Letter: Why Assessment of ChILI Severity Accurately Matters?

Abstract

In a timely study, Hountondji et al. [1] highlight an important limitation of the Common Terminology Criteria for Adverse Events (CTCAE) classification, which is widely used by oncologists in the management of checkpoint inhibitor-induced liver injury (ChILI). Authors found Drug-induced Liver Injury International Expert Working Group (DILI-IEWG) classification of severity had superior performance characteristics in predicting acute liver injury (compared with CTCAE and Model for End-stage Liver Disease) [2]. One of the reasons for inferior performance of CTCAE is because the latter overestimates severity of ChILI as life-threatening on the basis of alanine transaminase levels of 20-fold upper limit normal alone in isolation of other clinical criteria; this leads to avoidable hospital admissions [3]. In contrast, DILI-IEWG was able to predict 3 months of mortality while v5 of the CTCAE that incorporates total bilirubin was not able to [1].

Majority of patients with ChILI are started on high-dose corticosteroid therapy based entirely on CTCAE grading despite lack of evidence in its support [4]. A recent study highlights the value of liver biopsy and incorporation of severity of inflammation on liver histology into decision-making regarding corticosteroid therapy in patients with ChILI [5]; following this strategy, two-thirds of patients classified as having severe ChILI were spared of corticosteroid therapy. Early identification of poor outcome is crucial for planning management of ChILI since these patients are not candidates for liver transplantation in case of acute liver failure development [6].

Although Hountondji et al. [1] focus on the accuracy of methods of grading severity of ChILI, overestimation of severity of this adverse event may lead to unnecessary, prolonged and high dose of corticosteroid therapy in some with consequent complications [4].