Gastroenterologie
a hepatologie

Liver injury after the use of anabolic steroids to promote muscle growth – single-center experience

Pavol Molčan¹, Tomáš Koller ^{Orcid.org  2}, Natalia Bystrianska¹, Ján Strachan¹, Daniela Janceková¹, Janka Vnenčáková¹, Petra Vrbová², Pavel Strenáčik¹, Ľubomír Skladaný ^{Orcid.org  1}

+ Affiliation
¹ HEGITO – hepatologické, gastroenterologické a transplantačné oddelenie, II. interná klinika SZU a FNsP F. D. Roosevelta Banská Bystrica
² Gastroenterologické a hepatologické oddelenie, V. interná klinika LF UK a UN Bratislava

Summary

Introduction:

Anabolic agents are prohibited in professional sports, but their availability makes its use widespread among amateur athletes. Our goal was to report all cases of anabolic-induced liver injury.

Patients and methods:

We included all inpatients with acute liver injury and previous anabolic use over the last 4 years. We recorded history, demographics, laboratory data and imaging, histology, HPVG (hepatic venous pressure gradient) and the outcome.

Results:
Fifteen men with a median age of 33.1 years were identified. Common symptoms were dyspepsia (47%), jaundice (100%) and dark urine (26.7%); anabolics were used for a median of 66.5 days (25th–75th percentile, 18.3–113.5), baseline bilirubin level was 19.4-times higher than the upper limit of the normal (13.9–27.1), 1 patient (6.7%) had INR > 1.7. The character of the injury was cytolytic in 3 patients (20%), and cholestatic and mixed in 6 patients (40%). Signifi cant alcohol consumption was reported in 2 cases and 4 (26.7%) patients had hepatic steatosis. Patients consuming alcohol had higher baseline and maximum bilirubin level (367 vs. 731 and 454 vs. 801 μmol/ L, P < 0.05). All 10 patients with liver bio psy demonstrated cholestasis, the interface hepatitis in 5 patients (50%), one had F1 fi brosis. The median HVPG was 5 mmHg (4–6). All patients were treated with sylimarin, ACC and UDCA, two (13.3%) with steroids, three (20%) required MARS. The median time to normalize bilirubin was 99 days (64.3–113.5), no death was observed.

Conclusion:
Experience with anabolic-induced liver injury shows that they lead to cholestatic injury requiring hospitalization and slow recovery with signifi cant costs. Alcohol consumption and steatosis might have a cumulative eff ect

Keywords

liekmi indukované poškodenie pečene, anaboliká, prognosis, steatosis

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Literature

1. Bagatell CJ, Bremner WJ. Androgens in men – uses and abuses. New Engl J Med 1996; 334(11): 707–714. doi: 10.1056/NEJM199603143341107.
2. Cruz-Jentoft AJ, Bahat G, Bauer J  et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019; 48(1): 16–31. doi: 10.1093/ageing/afy169.
3. Fontana RJ. Pathogenesis of idiosyncratic drug-induced liver injury and clinical perspectives. Gastroenterology 2014; 146(4): 914–928. doi: 10.1053/j.gastro.2013.12.032.
4. Robles-Diaz M, Gonzalez-Jimenez A, Medina-Caliz I et al. Distinct phenotype of hepatotoxicity associated with illicit use of anabolic androgenic steroids. Aliment Pharmacol Ther 2015; 41(1): 116–125. doi: 10.1111/apt.13023.
5. Nieschlag E, Vorona E. MECHANISMS IN ENDOCRINOLOGY: Medical consequences of doping with anabolic androgenic steroids: effects on reproductive functions. Eur J Endocrinol 2015; 173(2): R47–R58. doi: 10.1530/EJE-15-0080.
6. Rowe R, Berger I, Copeland J. “No pain, no gainz”? Performance and image-enhancing drugs, health effects and information seeking. Drugs Educ Prev Policy 2017; 24(5): 400–408. doi: 10.1080/09687637.2016.1207752.
7. Ip EJ, Barnett MJ, Tenerowicz MJ  et al. The Anabolic 500  survey: characteristics of male users versus nonusers of anabolic-androgenic steroids for strength training. Pharmacotherapy 2011; 31(8): 757–766. doi: 10.1592/phco.31.8. 757.
8. Kimergård A. A  qualitative study of anabolic steroid use amongst gym users in the United Kingdom: motives, beliefs and experieces. J Subst Use 2015; 20(4): 288–294. doi: 10.3109/14659891.2014.911977.
9. Sagoe D, Andreassen CS, Pallesen S. The aetiology and trajectory of anabolic-androgenic steroid use initiation: a systematic review and synthesis of qualitative research. Subst Abuse Treat Prev Policy 2014; 9: 27. doi: 10.1186/17 47-597X-9-27.
10. Díaz FC, Sáez-González E, Benlloch S et al. Albumin dialysis with MARS for the treatment of anabolic steroid-induced cholestasis. Ann Hepatol 2016; 15(6): 939–943. doi: 10.5604/16652681.1222114.
11. Mikas J. Informácia o  výskyte škodlivého výrobku – výživový doplnok obsahujúci anabolické steroidy. 2020 [online]. Available from: https://www.uvzsr.sk/index.php?option=com_ content&view=article&id=4248:informacia-o-vyskyte-kodliveho-vyrobku-vyivovy-doplnok-obsahujuci-anabolicke-steroidy&catid=95:informacie-pre-spotrebiteov.
12. Krishnan PV, Feng ZZ, Gordon SC. Prolonged intrahepatic cholestasis and renal failure secondary to anabolic androgenic steroid-enriched dietary supplements. J  Clin Gastroenterol 2009; 43(7): 672–675. doi: 10.1097/ MCG.0b013e318188be6d.
13. Kafrouni MI, Anders RA, Verma S. Hepatotoxicity associated with dietary supplements containing anabolic steroids. Clin Gastroenterol Hepatol 2007; 5(7): 809–812. doi: 10.1016/ j.cgh.2007.02.036.
14. Shah NL, Zacharias I, Khettry U et al. Methasteron-associated cholestatic liver injury: clinicopathologic findings in 5 cases. Clin Gastroenterol Hepatol 2008; 6(2): 255–258. doi: 10.1016/j.cgh.2007.11.010.
15. Sanyal AJ, Bosch J, Blei A, et al. Portal hypertension and its complications. Gastroenterology 2008; 134(6): 1715–1728. doi: 10.1053/ j.gastro.2008.03.007.
16. Burroughs AK, McCormick PA. Natural history and prognosis of variceal bleeding. Baillieres Clin Gastroenterol 1992; 6(3): 437–450. doi: 10.1016/0950-3528(92)90031-9.
17. Krook H. Estimation of portal venous pressure by occlusive hepatic vein catheterization. Scand J Clin Lab Invest 1953; 5(3): 285–292. doi: 10.3109/00365515309094199.
18. La Mura V, Nicolini A, Tosetti G et al. Cirrhosis and portal hypertension: the importance of risk stratification, the role of hepatic venous pressure gradient measurement. World J  Hepatol 2015; 7(4): 688–695. doi: 10.4254/wjh.v7. i4.688.
19. Lebrec D, Nouel O, Bernuau J et al. Portal hypertension in fulminant viral hepatitis. Gut 1980; 21(11): 962–964. doi: 10.1136/gut.21.11.962.
20. Navasa M, Garcia-Pagán JC, Bosch J  et al. Portal hypertension in acute liver failure. Gut 1992; 33(7): 965–968. doi: 10.1136/gut.33.7.965.
21. Lebrec D, Benhamou JP. Noncirrhotic intrahepatic portal hypertension. Semin Liver Dis 1986; 6(4): 332–340. doi: 10.1055/s-2008-1040615.
22. Schröder T, Schmidt KJ, Olsen V et al. Liver steatosis is a risk factor for hepatotoxicity in patients with infl ammatory bowel disease under immunosuppressive treatment. Eur J  Gastroenterol Hepatol 2015; 27(6): 698–704. doi: 10.1097/MEG.0000000000000350.
23. Liu LW, Zhao XY, Jia JD. EASL clinical practice guidelines recommendations for drug-induced liver injury in 2019. Zhonghua Gan Zang Bing Za Zhi 2019; 27(6): 420–423. doi: 10.3760/cma.j.issn.1007-3418.2019.06.006.
24. Gillessen A, Schmidt HH. Silymarin as supportive treatment in liver diseases: a narrative review. Adv Ther 2020; 37(4): 1279–1301. doi: 10.1007/s12325-020-01251-y.
25. de Andrade KQ, Moura FA, dos Santos JM et al. Oxidative stress and infl ammation in hepatic diseases: therapeutic possibilities of N-Acetylcysteine. Int J  Mol Sci 2015; 16(12): 30269–30308. doi: 10.3390/ijms161226225.
26. Brůha R. Hepatoprotektiva. Klin Farmakol Farm 2006; 20(3): 154–157.
27. Katsinelos P, Vasiliadis T, Xiarchos P et al. Ursodeoxycholic acid (UDCA) for the treatment of amoxycillin-clavulanate potassium (Augmentin)-induced intra-hepatic cholestasis: report of two cases. Eur J Gastroenterol Hepatol 2000; 12(3): 365–368. doi: 10.1097/00042737-200012030-00017.
28. European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu; European Association for the Study of the Liver. EASL Clinical Practice Guidelines: the diagnosis and management of patients with primary biliary cholangitis. J Hepatol 2017; 67(1): 145–172. doi: 10.1016/j.jhep.2017.03.022.