Severe Drug-Induced Liver Injury in the Military: A Retrospective Review

ABSTRACT Objectives Drug-induced liver injury (DILI) is a significant cause of morbidity and mortality. Establishing a diagnosis is challenging due to the broad differential diagnosis of liver injury. We retrospectively reviewed patients with severe idiosyncratic DILI at Walter Reed National Military Medical Center in order to define the scope and patterns of injury in the military population. Methods Using the military health database, we identified a total of 110 patients who had an International Classification of Disease (ICD)-10 code for toxic liver injury in the electronic medical record at Walter Reed National Military Medical Center between 2016 and 2019. Each patient record was reviewed, and all pertinent data for included patients were recorded into a database for analysis. Results Twenty-seven out of 110 patients with a diagnostic code for toxic liver injury met inclusion criteria for severe idiosyncratic DILI. Nine cases were caused by supplements, including 5 active duty service members using synthetic anabolic steroids or preworkout supplements. The majority of patients were men and one-third were serving on active duty. The ranges of liver enzyme elevation and patterns of liver injury widely varied. Conclusion Military service members are at particularly high risk for DILI given the frequent use of over-the-counter and other unregulated strength- and performance-enhancing supplements. These injuries not only have significant medical consequences but can profoundly impact military readiness and mission capability. Diagnosis of DILI among active duty service members requires a strong index of suspicion, and inquiry regarding all ingestions is crucial. Educating physicians, providers, and policy makers on the risks of supplement-induced liver injury among service members is crucial. These data will facilitate additional studies exploring susceptibility to severe idiosyncratic DILI among the military population.

Protective Effect of Chemically Characterized Polyphenol-Rich Fraction from Apteranthes europaea (Guss.) Murb. subsp. maroccana (Hook.f.) Plowes on Carbon Tetrachloride-Induced Liver Injury in Mice

Apteranthes europaea (Guss.) Murb. subsp. maroccana (Hook.f.) Plowes (A. europaea) is a medicinal plant widely used in traditional medicines to treat various diseases including hepatic pathogenesis. This study was conducted to evaluate the protective effect of chemically characterized polyphenol-rich fraction from A. europaea on carbon tetrachloride-induced liver injury in mice. The chemical characterization of A. europaea polyphenol-rich fraction was carried out using HPLC-DAD (high-performance liquid chromatography (HPLC) with a diode-array detector (DAD)). Carbon tetrachloride (CCl4) was used to induce liver injuries in mice as described in previous works. A polyphenol-rich fraction from A. europaea was used at a dose of 50 mg/Kg to study its hepatoprotective effect. Next, histopathological and biochemical alterations were investigated. The HPLC analysis revealed the presence of several phenolic compounds: gallic acid, methyl gallate, rutin, ferulic acid, and resorcinol. Regarding the mice treated with a polyphenol-rich fraction from A. europaea up to 50 mg/Kg and carbon tetrachloride, no significant biochemical nor histological alterations occurred in their liver; meanwhile, serious biochemical and histopathological changes were noted for liver recovered from the mice treated with carbon tetrachloride only. In conclusion, A. europaea extract is a promising source of hepatoprotective agents against toxic liver injury.

Evaluation of silymarin and berberine efficiencies in the self-emulsifying drug delivery systemin paracetamol-induced experimental toxic liver injury

The hepatoprotective properties of the silymarin and the plant alkaloid berberine combinationin experimental paracetamol-inducedliver damage were studied. Silymarin was obtained from milk thistle seeds. The conditions for extraction of flavonolignans (silymarin) were optimized. 70 % ethyl alcohol, ethyl acetate and water were used as extractants. It was shown that the optimal conditions for the extraction of flavonolignans in order to obtain the maximum yield of flavonolignans were alcohol extraction in a Soxhlet apparatus. The experiment showed that the combined of silymarin and berberine was greater than their individual actions, which most effectively permitted stabilization of hepatocyte membranes and prevented altering their integrity in paracetamol-induced toxic liver damage. The self-emulsifying system with silymarin and berberine to a greater extent a significant extent prevented dystrophic changes in hepatocytes and necrosis in liver tissue, reduced hyperfermentemia in rat blood serum, prevented disturbance in the activity of thioredoxin reductase and enzymes of the glutathione antioxidant system and there by more effectively prevented hepatocyte functional impairment.

Study of clustered DNA lesions in the liver in acute toxic injury

Objective: to test and optimize a method for detecting clustered DNA lesions with an assessment of the quantitative characteristics of hepatic changes using an experimental model of acute toxic hepatitis.Material and methods: Laboratory C57Bl/6 mice at the age of 10 weeks were used for the study. Acute toxic liver injury was induced by means of a single intraperitoneal injection of 30 % CCI4 solution in olive oil. The withdrawal of the animals from the experiment was made after 72 hours. For the detection of clustered DNA lesions, a liver fragment was resected.Results. The electrophoretic parameters which are the most optimal for obtaining primary data for the subsequent calculation of the number of clustered DNA lesions have been proposed. The number of clusters in the DNA samples from the animals of the control group is significantly lower than in the experimental group and amounts to 54.80 [37.65; 59.24] and 76.82 [60.95; 92.41] APE1 clusters per million bp., respectively.Conclusion. Successful testing and optimization of the OCDL method for the detection of clustered lesions in liver DNA have been performed. The study has shown an increase in the number of APE1 clusters and double-strand breaks in the DNA of the C57Bl laboratory mice with induced acute toxic hepatitis, which indicates significant derangement of DNA integrity and a high risk of developing progressive liver diseases in its toxic damage.

Circulating PV-1 as a marker of celiac disease-associated liver injury

Aim: To investigate the role of endothelial PV-1 in patients with untreated celiac disease (CD)-associated liver injury. Materials & methods: PV-1 and PV-1 mRNA were measured in intestinal biopsies from untreated CD patients with elevated or normal alanine transaminase levels, controls, patients with inflammatory bowel disease and patients with toxic liver injury. Circulating PV-1 levels were also evaluated. Results: Circulating PV-1 levels were significantly increased in the serum of patients with CD-associated liver injury and reverted to normal following a gluten-free diet. Mucosal PV-1 and PV-1 mRNA were no different in patients with CD-associated liver injury. Conclusion: Serum but not mucosal PV-1 represents a marker of gluten-dependent liver injury and response to a gluten-free diet in patients with untreated CD.

Activity of enzymes of tyrosine metabolism in the rat liver under the conditions of acetaminophen-induced hepatitis on the background of protein deficiency

The contribution of the mis-metabolism of individual amino acids to the development of drug-induced damage to liver cells remains unexplored. The aim of the present study was to investigate the changes in liver tyrosine level and activity of the enzymes of its metabolism: tyrosine aminotransferase, 4-hydroxyphenylpyruvate dioxygenase, aldehyde dehydrogenase ALDH3A1 under the conditions of acetaminophen-induced hepatitis on the background of protein deficiency. Determination of tyrosine in deproteinized with 6% sulfosalicylic acid extracts of the liver tissue was performed using the automatic analyzer of amino acids T-339 (“Microtechnology”, Czech Republic). The enzyme activity was determined by spectrophotometric method – tyrosine aminotransferase by the amount of 4-hydroxybenzaldehyde, which has a maximum absorption at 330 nm, 4-hydroxyphenylpyruvate dioxygenase – by the colored product intensity at λ 336 nm, aldehyde dehydrogenase ALDH3A1 activity was measured at 340 nm wavelength. Results have shown that in animals with toxic liver injury which were maintained in conditions of alimentary protein deficiency, a 5-fold decrease in tyrosine level in the liver was observed. At the same time in animals of this group there was a decrease in TAT activity by 1.6 times, a 4-fold decrease in activity of aldehyde dehydrogenase ALDH3A1 and increase in the activity of 4-hydroxyphenylpyruvate dioxygenase by 2.5 time comparing to control parameters. Conclusion was made, that alimentary protein deficiency is a factor leading to an intensification of tyrosine metabolism disturbances in animals with toxic liver injury. The pronounced exhaustion of the tyrosine pool is accompanied by the activation of the homogentisate pathway of its metabolism, as evidenced by the increase in the activity of 4-hydroxyphenylpyruvate dioxygenase and simultaneous reduction in the aldehyde dehydrogenase ALDH3A1activity. The established changes open prospects to study the possible targets for the exogenous correction of metabolic disorders under the conditions of intoxication with acetaminophen, especially in people with protein deficiency.

Hepatoprotective Effect of Melatonin in Toxic Liver Injury in Rats

Background and objectives: toxic liver injury results in nitrooxidative stress. Melatonin is a potent free radical scavenger, an inducible nitric oxide synthase (iNOS) inhibitor and an activator of antioxidant enzymes. The aim of this study was to investigate the hepatoprotective effect of exogenous melatonin on animals with acute toxic hepatitis. Material and methods: 36 healthy Sprague-Dawley male rats were split into three equal groups and given carbon tetrachloride (CCl4), 2 g/kg (CCl4 group) or the same dose of CCl4 and melatonin, 10 mg/kg (CCl4/melatonin group) or saline (control group). The effect of melatonin on prooxidant and antioxidant system indexes, NO and NOS levels in serum and liver, data of mitochondrial chain functions and cytolysis in liver were evaluated in all three groups. Results: melatonin significantly decreased activities of AST, ALT, ceruloplasmine and thiobarbituric acid reactive substance (TBARS) in serum. Catalase activity was lowered in serum but not in the liver. Hepatic TBARS, lipid hydroperoxides and glutathione concentrations were decreased, while superoxide dismutase, mitochondrial cytochrome oxidase and succinate dehydrogenase activities increased. Melatonin inhibited synthesis of stable NO metabolites in serum: NO2-by 37.9%; NO3-by 29.2%. There was no significant difference in content NO2-in the liver, but concentration of NO3-increased by 32.6%. Melatonin significantly reduced iNOS concentrations both in serum (59.7%) and liver (57.8%) but did not affect endothelial isoform enzyme activities neither in serum, nor in liver. The histopathological liver lesions observed in the CCl4/melatonin group were less severe than those seen in the CCl4 group. Conclusions: we demonstrated an ameliorating effect of melatonin on prooxidants and antioxidants, NO-NOS systems balance, mitochondrial function and histopathological lesions in the liver in rats with CCl4-induced hepatitis.