Angiotensin-Converting Enzyme Inhibitor-Drug Induced Liver Injury: Clinical Features and Diagnostic Features - A Systematic Review of Current Reported Cases.

Background/Aims: Angiotensin-converting enzyme Inhibitor induced liver injury (ACEi-ILI) is a rare and frequently underrecognized condition. Its nonspecific gastrointestinal symptoms could lead to missed diagnoses, unnecessary procedures, and inappropriate treatments. Due to the scarcity of studies, we conducted a systematic review to summarize the clinical characteristics, diagnostic approach, and factors predicting delayed recovery. Methods: Electronic databases including MEDLINE, OVID, and EMBASE were used to identified eligible studies from inception to January 2025. Eligible cases were required to have a clear diagnosis of ACEi-ILI. Descriptive analysis and Kaplan Meier analysis were used to identify factors, outcomes and recovery time. The protocol was preregistered (PROSPERO: 640521). Results: Our systematic review included 54 eligible studies, comprising 60 ACEi-IAE cases with a mean age of 58 years old, and 43% were male. The majority came from the United States (27%). Patients were presented with 61% of jaundice. The median recovery time was 6 weeks after discontinuing ACEi. Diagnostic criteria were proposed and summarized based on the findings. Conclusions: Clinicians should be aware of ACEi-induced liver injury, particularly in ACEi users with non-specific jaundice. Implementing our proposed diagnostic criteria is recommended to prevent unnecessary investigation and inappropriate treatment.