Table 2.
Kratom-induced hepatotoxicity with review of literature in patients with liver biopsy
| Ref. | Age, sex | Clinical findings | Form, amount, duration of Kratom consumed | Peak bilirubin (mg/dL) | Disease pattern | Radiological findings | Histological findings |
| Kapp et al[11] | 25, M | Abdominal pain, brown urine, jaundice, pruritus | Powder, 1 to 2 teaspoon twice a day and increased to 4-6 teaspoon over 2 wk (1 teaspoon approximately 2-3 g) | Direct bilirubin 29.3 | Cholestatic (increased bilirubin, AST, ALT, ALP) | USG, CT-hepatic steatosis | Cholestatic injury, no hepatocellular damage, canalicular cholestasis |
| Drago et al[14] | 23, M | Jaundice, pale stool, brown urine for 4 d | Powder, 85 g total over 6 wk | Direct bilirubin 5.8 | Cholestatic (increased bilirubin, AST, ALT, ALP) | USG, CT-normal | Cholestatic liver injury |
| Bernier et al[15] | 41, F | Jaundice, diarrhea, pruritus | Form not available, 1 teaspoon twice daily for 1 wk | Direct bilirubin 15 | Cholestatic (increased bilirubin, AST, ALT, ALP) | - | Intralobular bile duct destruction with cholestatic overload |
| Shah et al[16] | 30, F | Abdominal pain, jaundice, dark urine, pruritus | Tea containing Kratom, dose not available | Direct bilirubin 18 | Cholestatic (increased bilirubin, AST, ALT, ALP) | MRI-normal, ERCP–no bile duct obstruction | Intrahepatic cholestasis |
| Riverso et al[13] | 38, M | Dark urine, light stools, fever | Not available | Total bilirubin 5.6 | Cholestatic (increased bilirubin, AST, ALT, ALP) | USG-normal | Acute cholestatic injury, mild bile duct injury, portal inflammation |
| Mackenzie et al[17] and De Francesco et al[18] | 27, M | Vomiting, epigastric pain, diarrhea with associated heavy alcohol intake | Powder, 3-4 teaspoon multiple times weekly for several wk | Total bilirubin 11.2 | Cholestatic (increased bilirubin, AST, ALT, ALP) | - | Widespread hepatocellular necrosis with extracellular cholestasis |
| Fernandes et al[12] | 52, M | Mild fatigue, jaundice | Crushed leaves with water, 1 teaspoon (approximately 1.5 g) once or twice a day for 2 mo | Total bilirubin 28.9 | Cholestatic (increased bilirubin, ALP; slightly increased AST, ALT) | MRI - normal | Canalicular cholestasis, bile duct injury, hepatic lobule injury, mixed inflammation in portal tracts |
| Aldyab et al[10] | 40, F | Abdominal pain, fever | Form not available, once a week for 1 mo | Total bilirubin 5.1 | Mixed cholestatic and hepatocellular (increased bilirubin, AST, ALT, ALP) | CT, MRCP–mild, nonspecific periportal edema | Granulomatous duct injury |
| Pronesti et al[19] | 30, M | Dark urine and pale stool for 1 wk, scleral icterus for 1 d | Powder with water, for 4-6 wk | Total bilirubin 5.7, direct bilirubin 4.5 | Cholestatic (increased bilirubin, AST, ALT, ALP) | USG–coarse hepatic echotexture | Hepatocellular and canalicular cholestasis with inflammation and focal prominent eosinophils. No fibrosis |
| LiverTox case 6972[20] | 25, M | Abdominal pain, fever, jaundice, dark urine, pruritus | Powder, for 23 d | Total bilirubin 22.4 | Mixed Hepatocellular and cholestatic (increased bilirubin, AST, ALT, ALP) | USG, CT–gall bladder wall thickening with increased perihepatic lymph nodes | Cholestatic injury with mild necrosis and inflammation |
M: Male; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; USG: Ultrasonography; CT: Computed tomography; F: Female; MRI: Magnetic resonance imaging; ERCP: Endoscopic retrograde cholangiopancreatography; MRCP: Magnetic resonance cholangiopancreatography.