MicroRNA-122 and cytokeratin-18 have potential as a biomarkers of drug-induced liver injury in European and African patients on treatment for mycobacterial infection

Abstract

Aims: Patients on antituberculosis (anti-TB) therapy are at risk of drug-induced liver injury (DILI). MicroRNA-122 (miR-122) and cytokeratin-18 (K18) are DILI biomarkers. To explore their utility in this global context, circulating miR-122 and K18 were measured in UK and Ugandan populations on anti-TB therapy for mycobacterial infection.

Methods: Healthy subjects and patients receiving anti-TB therapy were recruited at the Royal Infirmary of Edinburgh, UK (ALISTER-ClinicalTrials.gov Identifier: NCT03211208). African patients with human immunodeficiency virus-TB coinfection were recruited at the Infectious Diseases Institute, Kampala, Uganda (SAEFRIF-NCT03982277). Serial blood samples, demographic and clinical data were collected. In ALISTER samples, MiR-122 was quantified using polymerase chain reaction. In ALISTER and SAEFRIF samples, K18 was quantified by enzyme-linked immunosorbent assay.

Results: The study had 235 participants (healthy volunteers [n = 28]; ALISTER: active TB [n = 30], latent TB [n = 88], nontuberculous mycobacterial infection [n = 25]; SAEFRIF: human immunodeficiency virus-TB coinfection [n = 64]). In the absence of DILI, there was no difference in miR-122 and K18 across the groups. Both miR-122 and K18 correlated with alanine transaminase (ALT) activity (miR-122: R = .52, 95%CI = 0.42-0.61, P < .0001. K18: R =0.42, 95%CI = 0.34-0.49, P < .0001). miR-122 distinguished those patients with ALT>50 U/L with higher sensitivity/specificity than K18. There were 2 DILI cases: baseline ALT, 18 and 28 IU/L, peak ALT 431 and 194 IU/L; baseline K18, 58 and 219 U/L, peak K18 1247 and 3490 U/L; baseline miR-122 4 and 17 fM, peak miR-122 60 and 336 fM, respectively.

Conclusion: In patients treated with anti-TB therapy, miR-122 and K18 correlated with ALT and increased with DILI. Further work should determine their diagnostic and prognostic utility in this global context-of-use.

Keywords: cytokeratin-18; drug-induced liver injury; microRNA-122tuberculosis.

Conflict of interest statement

The authors declare no conflicts of interest.

© 2021 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.

Figures

FIGURE 1

Circulating concentration of A, alanine transaminase (ALT; IU/l), B, microRNA (miR)‐122 (fM) and C, K18 (U/L). Data are the first collected samples from the ALISTER study or SAEFRIF trial. Participants include healthy volunteers (n = 28), active tuberculosis (TB; n = 26), latent TB (n = 87), nontuberculous mycobacteria (NTM) infection (n = 25) and human immunodeficiency virus (HIV)–TB coinfection (n = 59). Data are presented as dot plots. Line shows median and bars show interquartile range. The significance of differences between groups were determined by 1‐way Kruskal–Wallis ANOVA (ALT P = .2; miR‐122 P = .09; K18 P = .03)

FIGURE 2

Circulating concentration of A, alanine transaminase (ALT; IU/L), B, microRNA (miR)‐122 (fM) and C, K18 (U/L) in sequential samples in patients within the ALISTER study, (active tuberculosis, n = 9; latent tuberculosis, n = 46; nontuberculous mycobacteria, n = 10) Data shown as dot plots. Black dots show patients with normal ALT activity at baseline and on treatment; blue dots show patients with ALT activity >50 U/L at baseline which decreased on treatment; red dots show patients whose ALT increased above 50 U/L with treatment. Dotted line on (A) ALT = 50 IU/L. The significance of differences between baseline and on treatment concentrations of biomarkers was determined by Wilcoxon signed rank test (ALT P = .03; miR‐122 P = .01; K18 P = .4)

FIGURE 3

Circulating concentration of A, alanine transaminase (ALT; IU/L) and B, K18 (U/L) for sequential samples in patients within the SAEFRIF trial. Black dots show patients with normal ALT throughout treatment, red points show patients whose ALT rises >50 IU/L during treatment, blue points show patients whose ALT falls from >50 IU/L upon starting treatment. Dotted line on (A) ALT = 50 IU/L

FIGURE 4

Correlation of A, microRNA (miR)‐122 (fM) vs. alanine transaminase (ALT; IU/L), B, K18 (U/L) vs. ALT (IU/L) and C, miR‐122 (fM) vs. K18 (U/L). Patient samples (healthy volunteers, n = 28; active tuberculosis [TB], n = 44; latent TB, n = 142; nontuberculous mycobacteria [NTM] infection, n = 39; human immunodeficiency virus–tuberculosis [HIV‐TB] coinfection, n = 241). Statistical analysis of the significance of the correlation calculated using Spearman's rank correlation coefficient (miR‐122 vs. ALT: n = 251, Spearman rank R = .52, 95% CI 0.42–0.61, P < .0001; K18 vs. ALT: n = 491, Spearman rank R = .42, 95% CI 0.34–0.49, P < .0001; miR‐122 vs. K18: n = 252, Spearman rank R = .32, 95% CI 0.20–0.43, P < .0001)

FIGURE 5

Comparison of samples grouped by normal alanine transaminase (ALT; ≤50 IU/L) and elevated ALT (>50 IU/L). A, MicroRNA (miR)‐122 concentration (fM) and B, K18 (U/L). Patient samples (healthy volunteers, n = 28; active tuberculosis [TB,] n = 44; latent TB, n = 142; nontuberculous mycobacteria infection, n = 39; HIV‐TB coinfection, n = 241). Statistical analysis of the significance of the difference between the groups calculated with the Mann–Whitney t‐test (miR‐122 P < .0001; K18 P < .0001). Receiver operator characteristic (ROC) analysis of samples grouped by normal ALT (≤50 IU/L) and elevated ALT (>50 IU/L), C, miR‐122 and D, K18. MiR‐122 (ROC‐area under the curve [AUC] = 0.93, 95% CI = 0.88–0.98, P < .001). K18 (ROC‐AUC = 0.80, 95% CI = 0.72–0.87, P < .0001)

FIGURE 6

Circulating concentration of (A, B) alanine transaminase (ALT; IU/L), (C, D) microRNA (miR)‐122 (fM) and (E, F) K18 (U/L) over the course of treatment (weeks) for 2 cases who developed DILI as predefined as >3× upper limit of normal ALT in the presence of symptoms or >5× upper limit of normal in absence of symptoms. Case 1 (A, C, E); Case 2 (B, D, F)