A study on Leflunomide-induced liver injury in Rheumatoid Arthritis Patients

 

Salmi Abdul Razak¹, Farida Islahudin²*, Ahmad Fuad Shamsuddin², Nor Shuhaila Shahril¹

¹Putrajaya Hospital, Federal Government Administrative Centre, Precint 7, 62250 Putrajaya, Malaysia

²Faculty of Pharmacy, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, 50300 Kuala Lumpur, Malaysia

*Corresponding Author E-mail: faridaislahudin@yahoo.com

 

Leflunomide is an effective disease-modifying anti rheumatic drug with reported adverse drug reactions. This retrospective study is aimed to quantify the incidence of adverse drug reactions and predict risk factors of leflunomide-induced liver injury in the treatment regimen of rheumatoid arthritis patients. Rheumatoid arthritis patients on leflunomide treatment were identified from a local tertiary hospital. Data was retrieved for 73 patients. A total number of 35 patients were found to have elevated liver enzyme levels during treatment with leflunomide. The mean onset of liver enzyme abnormalities occurred after 6.44 ± 8.11 months from the initiation of leflunomide in rheumatoid arthritis patients’ treatment regimen. Termination of disease-modifying anti rheumatic drug was found highest 15.1% (n=11) due to events of liver injury, followed by 12.3% (n=9) due to other adverse drug reactions. It has been shown that the type of rheumatoid factor (p=0.005) and dyslipidemia (p=0.029) are predictors to the incidence of liver injury based on liver enzyme abnormalities.

 

 

 

INTRODUCTION:

Drugs such as leflunomide, methotrexate, sulphasalazine, infliximab and adalimumab are common disease-modifying anti rheumatic drugs used in the treatment of rheumatoid arthritis.^{1, 2, 3} Nonetheless, the use of disease-modifying anti rheumatic drugs has been frequently associated with adverse drug reaction mainly drug-induced liver injury and hepatotoxicity.^{4, 5} Disease-modifying anti rheumatic drugs are responsible for 5% of all hospital admissions and 50% of acute liver failures.⁶

 

Initiation of leflunomide as monotherapy is currently recommended for rheumatoid arthritis patients of all disease duration and degree of disease activity, irrespective of poor prognostic features.⁷ Leflunomide when used as monotherapy or in combination with other disease-modifying anti rheumatic drug agents significantly increases incidence of hepatotoxicity.^{5, 8, 9} However, the use of leflunomide and methotrexate in combination can be used safely with appropriate monitoring of liver enzyme activity.⁵

 

The risk factors of drug-induced liver injury or leflunomide-induce liver injury includes age, gender, pregnancy, alcohol intake, concomitant hepatotoxic agent, obesity, and current smoker.¹⁰ Leflunomide-induced liver injury were also complicated by associated factors such as pre-existing liver disease, pre-existing or concurrent illness or comorbidity identified as heart failure, infection/sepsis, pulmonary failure, pancreatitis, and other possibly hepatotoxic co-medication possibly leading to poorer outcome.¹¹ The use of combination disease-modifying anti rheumatic drugs occurs frequently amongst rheumatoid arthritis patients in Malaysia.³ Therefore this study was performed to investigate risk factors of drug-induced liver injury and hepatotoxicity in rheumatoid arthritis patients on leflunomide in the local population.

 

MATERIALS AND METHODS:

This study was performed retrospectively in a local tertiary hospital. Data was collected from rheumatoid arthritis patients who had received treatment with leflunomide in the outpatient department identified from the pharmacy department. Patients’ clinical notes on incidence of liver injury or hepatotoxicity, medication record and continuous laboratory results were retrospectively reviewed and evaluated from patient medical records. Information on demographic profile, disease-modifying anti rheumatic drug dose and duration, baseline liver function test, liver function test (LFT) after leflunomide initiation, response to liver enzyme abnormalities, prediction of risk factors to leflunomide-induce liver injury, and other adverse drug effect of leflunomide encountered were recorded. Approval to conduct this study was registered and obtained from the National Medical Research Register (NMRR-09-259-3868).

 

For the purpose of this study, a patient-based drug-induced liver injury data collection form was used to assess causality and incidence of leflunomide-induced liver injury. This consists of the Roussel-Uclaf causality assessment method (RUCAM) clinical scale scoring. Laboratory data on alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP), albumin level, total bilirubin and total protein were collected. The occurrence of the hepatotoxicity event was based on the first event of liver enzyme abnormalities at the start of leflunomide treatment in every patient.

 

Liver enzymes abnormalities were calculated to their upper limit of the normal (ULN) or reference range to determine whether the type of hepatic injury is “hepatocellular”, “cholestatic” or “mixed”. The terms used referred to the pattern of serum enzyme elevations at disease onset and not at clinical features or liver biopsy findings. Determination of types of acute liver injury was defined by calculation of the “R value” which is the ratio of ALT to ALP elevations, expressed as multiples of the ULN or reference range (Table 1).¹² Once the R value and type of liver injury is determined, the remaining factors in the RUCAM score system were weighed to calculate the final score of RUCAM. Elevation of ALT defined as more than 31 U/L for female subjects and more than 41 U/L for male subjects, whereas elevation of ALP was defined as more than 104 U/L for all subjects.

 

 

Table 1 Type of acute liver injury¹²

Ratio (R) of serum activities of ALT/ALP, in xULN, measured together at time liver injury first recognized
Hepatocellular	R ≥ 5	OR	(ALT > 2 xULN and ALP in normal range)
Cholestatic	R ≤ 2	OR	(ALP > 2 xULN and ALT in normal range)
Mixed	2 < R < 5	AND	(ALT > 2 xULN and ALP > ULN)

 

 

Data analysis:

Appropriate contingency table test (X² test or Fisher’s Exact test) at a confidence interval of 95% was used to evaluate the association between variables and outcome. Binary logistic regression analysis was used for the prediction of risk factors and associations to incidence of liver injury were fitted to data. A p-value less than 0.05 were considered significant.

 

 

RESULTS:

A total of 93 patients were identified of which 73 patients were included. The mean age of the study population was 52.81 ± 8.57 years (range 31 to 76 years).  Majority of the patients were female (65, 89%). Of the total subjects, 39 patients (53.4%) were Malay, followed by 24 (32.9%) Indian and 10 (13.7%) were Chinese. Of these patients 24 (32.9%) were hypertensive, 19 (26%) patients had dyslipidemia, 8 (11%) had type 2 diabetes mellitus and 7 (9.6%) had underlying cardiovascular disease.

 

Upon initiation of leflunomide in the rheumatoid arthritis treatment regimen, only 4 (5.5%) patients were given leflunomide loading dose (LD) of 100 mg daily dose for 3 days followed by 20 mg daily dose. Among these 4 patients, 1 patient was given a LD despite a combination disease-modifying anti rheumatic drug therapy of methotrexate and sulphasalazine. Reasons for the initiation of LD leflunomide were due to untolerated drug allergy to other disease-modifying anti rheumatic drugs, contraindication to methotrexate, and severe rheumatoid arthritis. The types and combinations of disease-modifying anti rheumatic drugs used in the study population are as seen in Figure 1.

 

Of the 73 patients whom received leflunomide, 9 (12.3%) patients had a history of liver disorder prior to the initiation of the drug. The common diagnosis found upon liver disorder was hepatitis and non-alcoholic fatty liver disease (NAFLD). There were 35 (47.9%) patients with incidence of transaminase levels greater than ULN. The remaining 38 (52.1%) patients had normal liver enzymes throughout treatment with leflunomide. The mean onset of liver enzymes abnormalities occurred after 6.44 ± 8.11 months of leflunomide initiation. First episode of elevated ALT upon initiation of leflunomide elevation of liver enzymes are as seen in Table 2.

 

RUCAM score and its interpretation of the types of liver injury are shown in Figure 2. Drug-induced liver injury was found to be correlated to certain risk factors. Relationships of several risk factors to incidence of liver enzyme abnormalities with the use of leflunomide, were analyzed (Table 3).

 

Of all 73 patients, reasons to terminate suspected disease-modifying anti rheumatic drug were found to be hepatotoxicity or events of liver injury (n = 11) (15.1%), followed by other adverse drug reactions  encountered (n = 9) (12.3%) during therapy. On manual review, 7 types of adverse drug reactions were identified in 16 patients. Each adverse drug reaction was evaluated using the Naranjo causality scale to determine the extent of adverse drug reaction pertaining to leflunomide (Table 4). All adverse events occurred were observed to take place during use of leflunomide monotherapy as well as leflunomide combined with methotrexate.

Figure 1: Figure illustrates the study population based on disease-modifying anti rheumatic drugs used: leflunomide (lef), methotrexate (mtx), sulphasalazine (ssz), hydroxychloroquine (hcq) and cyclosporine A (csa) (N=73).

 

Table 2: Liver function test in subjects with elevated liver enzymes (n=35).

Liver function test			Reference range	Mean ± SD	Range
ALT
	Male		<41 U/L	53.24 ± 15.11	33.94 – 68.00
	Female		<31 U/L	82.71 ± 65.89	18.00 – 329.00
AST
		Male	<37 U/L	33.25 ± 11.30	18.00 - 44.00
		Female	<31 U/L	62.54 ± 50.53	17.00 – 264.00
ALP
		Male	35-104 U/L	95.87 ± 27.18	66.48 – 132.00
		Female	40-129 U/L	112.80 ± 48.10	56.62 – 255.00
Albumin			35-50 g/L	38.89 ± 7.35	4.20 – 47.00
Total bilirubin			0-17 mmol/L	10.86 ± 5.15	1.40 – 27.00
Globulin			22-34 g/L	37.64 ± 11.58	3.00 – 63.00
Total protein			66-87 g/L	75.85 ± 18.88	7.3 – 98.00

 

Figure 2: RUCAM score interpretation towards types of liver injury due to leflunomide-induced (n=35).

 

Table 3: Predicted risk factors and incidence of liver injury in the study population (N=73).

	Odds ratio	p-value	95% CI
Gender	1.097	0.902	0.252 -  4.765
Race	1.750	0.438	0.426 -  7.190
Age	0.985	0.588	0.933 -  1.040
Rheumatoid Factor	5.283	0.005	1.668 - 16.737
Alcohol	34.490	1.000	0.000
Cigarette smoker	1.687	0.580	0.265 - 10.748
History of liver disease	1.759	0.415	0.452 -  6.843
HMGCoA inhibitor (“statin”)	1.100	0.889	0.290 -  4.178
NSAID	11.862	0.999	0.000
Antimicrobial	1.771	0.308	0.590 -  5.323
Traditional/ herbal/ supplemental medicine	2.640	0.111	0.801 -  6.701
Dyslipidemia	4.097	0.029	1.154 - 14.549
Diabetes Mellitus	1.097	0.902	0.252 -  4.765
Hypertension	0.881	0.800	0.331 -  2.346
Cardiovascular disease	1.505	0.610	0.312 -  7.258

 

Table 4: Adverse drug reactions identified in the study population (N =73).

Adverse drug reaction	Number of event n (%)		Naranjo  adverse drug reaction probability score and number of events
Alopecia	2 (2.74)		6 (2 events)
Severe diarrhoea	3 (4.11)	a(2)	6 (2  events), 7 (1  events)
Leukopenia	4 (5.48)	a(1)	3 (3  events), 5 (1  events)
Thrombocytopenia	1(1.37)		5 (1  events)
Generalised Rash	3 (4.11)	a(1), b(1)	7 (3  events)
Generalised urticaria (itchiness)	2 (5.48)	a(2)	3 (1  events), 4(1  events)
Nausea and vomiting	4 (2.74)	a(2)	3 (3  events), 5(1  events)
Total	19 (26.03)
a(no. of  event) = Discontinued leflunomide, normal LFT b(no. of  event) = Discontinued leflunomide, abnormal LFT Naranjo adverse drug reaction scoring = >9, highly probable; 5-8, probable; 1-4, possible; 0, doubtful

 

DISCUSSION:

The distribution of gender and ethnicity was expected to be mostly females, as it correlates with the pattern of rheumatoid arthritis patients in West Malaysia in which female preponderance was found in all three ethnic groups.¹³ The corresponding incidence of rheumatoid arthritis among white populations similarly demonstrates twice as many females compared to males.¹⁴

 

Leflunomide LD of 100 mg daily for 3 days results in its primary active metabolite, teriflunomide, to achieve steady-state plasma levels within 3 to 5 days.¹⁵ Omitting the loading dose upon initiation of leflunomide may delay attainment of steady-state. As a result therapeutic drug levels are reached within 6 months with leflunomide 10 mg daily without a LD.¹⁵ However, the use of LD is associated with a higher incidence of side-effects, particularly nausea and diarrhoea, increased discontinuation, and a higher chance of adverse events.¹⁶ Although initiating leflunomide LD was found to be not significantly associated to the incidence of liver injury in this study population, current recommendation suggest to omit the LD in frail or adverse event - prone patients, thus reserving it for patients where a rapid clinical effect is required.¹⁷

 

The mean onset of liver enzyme abnormalities after initiation of leflunomide was six months in the study population. This figure correlates with previous studies that showed liver enzyme elevations occurred during the first six months of therapy and resolved during continued follow up.¹⁸ It has been demonstrated that most putative hepatic events occur within the first six months of treatment, which ranges from 3 days to over 3 years in a setting of multiple risk factors for hepatotoxicity, namely liver disease and other concomitant use of hepatotoxins.^{5, 19} Although it was found that abnormal liver enzyme activities occurred in only 5 (6.85%) patients on leflunomide monotherapy, this figure was in line with previous studies.^{20, 21} It was also clear that treatment with a combination of leflunomide and methotrexate had twice the risk of abnormalities in liver enzyme levels. This was something that was expected as both drugs were known to cause liver impairment.^{4, 5, 6}

 

The RUCAM score enabled a more detailed review of liver injury which identified 17 possible cases of leflunomide induced liver injury in the study population. The score was used as monitoring of increase activity in serum aminotransferase to detect hepatic injury in most clinical trials and findings have shown that progressively severe liver injury begins with serum aminotransferase activities as the most frequently abnormal and most sensitive test.²² Although serum ALT is a valid laboratory parameter for evaluation and follow-up of liver diseases and hepatocellular damage, elevated transaminases does not consistently predict a significantly increased risk of drug-induced liver injury.²³

 

Identification of risk factors allows support for diagnosis and earlier monitoring. Previous studies have demonstrated that age and gender was reported as an important determinant in identifying liver injury.^{24, 25} However, this was not found to be true in this study population. Among the risk factors for liver injury which were identified was seropositive rheumatoid factor (RF) and dyslipidemia. Seropositive RF was found to have twice the risk of abnormal liver enzyme levels which was similar to findings from previous studies.²⁶ Patients with autoimmune rheumatic disease present apparent hepatic manifestations such as chronic active hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and nodular regenerative hyperplasia in rheumatoid arthritis patients.²⁷ These patients are prone to have a high level of RF as a response to liver damage. Dyslipidemia on the other hand may present itself as a manifestation of metabolic syndrome. NAFLD which is a major cause of ALT elevation is in fact considered the hepatic manifestation of metabolic syndrome.²⁸ A high level of liver enzymes such as AST, ALT, and gamma-glutamyl transpeptidase is demonstrated when there is a family history of liver disease, whereas higher ALT levels are present with dyslipidemia.²⁹ Therefore, patients with dyslipidemia and RF would have to be monitored even more closely in rheumatoid arthritis patients.

 

Cessation of disease-modifying anti rheumatic drug therapy due to leflunomide adverse drug reaction has been previously documented ²⁰ and occurred in 11 (15.1%) patients in the study in view of liver injury. Apart from liver injuries, other adverse drug reactions were also encountered that were associated with leflunomide. Reports on adverse drug reactions in this study were retrospectively evaluated using the Naranjo causality scale as to verify events of adverse drug reactions due to leflunomide. A total of 9 (12.3%) patients presented with other adverse drug reactions in which generalised rash appeared in one patient with abnormal LFTs that consequently caused termination of leflunomide from the treatment regimen. The remaining 8 patients were withdrawn from therapy despite normal LFTs. Other adverse drug reactions identified were severe diarrhoea, nausea and vomiting, generalised rash, intolerable itchiness and leucopoenia.

 

The overall management of adverse drug reactions induced by leflunomide was dose reduction. It was found that leflunomide dose was decreased from 20 mg daily to 10 mg daily. Alternatively, the interval of leflunomide dose was changed from 10 mg daily to 10 mg every other day for one month then further continued to 10 mg daily dose. A dose reduction from 20 mg daily to 10 mg daily is unlikely to produce a rapid reduction of adverse events, as the half life of the teriflunomide, the active metabolite of leflunomide, is between 14 to 18 days.¹⁵ In view of the long half-life of teriflunomide, adverse reactions may result or remain even after administration of leflunomide has ceased. If drug dose reduction has controlled a specific adverse event, it may be possible to reintroduce the drug at the original dose if required.²⁷

 

In conclusion drug-induced liver injury can mimic various forms of liver diseases and its principal presentation remains systemic symptoms, jaundice, elevated ALT and ALP.  In this study population, it was found that abnormalities in liver enzymes due to the usage of leflunomide or leflunomide in combination as reported through the RUCAM score occurred in around half of the population in which leflunomide was possibly responsible in 17 (48.6%) cases. The discontinuation of leflunomide occurred in 11 patients due to liver injury. One patient was discontinued with leflunomide due to generalised rash with abnormal levels of LFTs. Risk factors of drug-induced liver injury in this population were found to be rheumatoid factor and dyslipidemia.  Further studies however are warranted to determine risk factors of drug-induced liver injury in a larger population.

 

REFERENCES:

1.       Dougados M, Emery P, Lemmel EM. Maintenance rate of leflunomide in patients with rheumatoid arthritis: RELIEF 1-year data. Arthritis and Rheumatism. 44; 2001: S173.

2.       Hansen KE, Cush J, Singhal A.  The safety and efficacy of leflunomide in combination with infliximab in rheumatoid arthritis. Arthritis and Rheumatism. 44(Suppl.); 2001: 84.

3.       Mohd S, Mohd S, Mohamed S. Multicentre survey of rheumatoid arthritis patients from Ministry of Health Rheumatology Centers in Malaysia.  International Journal of Rheumatic Diseases. 11; 2008: 287–292

4.       Adverse Drug Reactions Advisory Committee (ADRAC). Leflunomide: serious hepatic, blood, skin and respiratory reactions. Adverse Drug Reaction Bulletin. 20; 2001: 7.

5.       Kremer JM, Genovese MC, Cannon GW. Concomitant leflunomide therapy in patients with active rheumatoid arthritis despite stable doses of methotrexate. A randomized, double-blind, placebo-controlled trial. Annals of Internal Medicine. 137; 2002: 726–733.

6.       Ostapowicz G, Fontana RJ, Schiodt FV, Larson A, Davern TJ, Han SH, McCashland TM, Shakil AO, Hay JE, Hynan L, Crippin JS, Blei AT, Samuel G, Reisch J, Lee WM; U.S. Acute Liver Failure Study Group. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Annals of Internal Medicine. 137; 2002: 947-954.

7.       Saag KG, Teng GG, Patkar NM. American College Of Rheumatology 2008: Recommendations for the use of nonbiologic and biologic disease-modifying antirheumatic drugs in rheumatoid arthritis. Arthritis and Rheumatism. 59 (6); 2008: 762–784.        

8.       Weinblatt ME, Kremer JM, Coblyn JS. Pharmacokinetics, safety, and efficacy of combination treatment with methotrexate and leflunomide in patients with active rheumatoid arthritis. Arthritis and Rheumatism. 42; 1999: 1322-1328.

9.       Hoi A, Littlejohn GO. Aminotransferase levels during treatment of rheumatoid arthritis with leflunomide in clinical practice. Annals of the Rheumatic Diseases. 62; 2002: 379.

10.    Tajiri K, Shimizu Y. Practical guidelines for diagnosis and early management of drug-induced liver injury. World Journal of Gastroenterology. 14(44); 2008: 6774-6785.

11.    European Agency for the Evaluation of Medicinal Products. Post-authorisation evaluation of medicines for human use (EMEA). EMEA public statement on leflunomide (Arava) - severe and serious hepatic reactions. 844: 2 Document reference EMEA/H/5611/01/en. London. 2001.

12.    Benichou C. Criteria of drug induced liver disorders: report of an international consensus meeting. Journal of Hepatology. 11; 1990: 272–276

13.    Toh BH, Sengupta S, Ang AH, White JC, Lau KS. Pattern of rheumatoid arthritis in West Malaysia.  Annals of the Rheumatic Disease. 32; 1973: 151-156.

14.    Abdel - Nasser AM, Rasker JJ, Valkenburg HA. Epidemiological and clinical aspects relating to the variability of rheumatoid arthritis. Seminars in Arthritis and Rheumatism. 27(2); 1997: 123-140.

15.    Prakash A, Jarvis B. Leflunomide: a review of its use in active rheumatoid arthritis. Drugs. 58(6); 1999: 1137-1164.

16.    Erra A, Tomas C, Barcelo P, Vilardell M, Marsal S. Is the recommended dose of leflunomide the best regimen to treat rheumatoid arthritis patients? Rheumatology. 42; 2003: 1123–1124.

17.    Maddison P, Kiely P, Kirkham B, Lawson T, Moots R, Proudfoot D, Reece R, Scott D, Sword R, Taggart A, Thwaites C, Williams E. Leflunomide in rheumatoid arthritis: recommendations through a process of consensus. Rheumatology. 44; 2005: 280–286.

18.    Van Roon EN, Jansen T, Houtman PM, Spoelstra P, Brouwers JR. Leflunomide for rheumatoid arthritis in clinical practice. Incidence and severity of hepatotoxicity. Drug Safety. 27; 2004: 345-352.

19.    American College of Rheumatology (ACR) Subcommittee on Rheumatoid Arthritis Guidelines. Guidelines for the management of rheumatoid arthritis: 2002 update. Arthritis and Rheumatism. 46; 2002: 328–346.

20.    Emery P, Breedveld FC, Lemmel EM, Kaltwasser JP, Dawes PT, Gömör B, Van Den Bosch F, Nordström D, Bjorneboe O, Dahl R, Horslev-Petersen K, Rodriguez De La Serna A, Molloy M, Tikly M, Oed C, Rosenburg R, Loew-Friedrich I. A comparison of the efficacy and safety of leflunomide and methotrexate for the treatment of rheumatoid arthritis. Rheumatology. 39; 2000: 655-665.

21.    Van Riel PL, Smolen JS, Emery P, Kalden JR, Dougados M, Strand CV, Breedveld FC. Leflunomide: a manageable safety profile.  Journal of Rheumatology. Suppl. 71; 2004: 21-24.

22.    Lee WM, Senior JR. Recognizing Drug-Induced Liver Injury: Current Problems, Possible Solutions. Toxicologic Pathology. 33; 2005: 155.

23.    Kariv R, Leshno M, Beth-Or A, Strul H, Blendis L, Kokia E, Noff D, Zelber-Sagie S, Sheinberg B, Oren R, Halpern Z. Reevaluation of serum alanine aminotransferase upper normal limit and its modulating factors in a large-scale population study. Liver International. 26(4); 2006: 445-450.

24.    Lucena MI, Andrade RJ, Fernández MC, Pachkoria K, Pelaez G, Durán JA, Villar M, Rodrigo L, Romero-Gomez M, Planas R, Barriocanal A, Costa J, Guarner C, Blanco S, Navarro JM, Pons F, Castiella A, Avila S. Spanish Group for the Study of Drug-Induced Liver Disease (Grupo de Estudio para las Hepatopatías Asociadas a Medicamentos (GEHAM). Determinants of the clinical expression of amoxicillin-clavulanate hepatotoxicity: a prospective series from Spain. Hepatology. 44; 2006: 850–856.

25.    Russo MW, Galanko JA, Shrestha R, Fried MW, Watkins P. Liver transplantation for acute liver failure from drug induced liver injury in the United States. Liver Transplantation. 10; 2004: 1018–1023.

26.    Newkirk MM, Klein MH, Katz A. Estimation of polymeric IgA in human serum: an assay based on binding of radiolabeled human secretory component with applications in the study of IgA nephropathy, IgAmonoclonal gammopathy, and liver disease. The Journal of Immunology. 130; 1983: 1176–1181.

27.    Abraham S, Begum S, Isenberg D. Hepatic manifestations of autoimmune rheumatic diseases. Annals of the Rheumatic Diseases. 63; 2004: 123–129.

28.    Gasbarrini G, Vero V, Miele L, Forgione A, Hernandez AP, Greco AV, Gasbarrini A, Grieco A. Nonalcoholic fatty liver disease: defining a common problem. European Review for Medical and Pharmacological Sciences. 9; 2005: 253-259.

29.    Khedmat H, Fallahian F, Abolghasemi H, Hajibeigi B, Attarchi Z, Alaeddini F, Holisaz MT, Pourali M, Sharifi S, Zarei N. Serum γ-glutamyltransferase, alanine aminotransferase, and aspartate aminotransferase activity in Iranian healthy blood donor men. World Journal of Gastroenterology. 13(6); 2007: 889-894.

 

 

Received on 05.04.2013       Modified on 15.04.2013

Accepted on 19.04.2013      © RJPT All right reserved