One of the Earliest HCV Treatment Results with Direct Acting Antiviral Agents

( Aiymkul Ashimkhanova ),( Kakharman Yesmembetov ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: The aim of this case report is to present a successful treatment of hepatitis C infection in a cirrhotic patient with a new direct acting antiviral regimen. Introduction: Kazakhstan has a high burden of end stage liver diseases and anti-HCV prevalence varies from 3.2% up to 4.6% according to screening programs conducted in different areas of the country. According to the data presented by Hepatology centers were they conduct free governmental supported IFN+RBV treatment genotype 1 accounts for more than 50% of cases (figure-1: HCV genotypes). The introduction of new antiviral regimens for HCV-infection is expected to decrease the disease burden in Kazakhstan, especially in those hard to treat population including genotype-1 non-responders. Methods: A case report study is based on clinical observation of the patient. A 59 y.o. female from Southern Kazakhstan presented with chief complain of pain in the RUQ, decreased appetite, fatigue, and dyspepsia. History of present illness: abovementioned symptoms started 1-2 years ago, treated for the dyspepsia with PPI (omeprazole), antacids. Past history: 4 kids, natural delivery, no blood transfusion (or cannot remember of any). Had dyspepsia treatment for years (sanatorium and private clinics). Family history: no viral hepatitis among family members or liver diseases. Results: Complete blood count was remarkable for low platelet count (PLT - 113 x 109/L), all other parameters were within the normal ranges (WBC - 7,89 x 109/L, Hb - 149 g/L, HCT - 41.9%, RBC - 4,63 x 1012/L, PLT - 113 x 109/L, LYMF - 28/6%, Ne - 60.6 %). Coagulation: PT - 12,8sec, APTT - 28,2 sec, fibrinogen - 1,3 g/L (1,8-3,5), PT by Quick - 74,5%, INR - 1,03. Liver enzymes slightly elevated (ALT - 88,6 U/L, AST - 66,4). Other indicators were unremarkable or were slightly changed (TB - 13 mkmol/L, Total protein - 73,8 g/L, Albumin 43,4 g/L, Glucose - 5,37, Creatinine - 51 mkmol/L, Ferritin - 179,7 ng/ ml, Serum Fe - 19,34, AFP - 5,6, Total cholesterol - 4,8 mMol/L, TGC - 0,77 mMol/L). Antibodies for HBsAg - negative, Anti - HCV - positive, PCR (HCV - RNA) qualitative came positive with viral load 3.4x106/L, genotype - 1. GI endoscopy revealed esophageal varices stage 0-1, reflux esophagitis. Elastometry showed advanced fibrosis F4 by METAVIR, ECG showed no bradicardia, no arythmia in the past and current times. She was confirmed with a diagnosis of Chronic HCV induced Liver Cirrhosis, Child A-5. Portal hypertension: esophageal varices stage 0-1, splenomegaly and thrombocytopenia. The patient agreed to start on sofosbuvir 400mg + ledipasvir 90mg regimen for 12 weeks. Advised to exclude antacids and PPI``s for the duration of this treatment. As shown in the figure-2 (HCV-RNA) the viral load dropped 3 logs after 4 weeks from the initiation of therapy, the following 8 and 12 week assessment were negative for HCV- RNA, and patient cleared the virus (SVR 12). In the follow up lab results liver enzymes normalized, inflammation markers were decreased and the long-term effects of the treatment success will be tracked. Conclusions: This case report represents the importance of treatment of HCV-infection in a patient with a compensated cirrhosis to stop the progression of the end stage liver disease and delay the liver transplantation. I have no conflict of interests in this case report.

Pediatric Liver Transplantation Experience in Kazakhstan

( Gari Kuttymuratov ),( Damir Zhenalayev ),( Dulat Mustafinov ),( Aiymkul Ashimkhanova ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: The aim is to analyze the first results of pediatric liver transplantation experience. Currently in Kazakhstan on the waiting list for liver transplantation there are approximately 22 children various congenital or acquired liver pathologies. Most of the children with end stage liver disease need a donor organ transplant before the age of 1 year old. During the period from 2012 to 2015 at National Research Center for Maternity and Child in Astana, there are total of 6 pediatric living donor liver transplantations were performed in Kazakhstan. In all cases, the left lateral segment of the donor liver was allocated for transplantation. Age of recipients ranged from 5 months up to 6 year old. The donors are close relatives of the recipient, their age ranged from 24 to 36 years. In 5 out of 6 cases in children under the age of 1 year old the etiology of liver cirrhosis was biliary atresia. In a 6 y.o. child the underlying cause of cirrhosis was autoimmune hepatitis. All liver transplantation performed with the participation of foreign experts from India, Turkey, and The Republic of Belarus. Methods: Prospective study from the start of the first pediatric liver transplantation. Results: Postoperative complications were not observed in donors. One child under the age of 5 months had a PO-complication as hepatic artery thrombosis (HAT). The surgical actions to fix the vascular damage were unsuccessful and the child was taken by sanitary aviation to hospital in Istanbul, Turkey, where he had another liver transplantation from a living donor. In the remaining five recipients there were no complications observed, and they discharged from the hospital. Due to the severe shortage of donors, the mortality rate of children on a waiting list is up to 54%. Conclusions: The lack of experience of local transplant surgeons in carrying out highly advanced surgeries in young children, forcing patients to carry out similar operations in foreign clinics by governmental funding or on their own expense. The most common surgery for liver transplantation Kazakhstani children held in South Korean hospitals, Germany, Turkey, India. On behalf of our colleagues and patients we want to thank our friends - colleagues from South Korea, Turkey, India, for their help and support in the development of transplantation in the Republic of Kazakhstan.

Transplant Program Development in Kazakhstan: Experience of 6 Years

( Mels Assykbayev ),( Gani Kuttymuratov ),( Lyazzat Abdrakhmanova ),( Yermakhan Assylkanuly ),( Aiymkul Ashimkhanova ),( Kakharman Yesmembetov ),( Saitkarim Abdugaffarov ) 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: The aim of this analysis was to present the overall results of transplant service development in Kazakhstan. Background: Kazakhstan as the one of the fast developing countries in Central Asia has been improving the development of organ transplantation since 2010. There are 9 national and city level hospitals performing kidney, liver and heart transplantations in two major cities Almaty and Astana. A coordination center for organ transplantation was established in 2013 with the purpose of developing cadaveric donation service in Kazakhstan. In all 16 regions of our country we have transplant coordinators who work on finding potential donors, talking to their relatives, and making organ preservation. Considering the huge territory of the country there is a sanitary aviation service specially prepared for organ transportation, the special team for organ harvesting and for recipients. Methods: Prospective study started from 2010 at our center included all performed liver transplants and other organ transplants to analyze and follow up their results. Numbers are shown in percentages in Figure 1. The quantitative characteristics of all organ transplants in Kazakhstan. Results: Overall, 760 patients had undergone transplantations of kidneys, liver and heart for the last 5 years. The first kidney transplantation from a cadaveric donor performed in 1979, and this date considered as a beginning of the organ transplantation development in the Republic of Kazakhstan (RK). For the first time in our country, the multi-organ harvesting of organs: kidneys and the heart from cadaveric donor was performed in 2012. Our national center became a pioneer in performing liver transplantation from a cadaveric donor since 2013. The same year, the first pediatric liver transplantation from a living donor was carried out for a 6-year-old child. Starting from 2013 in collaboration with transplant surgeons from Turkey and South Korea many hospitals started to develop living donor liver transplant programs. Figure 1 illustrates the quantitative characteristics of organ transplants carried out in the Republic of Kazakhstan for the period from 2010 (including) to 2015. Conclusion: Our experience of Transplant program development highlights the demands of our population in organ donors with high mortality on a waiting list (72%). Thus, the development of living donor transplantation and overall transplant service will increase survival and quality of life of patients with end stage diseases.

Splenic Artery Steal Syndrome after Orthotopic Liver Transplantation

( Saitkarim Abdugafarov ),( Gani Kuttymuratov ),( Tokan Sultnaliyev ),( Mukazhanov Adilbek ),( Zheksembayev Asan ),( Kakharman Yesmembetov ),( Yermakhan Assylkhanuly ),( Aiymkul Ashimkhanova ),( Baizh 대한간학회 2016 춘·추계 학술대회 (KASL) Vol.2016 No.1

Aims: To present successful treatment of post liver transplant non occlusive hepatic artery hypoperfusion syndrome presented by splenic steal syndrome (SASS) cases managed by splenic artery embolization. SASS is one of possible arterial complications after living donor liver transplantation. Material includes personal experience in diagnostics and treatment of this syndrome. In each case complication was suspected based on laboratory and ultrasound data and proved by angiography. Successful treatment was performed using splenic artery embolization. Methods: From 2014 there are total of 13 liver transplantations were performed and we had 2 cases of SASS. All donor livers undergo biopsy and those biopsy tissues with no more than 10% steatosis could be eligible for transplantation. Results: One of the most threatening complications of liver transplantation from a living donor is hepatic artery thrombosis. There are many possible causes of thrombosis including technical, and coagulation dysfunctions that will lead to the different level of graft disorders. However, in some circumstances other possible factors may induce arterial dysfunction due to functional features of visceral blood flow under established portal hypertension. SASS develops in 1-4% of post-transplant cases at early period after surgery from 2-5 days, and is characterized by re-distribution of blood supply from celiac trunk predominantly to splenic or gastro-duodenal artery. As a result of this phenomenon the linear and volumetric blood flow rates in the hepatic artery decreases leading to arterial ischemia of liver graft and might even lead to thrombosis. During this process the level of transaminases and bilirubin increases along with the Doppler ultrasound changes and CT-angiography data. The most dangerous consequence of SASS is the development of hepatic artery thrombosis (HAT) with the possible loss of transplant. The main reason of SASS development is hyper perfusion of the transplant. The timely diagnosis of the formidable pathologic syndrome is very crucial in order to avoid the loss of the graft. Conclusions: It appears that patients with decompensated cirrhosis with long-time established portal hypertension should be carefully monitored early post-operative time after transplantation for any unexplained liver dysfunction confirmed with Doppler ultrasound, CT-angiography and coagulation abnormalities suggestive of SASS.