Development of a modified lymphocyte transformation test for diagnosing drug-induced liver injury associated with an adaptive immune response

Abstract Drug-induced liver injury (DILI) is a growing problem. Diagnostic methods to differentiate DILI caused by an adaptive immune response from liver injury of other causes or to identify the responsible drug in patients receiving multiple drugs, herbals and/or dietary supplements (polypharmacy) have not yet been established. The lymphocyte transformation test (LTT) has been proposed as a diagnostic method to determine if a subject with an apparent hypersensitivity reaction has become sensitized to a specific drug. In this test, peripheral blood mononuclear cells (PBMC) collected from a subject are incubated with drug(s) suspected of causing the reaction. Cell proliferation, measured by the incorporation of [3H]-thymidine into new DNA, is considered evidence of a drug-specific immune response. The objectives of the current studies were to: (1) develop and optimize a modified version of the LTT (mLTT) and (2) investigate the feasibility of using the mLTT for diagnosing DILI associated with an adaptive immune response and identifying the responsible drug. PBMC collected from donors with a history of drug hypersensitivity reactions to specific drugs (manifested as skin rash) were used as positive controls for assay optimization. Following optimization, samples collected from 24 subjects enrolled in the U.S. Drug-Induced Liver Injury Network (DILIN) were tested in the mLTT. Using cytokine and granzyme B production as the primary endpoints to demonstrate lymphocyte sensitization to a specific drug, most samples from the DILIN subjects failed to respond. However, robust positive mLTT responses were observed for two of four samples from three DILIN subjects with hepatitis due to isoniazid (INH). We conclude that the mLTT, as performed here on frozen and thawed PBMC, is not a reliable test for diagnosing DILI caused by all drugs, but that it may be useful for confirming the role of the adaptive immune response in DILI ascribed to INH.

[1]  Arun J. Sanyal,et al.  Zakim and Boyer's Hepatology: A Textbook of Liver Disease , 2016 .

[2]  Jiezhun Gu,et al.  Amoxicillin–Clavulanate-Induced Liver Injury , 2016, Digestive Diseases and Sciences.

[3]  William M. Lee,et al.  Persistent Liver Biochemistry Abnormalities Are More Common in Older Patients and those With Cholestatic Drug Induced Liver Injury , 2015, The American Journal of Gastroenterology.

[4]  M. Pirmohamed,et al.  Characterization of amoxicillin‐ and clavulanic acid‐specific T cells in patients with amoxicillin‐clavulanate–induced liver injury , 2015, Hepatology.

[5]  William M. Lee,et al.  Features and Outcomes of 899 Patients With Drug-Induced Liver Injury: The DILIN Prospective Study. , 2015, Gastroenterology.

[6]  V. Navarro.  Liver injury due to herbal and dietary supplements , 2015 .

[7]  William M. Lee,et al.  Comparative analysis of portal hepatic infiltrating leucocytes in acute drug‐induced liver injury, idiopathic autoimmune and viral hepatitis , 2015, Clinical and experimental immunology.

[8]  H. Bonkovsky,et al.  Herbal products and the liver: a review of adverse effects and mechanisms. , 2015, Gastroenterology.

[9]  H. Barnhart,et al.  Liver injury from herbals and dietary supplements in the U.S. Drug‐Induced Liver Injury Network , 2014, Hepatology.

[10]  D. Naisbitt,et al.  In vitro diagnosis of delayed-type drug hypersensitivity: mechanistic aspects and unmet needs. , 2014, Immunology and allergy clinics of North America.

[11]  William M. Lee,et al.  ACG Clinical Guideline: The Diagnosis and Management of Idiosyncratic Drug-Induced Liver Injury , 2014, The American Journal of Gastroenterology.

[12]  William M. Lee,et al.  Hepatic Histological Findings in Suspected Drug-Induced Liver Injury: Systematic Evaluation and Clinical Associations , 2013, Hepatology.

[13]  William M. Lee,et al.  Profiles of Serum Cytokines in Acute Drug-Induced Liver Injury and Their Prognostic Significance , 2013, PloS one.

[14]  W. Pichler,et al.  In vitro drug causality assessment in Stevens–Johnson syndrome – alternatives for lymphocyte transformation test , 2013, Clinical and experimental allergy : journal of the British Society for Allergy and Clinical Immunology.

[15]  R. Fontana,et al.  Drug-Induced Liver Injury Network (DILIN) Prospective Study: Rationale, Design and Conduct , 2013 .

[16]  Dean P. Jones,et al.  Chapter 25 – Drug-Induced Liver Injury , 2012 .

[17]  Avner Schlessinger,et al.  ICAHN SCHOOL OF MEDICINE AT MOUNT SINAI , 2012 .

[18]  M. Daly,et al.  Susceptibility to amoxicillin-clavulanate-induced liver injury is influenced by multiple HLA class I and II alleles. , 2011, Gastroenterology.

[19]  Imir G. Metushi,et al.  A Fresh Look at the Mechanism of Isoniazid‐Induced Hepatotoxicity , 2011, Clinical pharmacology and therapeutics.

[20]  R. Fontana,et al.  Mechanisms of drug-induced liver injury: from bedside to bench , 2011, Nature Reviews Gastroenterology &Hepatology.

[21]  R. Fontana,et al.  Standardization of nomenclature and causality assessment in drug‐induced liver injury: Summary of a clinical research workshop , 2010, Hepatology.

[22]  R. Fontana,et al.  Causality assessment in drug‐induced liver injury using a structured expert opinion process: Comparison to the Roussel‐Uclaf causality assessment method , 2010, Hepatology.

[23]  J. Hoofnagle,et al.  Important elements for the diagnosis of drug-induced liver injury. , 2010, Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association.

[24]  W. Pichler,et al.  In vitro detection of cytotoxic T and NK cells in peripheral blood of patients with various drug‐induced skin diseases , 2010, Allergy.

[25]  Michael P Holt,et al.  Drug-induced liver injury. , 2010, Handbook of experimental pharmacology.

[26]  W. Pichler,et al.  Drug‐specific in vitro release of IL‐2, IL‐5, IL‐13 and IFN‐γ in patients with delayed‐type drug hypersensitivity , 2009, Allergy.

[27]  W. Pichler,et al.  In vitro tests in drug hypersensitivity diagnosis. , 2009, Immunology and allergy clinics of North America.

[28]  R. Fontana,et al.  Causes, clinical features, and outcomes from a prospective study of drug-induced liver injury in the United States. , 2008, Gastroenterology.

[29]  R. Fontana,et al.  Reliability of the Roussel Uclaf Causality Assessment Method for assessing causality in drug‐induced liver injury , 2008, Hepatology.

[30]  T. Shiohara,et al.  Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption , 2007, Allergy.

[31]  T. Monna,et al.  Detection of hypersensitivity to drugs by lymphocyte cultures in drug-induced allergic hepatitis , 2007, Gastroenterologia Japonica.

[32]  J. Castell,et al.  Allergic hepatitis induced by drugs , 2006, Current opinion in allergy and clinical immunology.

[33]  C. Ju.  Immunological mechanisms of drug-induced liver injury. , 2005, Current opinion in drug discovery & development.

[34]  A. Shibuya,et al.  Validity study of a new diagnostic scale for drug-induced liver injury in Japan-comparison with two previous scales. , 2004, Hepatology research : the official journal of the Japan Society of Hepatology.

[35]  J. Hoofnagle,et al.  Drug‐induced liver injury network (DILIN) , 2004, Hepatology.

[36]  W. Pichler,et al.  The lymphocyte transformation test in the diagnosis of drug hypersensitivity , 2004, Allergy.

[37]  A. Watanabe,et al.  Detection and analysis of intracytoplasmic cytokines in peripheral blood mononuclear cells in patients with drug-induced liver injury. , 2003, Journal of hepatology.

[38]  R. Victorino,et al.  Diagnostic value of specific T cell reactivity to drugs in 95 cases of drug induced liver injury , 1997, Gut.

[39]  H. Nagai,et al.  Lymphocyte stimulation test with tetrazolium-based colorimetric assay for diagnosis of drug-induced allergic hepatitis. , 1994, Biological & pharmaceutical bulletin.

[40]  F. Iber.  Hepatology: A Textbook of Liver Disease , 1983 .

[41]  R. Warrington,et al.  The predictive value of the lymphocyte transformation test in isoniazid‐associated hepatitis , 1982, Clinical allergy.

[42]  A. Sehon,et al.  Evaluation of isoniazid-associated hepatitis by immunological tests. , 1978, Clinical and experimental immunology.