Failing Transplanted Liver from an Unrecognized Recently Discovered Autoimmunity

( Rabeea Azmat ) 대한간학회 2018 춘·추계 학술대회 (KASL) Vol.2018 No.1

Aims: Unfortunately, recurrent HCV infection of engraftment is inevitable if the virus was not eradicated in recipients. Because of immunosuppression, if left untreated, HCV infection progresses to cirrhosis quickly. The era of direct antiviral agents (DAAs) has greatly improved the SVR (sustained virological response) to 90%, and safety concerns were minimal. Despite advancements there remain a gray zone of mixed involvement in the form of viral hepatitis with autoimmunity. Here we are reporting a case of a patient whose graft showed features of deterioration despite achievement of SVR and ultimately, the question was answered by liver biopsy. Methods: 47years old man with living donor liver transplantation in October 2012 for HCV-CLD., remained uneventful on mycophenolate mofetil and tacrolimus & achieved SVR on Sofosbovir and Ribavirin therapy which was completed in December 2015. After 8 months of DAAs therapy he developed itching and fatigue, and on follow up he was found to have deranged LFTs in December 2016. Although, HCV PCR was negative and so was MRCP. Results: His liver biopsy revealed chronic ductopenic rejection with granuloma formation and features of autoimmune hepatitis. His ANA profile was found to be significantly positive. Despite steroids and further immunosuppression he could not manage to recover. He was sent to liver transplant centre for second liver transplant but concerns were reappearance of autoimmune flare and graft failure which limited his liver retransplant. Conclusions: This case is an eye opener for the transplan team as autoimmunity remains to be a difficult scenario to cope with in transplant setting.

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.

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.