiosyncratic drug-induced liver injury. J Hepatol 2016; 65:532-42. [PMID: 27184533 PMCID: PMC7458366 DOI: 10.1016/j.jhep.2016.05.003] [Citation(s) in RCA: 97] [Impact Index Per Article: 12.1] [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: 12/01/2015] [Revised: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Chronic outcome following acute idiosyncratic drug-induced liver injury (DILI) is not yet defined. This prospective, long-term follow-up study aimed to analyze time to liver enzyme resolutions to establish the best definition and risk factors of DILI chronicity. METHODS 298 out of 850 patients in the Spanish DILI registry with no pre-existing disease affecting the liver and follow-up to resolution or ⩾1year were analyzed. Chronicity was defined as abnormal liver biochemistry, imaging test or histology one year after DILI recognition. RESULTS Out of 298 patients enrolled 273 (92%) resolved ⩽1year from DILI recognition and 25 patients (8%) were chronic. Independent risk factors for chronicity were older age [OR: 1.06, p=0.011], dyslipidemia [OR: 4.26, p=0.04] and severe DILI [OR: 14.22, p=0.005]. Alanine aminotransferase (ALT), alkaline phosphatase (ALP) and total bilirubin (TB) median values were higher in the chronic group during follow-up. Values of ALP and TB >1.1 x upper limit of normal (xULN) and 2.8 xULN respectively, in the second month from DILI onset, were found to predict chronic DILI (p<0.001). Main drug classes involved in chronicity were statins (24%) and anti-infectives (24%). Histological examination in chronic patients demonstrated two cases with ductal lesion and seven with cirrhosis. CONCLUSIONS One year is the best cut-off point to define chronic DILI or prolonged recovery, with risk factors being older age, dyslipidemia and severity of the acute episode. Statins are distinctly related to chronicity. ALP and TB values in the second month could help predict chronicity or very prolonged recovery. LAY SUMMARY Drug-induced liver injury (DILI) patients who do not resolve their liver damage during the first year should be considered chronic DILI patients. Risk factors for DILI chronicity are older age, dyslipidemia and severity of the acute episode. Chronic DILI is not a very common condition; normally featuring mild liver profile abnormalities and not being an important clinical problem, with the exception of a small number of cases of early onset cirrhosis.
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Affiliation(s)
- Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Mercedes Robles-Diaz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Beatriz Garcia-Muñoz
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Camilla Stephens
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Aida Ortega-Alonso
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miren Garcia-Cortes
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Andres González-Jimenez
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Judith A Sanabria-Cabrera
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Inmaculada Moreno
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | - Manuel Romero-Gomez
- UCM Digestive Diseases, Virgen del Rocio University Hospital, Sevilla, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Jose M Navarro
- Area Integrada de Gestión de Medicina Interna, Hospital Costa del Sol, Marbella, Málaga, Spain
| | - Ana M Barriocanal
- Servicio de Farmacología Clínica, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Eva Montane
- Servicio de Farmacología Clínica, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Hacibe Hallal
- Servicio de Digestivo, Hospital Morales Meseguer, Murcia, Spain
| | - Sonia Blanco
- Servicio de Aparato Digestivo, Hospital de Basurto, Bilbao, Vizcaya, Spain
| | - German Soriano
- Servicio de Patología Digestiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Eva M Roman
- Servicio de Patología Digestiva, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | | | | | - Eva M Zapata
- Servicio de Digestivo, Hospital de Mendaro, Guipúzcoa, Spain
| | - Miguel Jimenez-Perez
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Regional de Málaga, Málaga, Spain
| | - Jose M Moreno
- Servicio de Digestivo, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | - Ana Aldea-Perona
- Servicio de Farmacología Clínica, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
| | | | - Martin Prieto
- Unidad de Hepatología, Hospital La Fe, Valencia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
| | - Miguel E Zoubek
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Neil Kaplowitz
- USC Research Center for Liver Diseases, Keck School of Medicine, Los Angeles, CA, United States
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain.
| | - Raul J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Spain
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7
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Robles-Diaz M, Garcia-Cortes M, Medina-Caliz I, Gonzalez-Jimenez A, Gonzalez-Grande R, Navarro JM, Castiella A, Zapata EM, Romero-Gomez M, Blanco S, Soriano G, Hidalgo R, Ortega-Torres M, Clavijo E, Bermudez-Ruiz PM, Lucena MI, Andrade RJ. The value of serum aspartate aminotransferase and gamma-glutamyl transpetidase as biomarkers in hepatotoxicity. Liver Int 2015; 35:2474-82. [PMID: 25809419 DOI: 10.1111/liv.12834] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [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: 01/13/2015] [Accepted: 03/18/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND & AIMS The current definition of the pattern of liver injury in hepatotoxicity (DILI) is given by the R (ratio) value, dividing alanine aminotransferase (ALT) and alkaline phosphatase (ALP) in upper limits of normal at DILI onset. We aimed to explore the validity of using aspartate aminotransferase (AST) and gamma-glutamyl transpeptidase (GGT) as biomarkers of hepatocelullar and cholestatic damage, respectively, when calculating the R value. METHODS Clinical, laboratory and histological data from 588 DILI episodes included in the Spanish DILI Registry were analyzed. Linear regression analysis was performed to establish the most appropriate cut-off points for hepatocellular and cholestatic patterns when calculating R with AST and GGT. RESULTS The overall agreement between ALT/ALP and AST/ALP was 76%, with 96%, 61% and 41% agreement in the hepatocellular (R ≥ 5), cholestatic (R ≤ 2) and mixed groups respectively (P < 0.001). Classified by the causative drug, the agreement was higher (87-95%) among drug classes that mainly present with hepatocellular damage and lower (48-58%) for those in which cholestatic-mixed injury predominate (P < 0.001)). The overall agreement between ALT/ALP and ALT/GGT was weak (59%), except for in hepatocellular cases that showed a good agreement (94%) (P = 0.001). Pattern of injury according to liver histology demonstrated 65%, 68% and 47% agreement for ALT/ALP, AST/ALP and ALT/GGT ratios respectively. CONCLUSIONS AST can reliably replace ALT when calculating pattern of liver injury in DILI, while GGT can only substitute ALP when the R value scores as hepatocellular. The biochemical signature of causative drugs does influence the validity of the ratios with AST or GGT.
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Affiliation(s)
- Mercedes Robles-Diaz
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Miren Garcia-Cortes
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Inmaculada Medina-Caliz
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Andres Gonzalez-Jimenez
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Rocio Gonzalez-Grande
- Unidad de Gestión Clínica de Enfermedades Digestivas, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Regional Universitario Carlos Haya, Málaga, Spain
| | - Jose M Navarro
- Unidad de Gestión Clínica de Aparato Digestivo, Hospital Costa del Sol, Marbella, Málaga, Spain
| | - Agustin Castiella
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital de Mendaro, Guipúzcoa, Spain
| | - Eva M Zapata
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital de Mendaro, Guipúzcoa, Spain
| | - Manuel Romero-Gomez
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital Universitario de Valme, Sevilla, Spain
| | - Sonia Blanco
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital de Basurto, Bilbao, Spain
| | - German Soriano
- Unidad de Gestión Clínica de Enfermedades Digestivas, Hospital de Sant Pau, Barcelona, Spain
| | - Ramon Hidalgo
- Servicio Central de Informática de la Universidad de Málaga, Málaga, Spain
| | - Maria Ortega-Torres
- Unidad de Gestión Clínica Intercentros de Microbiología, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Encarnacion Clavijo
- Unidad de Gestión Clínica Intercentros de Microbiología, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - Pilar M Bermudez-Ruiz
- Unidad de Gestión Clínica Intercentros de Microbiología, Hospitales Universitarios Regional y Virgen de la Victoria, Málaga, Spain
| | - M Isabel Lucena
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
| | - Raúl J Andrade
- Unidad de Gestión Clínica de Enfermedades Digestivas y Hepatología, Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain
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8
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Moreno P, Lazo MD, Andrade RJ, Camargo R, Fraile JM, Garcia-Cortes M, Poncet J, Alcántara R, Franquelo E. Unusual duodenal duplication cyst associated with partial gastric diverticulum in a middle-aged woman: are they congenital or acquired? Dig Dis Sci 2002; 47:304-8. [PMID: 11855545 DOI: 10.1023/a:1013709819896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Pedro Moreno
- Servicio Aparato Digestivo, Hospital Universitario Virgen de la Victoria, Málaga, Spain
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