Chief infectionist of Kirov region Head of department in Kirov ID Hospital

Transcription

1 Clinical case Elena Tikhomolova, MD Chief infectionist of Kirov region Head of department in Kirov ID Hospital

2 First referred for consultation in Sep 2014 Symptoms include: fatigue dizziness pruritis sleep disturbance recurrent nasal bleeding continuous heavy feeling in right hypochondrium

3 Higher education. Hobby - music, used to play in a rock band. Excessive alcohol consumption for years. Any drug use is denied. No history of acute hepatitis. Married and has an infant child. The wife doesn t have HCV. Time of HCV acquisition is unknown Concomitant diseases: chronic pancreatitis

4 HCV infection first diagnosed in 2013 during examination prior to elective surgery. Referred to infectionist for consultation developed GI bleeding, which was successfully managed without surgery

5 «Liver cirrhosis of mixed cause (viral and toxic), Child-Pugh class В (7 points). Portal hypertension, oesophageal varices grade 2, rectal varices grade 1, splenomegaly and hypersplenism (platelet and leucocytic lineage). Liver failure grade II : hypothrombineamia, hepatic encelopathy grade II»

6 Esophagogastroduodenoscopy Esophageal varices grade 2, signs of chronic gastritis, duodenitis Colonoscopy Rectal varices grade 1 Abdominal ultrasound Hepatosplenomegaly. Diffuse liver damage. Signs of portal hypertension.

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8 During the following year the patient hasn t visit a doctor Recurrent bleeding from esophageal varices, non-surgical correction

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11 Total bilirubin (mcmol/l ) 12,6 14 Conjugated bilirubin (mcmol/l) 7,9 - ALT (U/l) 19,2 24 AST (U/l) 33,6 29 AP (U/l) 222,3 68 GGT (U/l) 150,3 150,3 Serum protein, total (g/l) 78,9 79 Albumin (г/л) - 39 Creatinin (mcmol/l) 46,2 - Amylase (U/l) 24,3 - INR 1,24 1,43 Prothrombin (%) 73 - Prothrombin time - 16,5

12 WBC (х10 9 /l) 3,52 5,7 RBC (х10 12 /л) 4,19 3,56 Hb (г/л) PLT (х10 9 /l)

13 Height 193 cm, weight 111 kg, BMI=29,8 kg/м 2 General condition and mental state are satisfactory. Slightly euphoric. Tremor is absent. No sleep disturbances. Pale skin, vascular spiders, palmar erythema. No hemorrhages. Liver is enlarged, +5 cm (mid clavicular line), rigid, smooth bottom edge. Lower pole of splenum is palpable. No ascites or edema.

14 September 2014 drugs available in Russia: Regular IFN? Pegylated IFN Ribavirin PIs: TPV, ВСV, SMV

15 Antiviral treatment is contraindicated Further observation, examination of Gt and viral load, symptomatic therapy Referred to surgical dept for the correction of portal hypertension

16 Distal splenorenal venous shunt was applied No complications in post-surgical period Discharged to be followed up by a surgeon and local ID specialist Источник иллюстрации Рачков В.Е., Разумовский А.Ю. Феоктистова Е.В. Синдром портальной гипертензии у детей. Кафедра хирургических болезней детского возраста, РГМУ ДГКБ 13 им. Н. Ф. Филатова

17 May 2015 drugs registered in Russia: Regular IFN Pegylated IFN Ribavirin PIs: TPV, ВСV, SMV + The first IFN-free option - 3D (PTV/r/OBV/DSV)

18 Patient G, 38 year old, diagnosis: «Chronic HCV-infection, high replication rate, IE/ml, Gt 1b, minimal activity, F4. Liver cirrhosis Child-Pugh А (6 points)» The only possible option: IFN-free 3D regimen the patient started antiviral therapy: Viekira PAK + RBV 1200 mg daily

19 Tolerability was good Fatigue and moderate asthenia during the treatment Regimen was not modified during the complete course (12 weeks)

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24 Interferon-free therapy was the only possible option for the discussed patient At the moment of treatment initiation the patient has no contraindications Patient has achieved the SVR Treatment tolerability was good Virus elimination doesn t eliminate liver cirrhosis therefore due medical monitoring and appropriate medical restrictions for a patient with liver cirrhosis are applicable for the long period of time (in many cases - for the lifetime )

25 What is the main goal of antiviral therapy of HCVinfection in your opinion? 1) Virus elimination 2) Stabilization of patient medical condition and stop of liver disease progression 3) Regress of liver fibrosis 4) Prophylaxis of potential virus transmission

26 How many patients with decompensated cirrhosis have you treated (with any antivirals) during your clinical practice? 1) < 5 2) ) ) >30

27 Which therapy would you recommend to a patient with cirrhosis Child-Pugh B or C in Russia in 2016? 1) IFN-containing 2) Daclatasvir + asunaprevir 3) Paritaprevir + ombitasvir + dasabuvir 4) Sofosbuvir + simeprevir 5) Sofosbuvir + daclatasvir 6) None

28 How would you classify cirrhosis in patient with episode(s) of decompensation in medical history? 1) Compensated or decompensated depending on the current Child-Pugh score 2) Decompensated as an episode of decompensation has already been observed

29 Would you discontinue antiviral treatment with DAAs combination if a patient developed signs/symptoms of decompensation (Child-Pugh score > 7) during the course of therapy 1) Yes 2) No 3) Decision depends on the particular signs/symptoms, as Child-Pugh score doesn t take into account all the details of the situation