Liver Transplant M & M, from a Non Transplant University Hospital

( Hafiz Abdul Basit Siddiqui ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Liver transplant is the only curative therapy for decompensated cirrhosis, but there remained several regions throughout the globe where this important and lifesaving modality is non-existent or in the phase of early development. Pakistan ranks third among countries with highest burden of chronic hepatitis C, with a prevalence of >4.8%. For decompensated cirrhotics, only one liver transplant center is available. Post-transplant care remains a challenging domain for the hepatologists in the country Methods: This cross-sectional analysis was done for the post-transplant care and follow up of liver transplant patients in a facility devoid of transplantation. Apart from demographic information, data were collected for indications of liver transplant, post-transplant complications- immediate or within 4 weeks, delayed within one year and then during follow up periods, along with therapeutic modality for treatment of complication. Adverse effect, rejection episodes, their cause and management were recorded. Results: 41 transplant recipients were enrolled between 2016 and 2017. 80% were male. 39 were living donor liver transplant. Most common indication of transplant was HCV in 25 (61%), 13 were PCR positive and given directly acting antivirals (DAAs) with 100% eradication. 2 patients developed diabetes after 6 months of transplant, both were on tacrolimus. Thirteen patients developed biliary anastomotic strictures and went through successful therapeutic ERCP. 21 patients extensively worked up for deranged liver function test and there biopsy showed chronic rejection. Hepatoma recurrence was not seen. Conclusions: Pakistan is in a desperate need of liver transplant facilities and transplant hepatologists. Collaborative work is needed with expert centers.

Outcomes of Large Volume Paracentesis in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

( Hafiz Abdul Basit Siddiqui ),( Muhammad Tahir Khan ),( Hasnain Ali Shah ),( Rabeea Azmat ),( Saad Bin Zafar ) 대한간학회 2017 춘·추계 학술대회 (KASL) Vol.2017 No.1

Aims & Background: Bacterial infections are one of the most frequent complication in cirrhosis, particularly in patients with decompensated cirrhosis and accounts for significant mortality. Ascites is one of the most common complications of hepatic cirrhosis (1). In a country like Pakistan where the prevalence of Hepatitis C is on the rise, end stage liver disease is becoming a common scenario (2-4). Spontaneous bacterial peritonitis (SBP) occurs in 10-30% of such patients and is associated with high mortality rate among hospitalized patients (1, 5-7). The diagnosis of SBP through paracentesis is crucial in the management of SBP. SBP should be diagnosed early as for successful treatment of patients. Diagnostic paracentesis facilitates rapid initiation of antimicrobial therapy and permits optimal coverage in case a causative organism identified. However, more recently, the role of paracentesis in management of SBP is also explored through large volume removal of ascitic fluid. Despite the proposed risk of renal failure, Large Volume Paracentesis (LVP) among SBP patients has shown promising results indicated by lesser morbidity and mortality (8). Rationale of the study: Spontaneous bacterial peritonitis is a serious infectious condition with grave outcome in cirrhotic patients. Large volume paracentesis decreases the burden of infective fluid causing further deterioration of condition. Outcomes of LVP in SBP patients are not clearly addressed in previous studies. Furthermore, to date, no study from the country has reported the effect of large volume paracentesis on the management of SBP in hospitalized patients. This study will assess the outcomes of LVP in patients with SBP, both in terms of length of stay, in hospital 6 week mortality. Objectives: To compare the treatment outcomes among patients with and without large volume paracentesis diagnosed with Spontaneous Bacterial Peritonitis Methods: Study design: Analytical Cross-sectional Study Setting: Gastroenterology Unit, The Aga Khan University Hospital, Karachi Study Duration: 2 Years Study population: Patients admitted with Spontaneous Bacterial Peritonitis to Gastroenterology Unit, the Aga Khan University Hospital Sample Size: Using OpenEpi.com online sample size calculator and using the differences in hospital stay among patients with and without delayed paracentesis as 36.84% and 21.48% (8) the sample size was calculated to be 200 at 95% confidence level (100 in each group). Sampling Technique: Consecutive Sampling Inclusion Criteria: Patients admitted with ascites found to have spontaneous bacterial peritonitis on diagnostic paracentesis. 1) Patients with complete records 2) Above 18 and below 75 years of age Exclusion criteria: 1) Incomplete records 2) Secondary peritonitis Data Collection: The data will be extracted from the records and information analyzed will be patient age, gender, whether the patients receive large volume paracentesis or not, the length of hospital stay, and length of ICU stay. No patient will be enrolled for the study and retrospective data analysis will be carried out. Conclusions: Extracted data till now favours that LVP in patients with SBP translates into significantly positive outcomes in terms of length of hospital stay, spcecial care unit stay, need for terlipressin infusions, in hosptial mortality and 6 weeks mortality post large volume paracentesis. Hence LVP shoiuld be performed in patients suffering from SBP.

Singel Agent DAA in HCV PCR Positive Liver Transplant Patients, Experience from a Developing Country

( Hafiz Abdul Basit Siddiqui ),( Basit Siddiqui ),( Rabeea Azmat ),( Wasim Jafri ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Chronic hepatitis C (CHC) is the leading cause of decompensated liver disease and liver transplant indication in Pakistan, which is the second most prevalent country with a prevalence of 3.5% to 5.2%. Being the seventh most populous country in the world, lacking significantly on medical grounds reflected by only one liver transplant centre for more than 10 million chronically affected liver disease patients. Before the era of directly acting antiviral agents (DAAs) most common problem faced in the post liver transplant period was recurrence of HCV and most of the patients were non responders to interferon therapy well before transplantation of liver graft. Aim of this study is to see the outcomes of single agent DAA in HCV PCR positive liver transplant patients. Methods: This cross sectional analysis was carried out in CHC infected post liver transplant patients with high viremia. The effect of DAAs were noted in the form of eradication of virus and achievement of sustained virological response (SVR). DAAs used, were also recored. Also to note the interaction with immunosuppresants and development of side effects notably derangement of liver function test or failure of graft and anemia. And to note the development of acute kidney injury or any other untoward effect. Results: During study period of 24 months, from January 2015 to December 2016, 51 HCV positive liver transplant patients were enrolled in the study. 26 (52%) out of 51 found to have active viral replication with positive PCR. All 26 received combination of Sofosbuvir (only DAA avaialbe till December 2016 in Pakistan) and Ribavirin. Achievement of viral eradication was 100% so was for SVR. There was no interaction with immunosuppressants. Most commonly reported side effect was fatigue and a feeling of nausea. Kidney and liver function tests remained normal. Contrary to recent data, there was no recurrence of hepatocellular carcinoma (HCC) in patients who recieved liver graft for HCC on background of CHC cirrhosis. Conclusions: Directly acting antiviral therapy has revolutionized outcomes of HCV infected post liver transplant patients in a country lacking modern and advanced health care system. Even the single agent therapy has done wonders for the economically less privileged.