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Updated: Feb 13, 2026
Heterotopic Auxiliary Rat Liver Transplantation With Flow-regulated Portal Vein Arterialization in Acute Hepatic Failure
Published on: September 13, 2014
Acute Liver Failure from Tumor Necrosis Factor-α Antagonists: Report of Four Cases and Literature Review
Beverley Kok1, Erica L W Lester2, William M Lee3
1Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler-Ledcor Building, Edmonton, AB, T6G-2X8, Canada.
Background:
Tumor necrosis factor-α antagonists (anti-TNF-α) have been associated with drug-induced liver injury. However, cases of anti-TNF-α-associated acute liver failure have only been rarely reported.
Aims:
To identify cases of anti-TNF-α-associated acute liver failure and evaluate patterns of liver injury and common characteristics to the cases.
Methods:
The United States Acute Liver Failure Study Group database was searched from 1998 to 2014. Four subjects were identified. A PubMed search for articles that reported anti-TNF-α-associated acute liver failure identified five additional cases.
Results:
The majority of individuals affected were female (eight of nine cases). Age of individual ranged from 20 to 53 years. The most common anti-TNF-α agent associated with acute liver failure was infliximab (n = 8). The latency between initial drug exposure and acute liver failure ranged from 3 days to over a year. Of the nine cases, six required emergency LT. Liver biopsy was obtained in seven cases with a preponderance toward cholestatic-hepatitic features; none showed clear autoimmune features.
Conclusions:
Anti-TNF-α-associated acute liver failure displays somewhat different characteristics compared with anti-TNF-α-induced drug-induced liver injury. Infliximab was implicated in the majority of cases. Cholestatic-hepatitic features were frequently found on pre-transplant and explant histology.
Insights
Tumor necrosis factor-α antagonists (anti-TNF-α) can cause acute liver failure, though rarely. Infliximab was the most common agent, and cases often showed cholestatic-hepatitic features, differing from typical anti-TNF-α liver injury.
Area of Science:
- Hepatology
- Pharmacology
- Immunology
Background:
- Tumor necrosis factor-α antagonists (anti-TNF-α) are linked to drug-induced liver injury.
- Acute liver failure is a rare but serious adverse event associated with anti-TNF-α therapy.
Observation:
- A review of the US Acute Liver Failure Study Group database and PubMed identified nine cases of anti-TNF-α-associated acute liver failure.
- The majority of affected individuals were female, with ages ranging from 20 to 53 years.
- Infliximab was the most frequently implicated anti-TNF-α agent.
Findings:
- The latency period to acute liver failure varied widely, from days to over a year.
- Six of nine patients required emergency liver transplantation (LT).
- Liver biopsies revealed cholestatic-hepatitic features, without clear autoimmune characteristics.
Implications:
- Anti-TNF-α-associated acute liver failure presents distinct clinical and histological features compared to other anti-TNF-α-induced liver injuries.
- The findings highlight the importance of recognizing these specific patterns for timely diagnosis and management.
- Infliximab should be considered a key agent in cases of acute liver failure with cholestatic-hepatitic features.
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