Rechallenge in idiosyncratic drug-induced liver injury: An analysis of cases in two large prospective registries according to existing definitions

INTRODUCTION

Data on positive rechallenge in idiosyncratic drug-induced liver injury (DILI) are scarce. We aim to analyse the clinical presentation, outcome and drugs associated with positive rechallenge in two DILI registries.

METHODS

Cases from the Spanish and Latin American DILI registries were included. Demographics, clinical characteristics and outcome of cases with positive rechallenge according to CIOMS/RUCAM and current definitions were analysed.

RESULTS

Of 1418 patients with idiosyncratic DILI, 58 cases had positive rechallenge (4.1%). Patients with positive rechallenge had shorter duration of therapy (p=0.001) and latency (p=0.003). In patients with rechallenge, aspartate transaminase levels were increased (p=0.026) and showed a prolonged time to recovery (p=0.020), albeit no differences were seen in terms of fatal outcomes. The main drug implicated in rechallenge was amoxicillin-clavulanate (17%). The majority of re-exposure events were unintentional (71%). Using both existing definitions of positive rechallenge, there were four cases which exclusively fulfilled the current criteria and five which only meet the historical definition. All cases of positive rechallenge, irrespective of the pattern of damage, fulfilled the criteria of either alanine transaminase (ALT) ≥3 times the upper limit of normal (ULN) and/or alkaline phosphatase (ALP) ≥2 times ULN.

CONCLUSIONS

Episodes of rechallenge were characterised by shorter duration of therapy and latency, and longer time to resolution, but did not show an increased incidence of fatal outcome. Based on our findings, ALT ≥3 times ULN and/or ALP ≥2 times ULN, regardless of the pattern of damage, is proposed as a new definition of rechallenge in DILI.

Characterization of drug-induced liver injury associated with drug reaction with eosinophilia and systemic symptoms in two prospective DILI registries

Idiosyncratic drug-induced liver injury (DILI) associated with drug reactions with eosinophilia and systemic symptoms (DRESS) is poorly characterized among patients of Western countries. We aimed to comprehensively assess the clinical characteristics, outcomes, and causative agents in a prospective, well-vetted cohort of DILI patients with DRESS (DILI-DRESS). We identified 53 DILI-DRESS cases from the Spanish DILI Registry and the Latin American DILI Network. For comparison purposes, we defined a group of DILI patients (n = 881). DILI-DRESS cases were younger (47 vs. 53 years, respectively; p = 0.042) and presented more frequently with cholestatic/mixed damage (p = 0.018). Most DILI-DRESS patients showed moderate liver injury, 13% developed severe damage, and only one patient (with hepatocellular injury due to anti-tuberculosis drugs) progressed to acute liver failure and died. DILI-DRESS cases showed a distinctive causative drug pattern compared to DILI cases. The most frequent drugs were carbamazepine (13%), anti-tuberculosis drugs (13%), amoxicillin-clavulanate (11%), and allopurinol and lamotrigine (7.6% each). Among all cases of DILI due to allopurinol and lamotrigine, 67% presented with a DILI-DRESS phenotype, respectively. Higher total bilirubin (TBL) levels at DILI recognition (odds ratio [OR] 1.23; 95% confidence interval [CI] 1.04-1.45) and absence of eosinophilia (OR 8.77; 95% CI 1.11-69.20) increased the risk for developing a severe-fatal injury in DILI-DRESS patients. DILI-DRESS patients have a more frequent cholestasis/mixed pattern of injury at presentation, with antiepileptics as distinctive causative drug class. Most of the lamotrigine and allopurinol cases present with this phenotype. Higher TBL levels and absence of eosinophilia at DILI recognition are markers of poor outcomes.

Clinical presentation, causative drugs and outcome of patients with autoimmune features in two prospective DILI registries

BACKGROUND & AIMS

Idiosyncratic drug-induced liver injury (DILI) with autoimmune features is a liver condition with laboratory and histological characteristics similar to those of idiopathic autoimmune hepatitis (AIH), which despite being increasingly reported, remains largely undefined. We aimed to describe in-depth the features of this entity in a large series of patients from two prospective DILI registries.

METHODS

DILI cases with autoimmune features collected in the Spanish DILI Registry and the Latin American DILI Network were compared with DILI patients without autoimmune features and with an independent cohort of patients with AIH.

RESULTS

Out of 1,426 patients with DILI, 33 cases with autoimmune features were identified. Female sex was more frequent in AIH patients than in the other groups (p = .001). DILI cases with autoimmune features had significantly longer time to onset (p < .001) and resolution time (p = .004) than those without autoimmune features. Interestingly, DILI patients with autoimmune features who relapsed exhibited significantly higher total bilirubin and transaminases at onset and absence of peripheral eosinophilia than those who did not relapse. The likelihood of relapse increased over time, from 17% at 6 months to 50% 4 years after biochemical normalization. Statins, nitrofurantoin and minocycline were the drugs most frequently associated with this phenotype.

CONCLUSIONS

DILI with autoimmune features shows different clinical features than DILI patients lacking characteristics of autoimmunity. Higher transaminases and total bilirubin values with no eosinophilia at presentation increase the likelihood of relapse in DILI with autoimmune features. As the tendency to relapse increases over time, these patients will require long-term follow-up.

Nitrofurantoin-induced liver injury: long-term follow-up in two prospective DILI registries

Nitrofurantoin is a synthetic antibiotic that is recommended as first-choice treatment for uncomplicated urinary tract infections. The prescription of this drug has increased dramatically, especially in Latin American countries. We described the demographics, clinical characteristics, biochemical features, and outcome of nitrofurantoin-induced liver injury. We analyzed 23 cases from the Latin American DILI Network (LATINDILI) and the Spanish DILI Registry. Causality was assessed with the RUCAM and RECAM scale. Of the 23 DILI cases included in our series, 96% patients were women, and the mean age of the whole cohort was 61 years. The median time of drug exposure was 175 days (interquartile range [IQR] 96-760), with 11 patients who were prescribed nitrofurantoin for more than six months. Hepatocellular damage was the most frequent pattern of liver injury (83%), and nearly half of the patients had an asymptomatic presentation (52%). Neither death nor liver transplantation was documented in this series. Overall, 65% of the patients (n = 15) presented with positive autoantibody titres. The median time to resolution was 81 days (IQR 57-141), and 15 patients (83%) recovered within six months. Five patients (22%) developed nitrofurantoin-induced autoimmune-like hepatitis (NI-AILH), of whom two were characterized by a persistent increase in transaminases that required immunosuppressive treatment to achieve normalization of liver enzymes. Clinicians who prescribe nitrofurantoin should be aware that patients who had taken nitrofurantoin for a long term may be at risk of developing nitrofurantoin-induced autoimmune-like hepatitis.

AB1543-HPR WAITING ROOM PROJECT: IMPROVING HEALTHCARE OF SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS

Background

Systemic lupus erythematosus (SLE) prognosis is determined by a wide range of factors, such as the severity of the disease manifestations, the psychosocial aspects of patients, the proper management of comorbidities, adoption of a healthy lifestyle and adherence to treatment. Studies on chronic diseases highlight the value of patient education to foster treatment adherence and improve prognosis.

Objectives

To promote health education to SLE patients and their families providing accessible and comprehensive scientific information, in order to improve adherence to treatment and the patient’s prognosis.

Methods

The Waiting Room Project is linked to the Extension Health Care Program for SLE patients and their families of Universidade Federal de Minas Gerais, Brazil, since 2011. A total of 700 patients under SLE treatment at the Rheumatology Unit of the University Hospital are involved. Medical students and rheumatology fellows, altogether, developed high-quality informative texts, with clear content and layman language appropriate for the patient, under the supervision of the rheumatology professors. The texts are illustrated by the team of the Communication Department of the Medical School and medical students, and are printed in a leaflet format. The material is handed out to the patients, while they wait for their medical appointment, by the students and the care team. The content of the leaflets is discussed, making sure that all the concerns and doubts are properly addressed

Results

The Waiting Room Project has produced 17 leaflets, addressing different aspects of SLE, comorbidities, and treatment. The texts approach the traditional cardiovascular risk factors (Smoking, Arterial Hypertension, Diabetes, Obesity, Physical Activity), and some medical conditions related to general health and SLE treatment (Sun Protection, Healthy Food, Oral Care, Vaccination, Pregnancy, Osteoporosis). In 2020 and 2021, two leaflets about Covid-19 were produced in order to clarify important aspects of this disease, its impact on lupus patients and to solve questions about SLE medications: one regarding the association between Lupus and Covid-19 and another about the treatment of lupus and Covid-19. Other four leaflets were produced concerning SLE treatment, including Adherence to Treatment, the use of Antimalarials, Corticosteroids, and Immunosuppressants. Information about the drugs, general importance on lupus treatment, recommendations and possible adverse events were described. Futhermore, additional content is currently in production with themes such as Intravenous Corticosteroid and Cyclophosphamide, Human Papillomavirus Infection, Malignant Neoplasm, and specific cancers frequently affecting women, such as Colorectal Cancer, Cervical Cancer, and Breast Cancer. The leaflets are also available online on the Medical School website in Portuguese and in English (medicina.ufmg.br/alo/material-didatico/), on the Minas Gerais Rheumatology Society website (reumatologia.org.br/orientacoes-ao-paciente/), and on the Instagram page @lupusufmg

Conclusion

The leaflets have been an important source of information and health education for SLE patients and their families, improving student/physician-patient communication. Despite the adversities caused by the coronavirus pandemic, the Waiting Room Project has kept its purpose to make each patient with SLE an agent of their healthcare. Improving the patients’ access to evidence-based information must be a goal of healthcare professionals that treat patients with SLE

References

[1]Koehn CL, Esdaile JM. Patient education and self-management of musculoskeletal diseases. Best Pract Res Clin Rheumatol. 2008; 22: 395-405.

[2]Navarra SV, Zamora LD, Collante MaTM. Lupus education for physicians and patients in a resource-limited setting. Clinical Rheumatol. 2019; 39:697–702.

[3]Zhang L, Luan W, Geng S, et al. Lack of patient education is risk factor of disease flare in patients with systemic lupus erythematosus in China. BMC Health Serv Res. 2019; 19: 378.

Disclosure of Interests

None declared

Herbal and Dietary Supplements-Induced Liver Injury in Latin America: Experience From the LATINDILI Network

BACKGROUND

Herbal and dietary supplements (HDS) consumption, a growing cause of hepatotoxicity, is a common practice among Latin-American populations.

OBJECTIVES

To evaluate clinical, laboratory features and outcome in HDS-hepatotoxicity included in the Latin America-Drug Induced Liver Injury (LATINDILI) Network.

METHODS

A total of 29 adjudicated cases of HDS hepatotoxicity reported to the LATINDILI Network from October 2011 through December 2019 were compared with 322 DILI cases due to conventional drugs and 16 due to anabolic steroids as well as with other series of HDS-hepatotoxicity.

RESULTS

From 367 DILI cases, 8% were attributed to HDS. An increasing trend in HDS-hepatotoxicity was noted over time (p = .04). Camellia sinensis, Herbalife® products, and Garcinia cambogia, mostly used for weight loss, were the most frequently adjudicated causative agents. Mean age was 45 years (66% female). Median time to onset was 31 days. Patients presented typically with hepatocellular injury (83%) and jaundice (66%). Five cases (17%) developed acute liver failure. Compared to conventional medications and anabolic steroids, HDS hepatotoxicity cases had the highest levels of aspartate and alanine transaminase (p = .008 and p = .021, respectively), had more re-exposure events to the culprit HDS (14% vs 3% vs 0%; p = .026), and had more severe and fatal/liver transplantation outcomes (21% vs 12% vs 13%; p = .005). Compared to other DILI cohorts, less HDS hepatotoxicity cases in Latin America were hospitalized (41%).

CONCLUSIONS

HDS-hepatotoxicity in Latin-America affects mainly young women, manifests mostly with hepatocellular injury and is associated with higher frequency of accidental re-exposure. HDS hepatotoxicity is more serious with a higher chance of death/liver transplantation than DILI related to conventional drugs.

Budd-Chiari syndrome due to hepatic venous web outflow obstruction: percutaneous treatment with balloon angioplasty

The Budd-Chiari syndrome is a rare hepatic venous disease. It is more prevalent in young adults and may present in acute, subacute, or chronic forms, causing portal hypertension. Traditional treatment consists of thrombolysis techniques and transjugular intrahepatic portosystemic shunt, as a bridge to liver transplantation. Recently, use of balloon or stent angioplasty techniques has been reported for treatment of this condition. In this article, we report and discuss a case of BCS by membranous obstruction in the hepatic vein outflow tract, with middle hepatic vein thrombosis, in a 24-year-old patient. The treatment chosen and employed was transjugular balloon angioplasty, which achieved satisfactory results and good clinical evolution.

Sensing soluble uric acid by Naip1-Nlrp3 platform

Uric acid (UA), a product of purine nucleotide degradation able to initiate an immune response, represents a breakpoint in the evolutionary history of humans, when uricase, the enzyme required for UA cleavage, was lost. Despite being inert in human cells, UA in its soluble form (sUA) can increase the level of interleukin-1β (IL-1β) in murine macrophages. We, therefore, hypothesized that the recognition of sUA is achieved by the Naip1-Nlrp3 inflammasome platform. Through structural modelling predictions and transcriptome and functional analyses, we found that murine Naip1 expression in human macrophages induces IL-1β expression, fatty acid production and an inflammation-related response upon sUA stimulation, a process reversed by the pharmacological and genetic inhibition of Nlrp3. Moreover, molecular interaction experiments showed that Naip1 directly recognizes sUA. Accordingly, Naip may be the sUA receptor lost through the human evolutionary process, and a better understanding of its recognition may lead to novel anti-hyperuricaemia therapies.

Impact of Herbal and Dietary Supplements Causing Drug-Induced Liver Injury in Latin America

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Hepatic epithelioid hemangioendothelioma: An international multicenter study

BACKGROUND AND AIMS

Hepatic epithelioid hemangioendothelioma is an ultra-rare hepatic vascular tumor, diagnosed more frequently in females. The knowledge about this tumor derives mainly from small case series with sub-optimal treatment outcomes. The aim of this study is to identify the clinical and radiological issues helpful to develop an international prospective registry.

METHODS

We conducted an international multicentric and retrospective study of patients with hepatic hemangioendothelioma. The clinical, pathological and radiological images collected during follow-up were reviewed. Central radiological revision was performed and 3 patterns of contrast were defined.

RESULTS

Between 1994 and 2016, 27 patients with hepatic hemangioendothelioma were identified in three institutions but the final diagnosis was hepatic angiosarcoma in one. The majority were females, median age was 38.7-years and 17 patients were asymptomatic at diagnosis. No patient had Two out of ten (20%) patients had surgical specimens with positive macro-vascular invasion and 50% had extrahepatic disease, and the most frequent pattern was the progressive-central-contrast-uptake. After a median follow-up of 6.7-years, the 5- and 10-year survival rates are 91.5% and 51.9%, respectively.

CONCLUSIONS

This multicentric study shows the heterogeneous profile of patients with hepatic hemangioendothelioma, reflecting the need to establish a reference network in order to better characterize these patients and ultimately develop a personalized treatment strategy.

Profile of herbal and dietary supplements induced liver injury in Latin America: A systematic review of published reports

Hepatotoxicity related to HDS is a growing global health issue. We have undertaken a systematic review of published case reports and case series from LA from 1976 to 2020 to describe the clinical features of HDS related hepatotoxicity in this region. We search in PubMed, Web of Science, Scopus and specific LA databases according to PRISMA guidelines. Only HILI cases published in LA that met criteria for DILI definition were included. Duplicate records or reports that lacked relevant data that precluded establishing causality were excluded. Finally, 17 records (23 cases) were included in this review. Centella asiatica, Carthamus tinctorius, and Herbalife® were the most reported HDS culprit products, the main reason for HDS consumption was weight loss. The clinical characteristics of HDS hepatotoxicity in our study were compared to those of other studies in the USA, Europe and China showing a similar signature with predominance of young females, hepatocellular damage, a high rate of ALF and mortality, more frequent inadvertent re-challenge and chronic damage. This study underscores the challenge in causality assessment when multi-ingredients HDS are taken and the need for consistent publication practice when reporting hepatotoxicity cases due to HDS, to foster HDS liver safety particularly in LA.

164 Gonadotrophin-releasing hormone injection and colour flow Doppler ultrasound of the preovulatory follicle as a tool to increase pregnancy outcome after timed AI in beef cows

The aims of this study were to determine (1) the association between Doppler vascularisation scores (DVS) of the preovulatory follicle (POF) and fertility of beef cows submitted to timed AI (TAI) and (2) whether cows with low DVS benefit from a gonadotrophin-releasing hormone (GnRH) treatment at TAI. Multiparous lactating Nelore cows (Bos indicus; n=69) from a commercial beef farm in the state of Rondônia, Brazil, were enrolled in this study. Cows received 2mg of oestradiol benzoate intramuscularly (Bioestrogen, Biogénesis Bagó) and an intravaginal progesterone-releasing device (1.9g of progesterone; controlled internal drug release, CIDR) to synchronise follicular wave emergence on Day 0. The CIDR device was removed and cows were treated with 150μg of D-cloprostenol intramuscularly (prostaglandin F2α analogue; Croniben), 1mg of oestradiol cypionate intramuscularly, and 300IU of equine chorionic gonadotrophin (Novormon) intramuscularly on Day 8. Cows were then painted with a tail chalk marker to identify those displaying oestrus. All cows were submitted to TAI 48h after CIDR removal. At TAI, occurrence of oestrus was recorded and all cows were examined using transrectal ultrasonography. Blood flow of the POF was evaluated using colour Doppler imaging. Colour Doppler signals present on the follicular wall were subjectively scored using a 1-to-4 scale (1=absence or very low blood flow, and 4=intense blood flow detected on most of the follicular wall surface) adapted from Ginther (2007Ultrasonic Imaging and Animal Reproduction: Color-Doppler Ultrasonography, pages 87-114). Then, cows were divided into three groups according their DVS of the POF: (1) high DVS (DVS ≥3; n=36), (2) low DVS (DVS &lt;3; n=16), and (3) low DVS (DVS &lt;3; n=17) plus a GnRH treatment at TAI. The diameter of the POF was analysed using analysis of variance (PROC GLIMMIX of SAS; SAS Institute Inc.), and the means were compared among groups using Tukey's test. The proportion of cows that displayed oestrus and pregnancy rates was analysed using chi-square test. Cows in the high-DVS group had a larger POF than cows in the low-DVS and low-DVS-GnRH groups (13.2±0.2, 11.7±0.5, and 12.2±0.4, respectively; P&lt;0.05). The proportion of cows that displayed oestrus was greater (P&lt;0.05) in the high-DVS group (72%, 26/36) than in the low-DVS (37.5%, 6/16) or low-DVS-GnRH (53%, 9/17) groups. Finally, greater (P&lt;0.05) pregnancy rates were observed in cows from the high-DVS (47.2%; 17/36) and low-DVS-GnRH (52.9%; 9/17) groups than in cows from the low-DVS group (18.7%; 3/16). The preliminary results from this study demonstrated that diameter of POF is positively associated with DVS. Moreover, cows that presented POF with higher DVS are more likely to become pregnant, and the administration of GnRH to females with low DVS can increase the fertility of beef cows submitted to TAI protocols. This study received funding support from Embrapa (MP1/PC3 project no. 01.03.14.011.00.00) and from CNPq (universal project no. 407307/2016-8).

Concordance of non-invasive mechanical and serum tests for liver fibrosis evaluation in chronic hepatitis C

AIM

To determine the sensitivity and specificity of liver stiffness measurement (LSM) and serum markers (SM) for liver fibrosis evaluation in chronic hepatitis C.

METHODS

Between 2012 and 2014, 81 consecutive hepatitis C virus (HCV) patients had METAVIR score from liver biopsy compared with concurrent results from LSM [transient elastography (TE) [FibroScan^®/ARFI technology (Virtual Touch^®)] and SM [FIB-4/aspartate aminotransferase-to-platelet ratio index (APRI)]. The diagnostic performance of these tests was assessed using receiver operating characteristic curves. The optimal cut-off levels of each test were chosen to define fibrosis stages F ≥ 2, F ≥ 3 and F = 4. The Kappa index set the concordance analysis.

RESULTS

Fifty point six percent were female and the median age was 51 years (30-78). Fifty-six patients (70%) were treatment-naïve. The optimal cut-off values for predicting F ≥ 2 stage fibrosis assessed by TE were 6.6 kPa, for acoustic radiation force impulse (ARFI) 1.22 m/s, for APRI 0.75 and for FIB-4 1.47. For F ≥ 3 TE was 8.9 kPa, ARFI was 1.48 m/s, APRI was 0.75, and FIB-4 was 2. For F = 4, TE was 12.2 kPa, ARFI was 1.77 m/s, APRI was 1.46, and FIB-4 was 3.91. The APRI could not distinguish between F2 and F3, P = 0.92. The negative predictive value for F = 4 for TE and ARFI was 100%. Kappa index values for F ≥ 3 METAVIR score for TE, ARFI and FIB-4 were 0.687, 0.606 and 0.654, respectively. This demonstrates strong concordance between all three screening methods, and moderate to strong concordance between them and APRI (Kappa index = 0.507).

CONCLUSION

Given the costs and accessibility of LSM methods, and the similarity with the outcomes of SM, we suggest that FIB-4 as well as TE and ARFI may be useful indicators of the degree of liver fibrosis. This is of particular importance to developing countries.

Massive gastrointestinal bleeding after chemotherapy for gastric lymphoma

INTRODUCTION

Gastrosplenic fistula (GSF) is a rare condition almost always associated with lymphoma, with gastric and splenic involvement.

CASE REPORT

We report a 52 year old male with gastric lymphoma admitted to the emergency department with hematemesis. The first chemotherapy cycle had been completed four weeks before. Oesophagoduodenoscopy showed a pulsatile ulcerated lesion. Surgical hemostasis was performed. Four days after surgery, the patient initiated sudden and massive upper gastrointestinal bleeding with hemodynamic compromise. A gastrosplenic fistula was recognized during emergency laparotomy and an en bloc total gastrectomy and splenopancreatectomy resection was performed, with massive blood transfusion. Patient was discharged 13 days after the second surgery.

DISCUSSION

Gastrosplenic fistula is a rare condition, previously described associated with gastric lymphoma at presentation or after treatment. A prompt recognition of the underlying pathology could avoid a second surgery.

CONCLUSION

A systematic and interdisciplinary approach is the key for success in rare challenging emergencies. Infrequent etiologies must always be considered as they need specific therapeutic approaches that defy paradigms.

New insights into cystinuria: 40 new mutations, genotype-phenotype correlation, and digenic inheritance causing partial phenotype

OBJECTIVE

To clarify the genotype-phenotype correlation and elucidate the role of digenic inheritance in cystinuria.

METHODS

164 probands from the International Cystinuria Consortium were screened for mutations in SLC3A1 (type A) and SLC7A9 (type B) and classified on the basis of urine excretion of cystine and dibasic amino acids by obligate heterozygotes into 37 type I (silent heterozygotes), 46 type non-I (hyperexcretor heterozygotes), 14 mixed, and 67 untyped probands.

RESULTS

Mutations were identified in 97% of the probands, representing 282 alleles (86.8%). Forty new mutations were identified: 24 in SLC3A1 and 16 in SLC7A9. Type A heterozygotes showed phenotype I, but mutation DupE5-E9 showed phenotype non-I in some heterozygotes. Type B heterozygotes showed phenotype non-I, with the exception of 10 type B mutations which showed phenotype I in some heterozygotes. Thus most type I probands carried type A mutations and all type non-I probands carried type B mutations. Types B and A mutations contributed to mixed type, BB being the most representative genotype. Two mixed cystinuria families transmitted mutations in both genes: double compound heterozygotes (type AB) had greater aminoaciduria than single heterozygotes in their family.

CONCLUSIONS

Digenic inheritance is an exception (two of 164 families), with a limited contribution to the aminoaciduria values (partial phenotype) in cystinuria. Further mutational analysis could focus on one of the two genes (SLC3A1 preferentially for type I and SLC7A9 for type non-I probands), while for mixed probands analysis of both genes might be required, with priority given to SLC7A9.