Acute liver failure from anti-tuberculosis drug-induced liver injury: An update

Abstract

Tuberculosis (TB) is still a major public health issue in developing countries, where it causes a heavy disease burden. Although current anti-TB treatment regimens demonstrate high efficacy, the hepatotoxic potential of first-line anti-TB drugs (ATDs) - particularly isoniazid, rifampicin, and pyrazinamide—poses a considerable risk, as these agents are associated with a significant incidence of ATD-induced liver injury (AT-DILI). The clinical presentation of AT-DILI can range from asymptomatic elevations in serum transaminases, which may resolve spontaneously due to hepatic adaptation, to acute liver failure (ALF), a potentially life-threatening condition. A recent meta-analysis reported a global incidence of AT-DILI of 11.5%, with rates varying from 2% to 28%. Approximately 7% of patients with AT-DILI progress to ALF, a condition characterized by a poor survival rate with medical therapy. ATD-induced ALF (AT-ALF) is clinically indistinguishable from ALF due to other causes and disproportionately affects young female patients, typically within eight weeks of treatment initiation. Emergency liver transplantation has become an effective therapeutic option for AT-ALF, although outcomes are generally poorer compared to elective transplantation. This minireview provides a comprehensive overview of AT-ALF, covering its epidemiology, risk factors, clinical presentation, prognosis, and treatment options.

Keywords: Tuberculosis; Anti-tuberculosis drugs; Hepatotoxicity; Drug-induced liver injury; Acute liver failure

Core Tip: Tuberculosis (TB) remains a significant public health concern in developing countries. First-line anti-TB drugs (ATDs) pose a risk of drug-induced liver injury (DILI), which can progress to acute liver failure (ALF), a life-threatening condition. The global incidence of ATD-induced DILI is approximately 11.5%, with around 7% of cases progressing to ALF within two months of treatment initiation. Notably, young female patients are disproportionately affected by this condition, which is clinically indistinguishable from other causes of ALF and is associated with a high mortality rate, necessitating emergency liver transplantation. This minireview provides a comprehensive overview of ATD-induced ALF, covering epidemiology, risk factors, and treatment options.