Idiosyncratic Drug-Induced Liver Injury: From Pathogenesis to Risk Reduction

Idiosyncratic drug-induced liver injury (iDILI) is a rare and poorly predictable adverse drug reaction that may lead to death or liver transplantation in severe cases.

The aim of the study was to review contemporary concepts of the immune-mediated pathogenesis of iDILI and possible ways to predict and prevent the risk of developing this condition.

The liver is characterised by high immune tolerance due to a complex of mechanisms involving various cells (antigen-presenting cells, T-cells), cytokines, and other molecules, which prevents severe immune responses to xenobiotics entering the body. Previous research has shown that iDILI results from a combination of multiple synergistic unfavourable factors that impair liver immune tolerance at different levels. These factors include the hepatotoxicity-associated chemical properties of medicines and the individual characteristics of the patient, including the genetically determined structure and function of the adaptive immune system components. Since iDILI has a multilevel and multifactor pathogenesis, it is difficult to determine a risk biomarker for a particular medicine. According to the literature review, the risk of hepatotoxicity of a drug candidate and/or a metabolite can be reduced at the preclinical level by assessing the ability to cause mitochondrial damage, form non-covalent bonds, produce reactive oxygen species, and release damage-associated molecular patterns (DAMPs). The association of iDILI with gene polymorphisms in patients receiving certain medicines has a high negative predictive value and can be used in clinical practice to rule out iDILI or identify hepatotoxic medicinal products in polypharmacy. The identification of the allele combinations associated with an increased risk of iDILI seems promising for enhancing the predictive value of genetic studies and may be used in personalised medicine.

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