Susceptibility Factors in Idiosyncratic Drug-Induced Liver Injury Steven Yee Molecular and Cellular...
-
Upload
yvonne-gundry -
Category
Documents
-
view
215 -
download
0
Transcript of Susceptibility Factors in Idiosyncratic Drug-Induced Liver Injury Steven Yee Molecular and Cellular...
Susceptibility Factors in IdiosyncraticSusceptibility Factors in IdiosyncraticDrug-Induced Liver InjuryDrug-Induced Liver Injury
Steven YeeSteven YeeMolecular and Cellular Toxicology SectionMolecular and Cellular Toxicology Section
National Institutes of HealthNational Institutes of [email protected]@nhlbi.nih.gov
8 June 20048 June 2004
U.S. Department of Healthand Human Services
National Institutes of Health
National Heart, Lung, and Blood Institute
• Occurs in small fraction of individualsOccurs in small fraction of individuals
• Difficult to predictDifficult to predict
• Major clinical problem; often life-threateningMajor clinical problem; often life-threatening • Leading cause of acute liver failureLeading cause of acute liver failure
• Reason drugs removed from clinical Reason drugs removed from clinical development and widespread usedevelopment and widespread use
Drug-Induced Liver InjuryDrug-Induced Liver Injury
Examples of Drugs Withdrawn Due to Examples of Drugs Withdrawn Due to Liver DiseaseLiver Disease
IproniazidIproniazid19561956
Ibufenac (in Europe only)Ibufenac (in Europe only)19751975
TicrynafenTicrynafen1979 1979
BenoxaprofenBenoxaprofen1982 1982
Perhexiline (in France)Perhexiline (in France) 19851985
Dilevalol (in Portugal, Ireland)Dilevalol (in Portugal, Ireland)19901990
BromfenacBromfenac 19981998
Troglitazone Troglitazone 20002000
SerzoneSerzone20042004
• Mechanism often involves drug metabolitesMechanism often involves drug metabolites– Affect critical biochemical functionsAffect critical biochemical functions– Specific immune responsesSpecific immune responses
• Only a few drugs demonstrate these Only a few drugs demonstrate these underlying causesunderlying causes
• Tissue susceptibility: imbalance between Tissue susceptibility: imbalance between protoxicants and protectantsprotoxicants and protectants
– Environmental factorsEnvironmental factors– Genetic polymorphismGenetic polymorphism
Putative MechanismsPutative Mechanisms
Hepatotoxicants Potentiated by Exposure to Hepatotoxicants Potentiated by Exposure to Small Doses of Lipopolysaccharide (LPS)Small Doses of Lipopolysaccharide (LPS)
XenobioticsXenobioticsCClCCl44
GalactosamineGalactosamine
EthanolEthanol
T2-toxinT2-toxin
CadmiumCadmium
HalothaneHalothane
LeadLead
Allyl AlcoholAllyl Alcohol
Aflatoxin BAflatoxin B11
ChlorpromazineChlorpromazine
RanitidineRanitidine
SourceSourceFormal Formal et al.et al., 1960, 1960
Galanos Galanos et al.et al., 1979, 1979
Nolan Nolan et al.et al., 1980, 1980
Tai and Petska, 1988Tai and Petska, 1988
Cook Cook et al.et al.., 1974., 1974
Lind Lind et al.et al., 1984, 1984
Honchel Honchel et alet al., 1991., 1991
Sneed Sneed et al.et al., 1997, 1997
Barton Barton et al.et al., 2000, 2000
Buchweitz Buchweitz et al.et al., 2002, 2002
Luyendyk Luyendyk et al.et al., 2003, 2003
LPSLPS MacrophagesMacrophagesNeutrophilsNeutrophils
Endothelial CellsEndothelial CellsEpithelial CellsEpithelial Cells
TLR4TLR4
CytokinesCytokines Coagulation FactorsCoagulation FactorsPlatelet Activating FactorPlatelet Activating Factor Complement ActivationComplement ActivationLeukotrienesLeukotrienes Arachidonic Acid MetabolitesArachidonic Acid MetabolitesProstaglandinsProstaglandins Reactive Oxygen SpeciesReactive Oxygen SpeciesNitric OxideNitric Oxide
Cellular Level Events of LPSCellular Level Events of LPS
Monocrotaline (MCT)Monocrotaline (MCT)
NN
CHCH22OO
OOO=CO=C
CC C=OC=O
CCCC
OHOH
CHCH33 CHCH33
OHOHHH33CCHH
MonocrotalineMonocrotaline
Crotalaria SpectabilisCrotalaria Spectabilis(Rattlebox)(Rattlebox)
NN
CHCH22OO
OOO=CO=C
CC C=OC=O
CCCC
OHOH
CHCH33 CHCH33
OHOHHH33CCHH
MCTMCT
NN
CHCH22OO
OOO=CO=C
CC C=OC=O
CCCC
OHOH
CHCH33 CHCH33
OHOHHH33CCHH
MonocrotalineMonocrotalinePyrrolePyrrole(MCTP)(MCTP)
CYP 3ACYP 3A
CovalentCovalentBinding toBinding toCellular Cellular
MacromoleculesMacromolecules
Cell DeathCell Death
MCT ToxicityMCT Toxicity
MCT/LPS Treatment ProtocolMCT/LPS Treatment Protocol
0 hr 4 hr X hr0 hr 4 hr X hr
MCT or MCT or VehVeh(i.p.)(i.p.)
LPS orLPS orVehVeh(i.v.)(i.v.)
1. Plasma1. Plasma2. Liver2. Liver
• • Male Sprague-Dawley RatsMale Sprague-Dawley Rats
Hours After MCT Administration
0 12 24 36 48 60 72 84 96
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
200
400
600
800
1000
1200a
a
aa
a
a
Veh/VehVeh/LPSMCT/VehMCT/LPS
Modest Inflammation EnhancesModest Inflammation EnhancesMCT ToxicityMCT Toxicity
LPS 4 hours after MCTLPS 4 hours after MCT
LPS Lowers the Threshold for MCT ToxicityLPS Lowers the Threshold for MCT Toxicity
MCT (mg/kg)
0 50 100 150 200
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
250
500
750
1000
1250
1500
aa
a
a
MCT/Veh MCT/LPS
Kupffer Cell Inactivation Reduces Kupffer Cell Inactivation Reduces HepatotoxicityHepatotoxicity
Pla
sma
TN
F-
(p
g/m
l)0
20
40
60
80
100
120
Veh/Veh MCT/LPS
aVehGdCl3
b
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
200
400
600
800
1000
1200
Veh/Veh MCT/LPS
a,b
aVehGdCl3
TNF-TNF- Depletion Attenuates MCT/LPS Depletion Attenuates MCT/LPS HepatotoxicityHepatotoxicity
Pla
sma
TN
F-
(p
g/m
l)0
20
40
60
80
100
Veh/Veh MCT/LPS
a
b
CSATS
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
200
400
600
800
1000
1200
Veh/Veh MCT/LPS
a,b
aCSATS
Neutrophil Depletion AttenuatesNeutrophil Depletion Attenuates MCT/LPS HepatotoxicityMCT/LPS Hepatotoxicity
Nu
mb
er o
f P
MN
s/H
PF
0
10
20
30
40
Veh/Veh MCT/LPS
a
a,b
CSNAS
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
200
400
600
800
1000
Veh/Veh MCT/LPS
a
b
CSNAS
Inactivation of the Coagulation System Inactivation of the Coagulation System Decreases Liver InjuryDecreases Liver Injury
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
300
600
900
1200
Veh/Veh MCT/LPS
a
a,b
VehHep
Pla
sma
AL
T A
ctiv
ity
(U/L
)
0
300
600
900
1200
1500
Veh/Veh MCT/LPS
a
a,b
VehWarf
Pla
sma
Fib
rin
og
en (
mg
/dl)
0
100
200
300
400
Veh/Veh MCT/LPS
a
VehWarf
Pla
sma
Fib
rin
og
en (
mg
/dl)
0
100
200
300
400
Veh/Veh MCT/LPS
a
VehHep
SummarySummary
Sinusoid
SEC
Space of Disse
HPC
MCT
LPS
PMN
PMN
CINC-1
TNF
[Early Injury]
[Injury]
[Late Injury]MCT MCTP
MCT MCTP
Kupffer Cell
[Early Injury][Activated SEC]
MCT
[Activated/ Sensitized HPC]
Kupffer Cell
PMN
Approximate Time (hr)
0 64 8
CoagulationSystem Activation
Thrombin Fibrin Clot
Toxic Factors (proteases, etc.)
HypoperfusionSinusoid
SEC
Space of Disse
HPC
MCT
LPS
PMN
PMN
CINC-1
TNF
[Early Injury]
[Injury]
[Late Injury]MCT MCTPMCT MCTP
MCT MCTPMCT MCTP
Kupffer Cell
Kupffer Cell
[Early Injury][Activated SEC]
MCT
[Activated/ Sensitized HPC]
Kupffer Cell
Kupffer Cell
PMN
Approximate Time (hr)Approximate Time (hr)
0 64 8
CoagulationSystem Activation
Thrombin Fibrin Clot
Toxic Factors (proteases, etc.)
Hypoperfusion
Does a loss in Does a loss in hepatoprotective factors hepatoprotective factors
result in drug-induced liver result in drug-induced liver disease?disease?
DrugDrugLiverLiver
ReactiveReactiveMetabolitesMetabolites
ProteinProteinAdductsAdducts
CellularCellularHomeostasisHomeostasis
AlteredAltered
(Inhibition)(Inhibition)
ResponseResponse
ToxicityToxicity ProtectionProtectionIL-6, IL-10, COX-2Stress Proteins
ProtectiveProtectiveFactorsFactors
ExtensiveExtensiveLiver InjuryLiver InjuryAnd DeathAnd Death
Model CompoundModel Compound
• Many of the protective factors discovered through Many of the protective factors discovered through research on acetaminophen (APAP) toxicityresearch on acetaminophen (APAP) toxicity
• AcetaminophenAcetaminophen– Clinically relevant; analgesic, antipyreticClinically relevant; analgesic, antipyretic– Over 50,000 ER visits per yearOver 50,000 ER visits per year– 450 death per year450 death per year
• SuicideSuicide• Accidental ingestionAccidental ingestion• “ “Therapeutic misadventures”Therapeutic misadventures”
– Unlike with drug idiosyncrasy, it is well characterized Unlike with drug idiosyncrasy, it is well characterized and reproducible in animalsand reproducible in animals
• Bioactivation to Bioactivation to NN-acetyl--acetyl-pp-benzoquinone imine -benzoquinone imine (NAPQI)(NAPQI)
APAP-Induced Liver InjuryAPAP-Induced Liver Injury
HN CH3
O
OH
ACETAMINOPHEN
N CH3
O
O
NAPQI
Sulfation Glucuronidation
DetoxDetox
GSHDetox
CysteinylConjugate
Protein Adducts
Mitochondria Dysfunction
Reactive Oxygen Species
LIVERINJURY
P450 2E1P450 1A2P450 3A4
Depleted
Serum Cytokines After Administration ofSerum Cytokines After Administration of300 mg APAP/kg to C57BL/6 Mice300 mg APAP/kg to C57BL/6 Mice
Time (hr)
4 8 12 240
3000
6000
9000
12000
15000ALT
IU/L
4 8 12 240
100
200
300IL-4
pg/m
L
4 8 12 240
100
200
300IL-10
pg/m
L
4 8 12 240
100
200
300
400
500IL-13
pg/m
LIL-6
4 8 12 240
40
80
120
160
200
pg/
mL
Bourdi (2002), Hepatology, 35:289Bourdi (2002), Hepatology, 35:289
Development of Hepatotoxicity in Mice Given Development of Hepatotoxicity in Mice Given IL-13 Neutralizing Antibody 2 Hours beforeIL-13 Neutralizing Antibody 2 Hours before
200 mg APAP/Kg 200 mg APAP/Kg
Ser
um
AL
T (
IU/L
)
0
1000
2000
3000
4000
______ ______ ______ 4 8 24
Hours After APAP Administration
a
CAb/APAPIL-13 NAb/APAP
a
a
Ser
um
IL
-13
(pg
/ml)
0
25
50
75
100
______ ______ ______ 4 8 24
Hours After APAP Administration
CAb/APAPIL13NAb/APAP
a a
Ser
um
AL
T (
IU/L
)
0
3000
6000
9000
12000
______ ______ ______ 4 8 24
Hours After APAP Administration
a
WTKO
a
a
Development of Hepatotoxicity in IL-13 KO Development of Hepatotoxicity in IL-13 KO Mice Treated With 200 mg APAP/Kg Mice Treated With 200 mg APAP/Kg
Liver Histopathology at 8 hoursLiver Histopathology at 8 hours
CVCV CVCV
CVCV
CVCV
CVCV
CVCV
CVCV
CVCV
CAb/VehCAb/Veh CAb/APAPCAb/APAP
IL-13 NAb/APAPIL-13 NAb/APAP APAP - KOAPAP - KO
Nitric Oxide PathwayNitric Oxide Pathway
L-Arginine
L-Ornithine
IL-4, IL-10, IL-13IL-4, IL-10, IL-13
IL-1, IL-6, IL-1, IL-6, TNF-TNF-IFN-IFN-γγ
NOiNOSiNOS
ArginaseArginase
Citrulline
Urea
L-NILAminoguanidine (AMG)
Nitrite/Nitrate
Peroxynitrite+Superoxide+Superoxide
• Endogenous IL-13 is a hepatoprotective Endogenous IL-13 is a hepatoprotective factor in APAP-induced liver injuryfactor in APAP-induced liver injury
• Elevated serum TNF-Elevated serum TNF-α concentration – α concentration – causal role?causal role?
• Elevated NO levels – causal role?Elevated NO levels – causal role?
• Deficiency in IL-13 may increase Deficiency in IL-13 may increase susceptibility to drug-induced liver susceptibility to drug-induced liver diseasedisease
SummarySummary
Idiosyncratic Drug-Induced Liver DiseaseIdiosyncratic Drug-Induced Liver Disease
• Complex “multihit” process Complex “multihit” process
• Liver protoxicants and protectants have Liver protoxicants and protectants have a role in the overall pathogenesisa role in the overall pathogenesis
– Environmental FactorsEnvironmental Factors– Genetic polymorphismsGenetic polymorphisms
• Underproduction of hepatoprotective and Underproduction of hepatoprotective and overproduction of hepatoprotoxicant overproduction of hepatoprotoxicant
factors (i.e., imbalance) influences factors (i.e., imbalance) influences susceptibility to this susceptibility to this liver diseaseliver disease
Determination of Susceptibility FactorsDetermination of Susceptibility Factors
• Identification of liver protoxicant and protectant Identification of liver protoxicant and protectant factors results in better understanding of factors results in better understanding of mechanism and in facilitating prediction of mechanism and in facilitating prediction of drug-drug-induced liver diseaseinduced liver disease
– Inflammatory mediatorsInflammatory mediators– COX-2 productsCOX-2 products– Heat shock proteinsHeat shock proteins
• Application of new technologiesApplication of new technologies– ToxicogenomicsToxicogenomics– ProteomicsProteomics– MetabonomicsMetabonomics
AcknowledgmentsAcknowledgments
Michigan State UniversityMichigan State University
Robert RothRobert Roth
Patricia GaneyPatricia GaneyJack HarkemaJack Harkema
Chuck BartonChuck BartonJohn BuchwietzJohn BuchwietzBryan CoppleBryan CoppleShawn KinserShawn KinserJim LuyendykJim LuyendykJane MaddoxJane MaddoxRosie SneedRosie Sneed
National Institutes of HealthNational Institutes of Health
Lance PohlLance Pohl
Michael AdamsMichael AdamsHamid AmouzadehHamid AmouzadehMohammed BourdiMohammed BourdiJohn GeorgeJohn GeorgeMichael HoltMichael HoltMary Jane MassonMary Jane MassonKevin WelchKevin Welch
Santana FloresSantana Flores
Thomas Wynn, NIAIDThomas Wynn, NIAID