Nasir Khokhar

Psychological implications of hepatitis C virus diagnosis

Background and Aims:  Hepatitis C virus (HCV) diagnosis causes significant psychological stress and anxiety. We thought it would be important to illustrate the anxiety caused by HCV diagnosis in patients from the developing world.

Severity of Depression in Hepatitis B and Hepatitis C Patients

OBJECTIVE To assess and compare the severity of depression in chronic hepatitis B (CHB), chronic hepatitis C (CHC) and healthy subjects. STUDY DESIGN Comparative study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad from July 2011 to February 2012. METHODOLOGY A total of 206 subjects were divided in three groups. Group-I (chronic hepatitis C, n = 95), group-II (chronic hepatitis B, n = 29) and group-III (healthy subjects, n = 82). They were matched for age, gender and socioeconomic status and were compared for frequency and severity of depression as measured by Hospital Anxiety and Depression Scale (HADS). RESULTS Some degree of depression was noted in all groups. Frequency of depression was 72.6% in group-I, 58.6% in group-II and 37.8% in group-III (p value < 0.001). CONCLUSION Both CHC and CHB had high frequency of some degree of depression. Hepatitis C patients had more depressive features than CHB. It is worthwhile to do more close mental health observation in them. A multidisciplinary team including a psychiatric specialist can help in this approach.

Comparison of once a day rifaximin to twice a day dosage in the prevention of recurrence of hepatic encephalopathy in patients with chronic liver disease

Rifaximin has been used for prevention of recurrence of hepatic encephalopathy in twice a day dosage. The drug is expensive and lower dising may be possible.

Initial results of efficacy and safety of Sofosbuviramong Pakistani Population: A real life trial Hepatitis Eradication Accuracy Trial of Sofosbuvir (HEATS)

Objective: The uridine nucleotide analogue sofosbuvir is a selective inhibitor of hepatitis C virus (HCV) NS5B polymerase approved for the treatment of chronic HCV infection with genotypes 1 – 4. The objective of the study was to evaluate the interim results of efficacy and safety of regimens containing Sofosbuvir (Zoval) among Pakistani population with the rapid virologic response (RVR2/4 weeks) with HCV infections. Methods: This is a multicenter open label prospective observational study. Patients suffering from chronic Hepatitis C infection received Sofosbuvir (Zoval) 400 mg plus ribavirin (with or without peg interferon) for 12/24 weeks. The interim results of this study were rapid virological response on week 4. Data was analyzed using SPSS version 21 for descriptive statistics. Results: A total of 573 patients with HCV infection were included in the study. The mean age of patients was 46.07 ± 11.41 years. Out of 573 patients 535 (93.3%) were treatment naive, 26 (4.5%) were relapser, 7 (1.2%) were non-responders and 5 (1.0%) were partial responders. A rapid virologic response was reported in 563(98.2%) of patients with HCV infection after four weeks of treatment. The treatment was generally well tolerated. Conclusion: Sofosbuvir (Zoval) is effective and well tolerated in combination with ribavirin in HCV infected patients.

Hepatocellular carcinoma after sustained viral response to interferon and ribavirin therapy in cirrhosis secondary to chronic hepatitis C.

OBJECTIVE To determine the frequency of development of hepatocellular carcinoma in patients with chronic liver disease secondary to hepatitis C who had achieved sustained virological response with Interferon and Ribavirin therapy. STUDY DESIGN Retrospective descriptive study. PLACE AND DURATION OF STUDY Shifa International Hospital, Islamabad, Pakistan, from January 2007 to January 2012. METHODOLOGY Hepatitis C related chronic liver disease patients who were treated with interferon and ribavirin, after they achieved sustained virological response, they were followed for a mean of 42 ± 17 months. During this time, development of hepatocellular carcinoma was ascertained. All underwent surveillance with alpha-feto-protein and ultrasonography every 6 months. RESULTS Out of the 58 patients who had achieved sustained virological response, 3 developed hepatocellular carcinoma after a mean follow-up of 38 ± 14 months. It was multifocal in 2 cases and was single lesion in the 3rd. Two patients ultimately died, one with upper GI bleeding and the other with hepatic encephalopathy, while 3rd patient with single lesion is still surviving. CONCLUSION Three out of 58 patients of hepatitis C related chronic liver disease developed hepatocellular carcinoma during follow-up in patients who had achieved sustained virological response. These patients need closer follow-up, for development of complications, even if they have achieved sustained viral response.

Perioperative management of cirrhosis.

Patients with cirrhosis present a clinical challenge in the normal course of their illness. Management becomes particularly challenging in the event of surgery. The stress of surgery and effects of anesthesia can affect the outcome and require identification of risk factors before any surgery is contemplated. Patients with decompensated liver disease have a higher risk of postoperative complications such as acute liver failure, sepsis, hemorrhage, and renal dysfunction.1 Surgical risk factors should be addressed prior to surgery in these patients. Traditionally, this has been performed by means of the Child-Pugh-Turcotte (CPT) score and Model for End-stage Liver Disease (MELD) score. The CPT score takes into consideration three biochemical elements (prothrombin time, albumin and bilirubin) and two clinical parameters (ascites and encephalopathy). Patients are deemed class A, B, or C according to the score. A higher score is suggestive of higher risk for perioperative complications. A patient with class A score is estimated to have 10% mortality after abdominal surgery, but this risk increases to 30% in class B and nearly 70-80% in class C.2 MELD score was originally developed for transjugular intrahepatic portosystemic shunt (TIPS), but has evolved for use in orthotopic liver transplantation. This score takes into account serum bilirubin, creatinine, and INR (International Normalized Ratio) and is arrived at by a validated calculation (3.8 x bilirubin + 11.2 x INR + 9.6 creatinine, values in mg). A MELD score of less than 8 predicts a good outcome for TIPS, whereas a score of > 18 portends a poor outcome.1 MELD has also been used to predict the mortality of hepatic resection for hepatocellular carcinoma; a MELD score of less than 5 was associated with 0% postoperative liver failure.3 Scores of 9-10 were associated with 3.6% postoperative failure, and a score of > 10 was associated with 37% incidence of postoperative liver failure.3 MELD score has been validated as an independent predictor to calculate postoperative mortality and it compares fairly well with Child-Pugh score.4

Treatment of chronic hepatitis C in hereditary spherocytosis

TO THE EDITOR: Hepatitis C is a worldwide problem, with millions suffering from the condition. Initial treatment with interferon alfa 2B and ribavirin has been effective in this condition (1) and has resulted in histological improvement of fibrosis in these patients (2). Treatment of hepatitis C is not free of side effects and can cause problems with hemolysis and anemia. Hereditary spherocytosis is a disorder of the red blood cell membrane that leads to chronic hemolytic anemia (3). It happens because 7–8 mm size red blood cells break down because of trapping in the spleen, as they are unable to pass through 2mm fenestrations in the splenic red pulp (3). Treatment of these patients with interferon and ribavirin could cause further problems with anemia as these patients are prone to constant hemolysis. Here is described a patient with chronic spherocytosis who had hepatitis C, was successfully treated with a combination of interferon and ribavirin, and had a sustained response to the treatment without undergoing any serious adverse effects. A 42-yr-old male presented with a history of prolonged elevated ALT. He had no history of any other problem and had no other complaints. His physical examination showed a pulse of 80/min, blood pressure 110/70, respiration 14/ min, weight 55 kg, and height 160 cm. A slightly palpable spleen and no ascites, edema, or any other stigmata of chronic liver disease were noted. Complete blood count showed a hemoglobin of 11.8, a WBC count of 9,600, a platelet count of 177,000, and a mean corpuscular volume of 102; peripheral smear showed spherocytes and few elliptocytes. PT was 15 s. A liver function test showed a total bilirubin of 6.3 and a direct bilirubin of 1.2. ALT was 100, AST was 114, hepatitis B surface antigen was negative, anti–hepatitis C virus (anti-HCV) was positive, and HCV RNA was positive. Reticulocyte count was 16%, and Coombs’ test and antinuclear antibody were negative. Serum ceruloplasmin anda1-antitrypsin were normal. Serum creatinine was 1.0. Osmotic fragility was positive. The patient underwent liver biopsy, which showed grade II portal inflammation and stage 0 fibrosis. He was treated with interferon (3 million U s.c., three injections weekly) and with ribavirin (400 mg b.i.d.). His initial ALT came to normal in 3 months, and HCV RNA became negative. His ALT remained within the normal range throughout for 12 months, and every 3 months HCV RNA was negative. His hemoglobin dropped from 11 to its lowest point, 7.1, after 9 months. He was given folic acid 5 mg/day. The patient remained asymptomatic, and no transfusion was thought to be necessary. As his treatment finished after 12 months, ribavirin and interferon were discontinued. His hemoglobin gradually improved to baseline and he felt well (Fig. 1). Patients with chronic anemia like thalassemia have been treated successfully with interferon/ribavarin treatment (4, 5), although sometimes blood transfusions had to be given if hemoglobin had significantly dropped and the patients became symptomatic. In general, it is recommended that if