Supplements for the Body, Toxins for the Liver?

Abstract

Use of dietary supplements (DS) is now a health trend in the United States as we have become greatly influenced by media and outward appearances. There is great risk in use of DS as they cause a dose dependent liver injury. The mechanism involves a direct toxic effect on hepatocytes, the P450 pathway, and an unpredictable idiosyncratic effect. Given the trend of supplement use, it is imperative to make clinicians and patients aware of the potential adverse outcomes. A 20 year-old male presented to the emergency department complaining of 1 week of abdominal pain with scleral icterus, dark urine, light stools, and pruritus. He admitted to exercising 6 times weekly for the last month and using L-glutamine supplement. He denied recent travel, intravenous drug use, anabolic steroid use, and high risk sexual behavior. Initial labs demonstrated ALT of 2930, AST 1265, ALP 150, total bilirubin 8.1 and direct bilirubin 6.0. Imaging was negative for hepatobiliary abnormalities. Extensive workup revealed ANA of 1:640. INR was corrected with vitamin K and FFP prior to liver biopsy, which demonstrated changes consistent with DILI. Intravenous steroids were initiated but he developed grade II hepatic encephalopathy. He was transferred to a liver transplant center but not a candidate due to insurance issues. Eventually, his mental status returned to baseline. He was initiated on a steroid taper and discharged home to follow up with hepatology. The etiology of his DILI linked to consumption of L-glutamine supplement. Acute DILI is associated with a significant fatality rate or need for liver transplant of 10% or higher.1 The current focus of DILI management is prevention with identification of pharmacologic risk factors leading to liver injury. Consumption of unregulated DS has introduced new challenges in assessment and clinical management. A risk stratification tool to categorize risk among the various supplements would educate consumers and provide insight into timely identification and treatment of acute liver injury. Literature lags behind the massive availability of DS and their widepread use. Patients and medical professionals should develop a critical attitude regarding potential risks of DS given the unknown efficacy, unpredictability of disease course, and safety.