Clinical Case HCV therapy following liver transplantation.

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Presentation transcript:

Clinical Case HCV therapy following liver transplantation

Medical history 65 yrs old HCV (+) LT recipient. HCV-related history: –HCV GT1b –Naïve pre-LT Comorbidities –AHT (nifedipine 60 mg qd) –IDDM (insulin) –Frequent cephalea LT-related history –LT 6 yrs before –MELD 16, Child-Pugh C10 –Anti-core positive donor (recipient HBV serology negative)----LAM prophylaxis –Uneventful surgery & early postLT recovery –IS: Tac + P Recurrent hepatitis C –First month on-demand liver biopsy: mild NI, no fibrosis –6th-month on-demand liver biopsy (ALT 666 UI/ml, AST 373 UI/ml, GGT 280 UI/ml, AP 104 UI/ml) : moderate NI, F2/4

Tests performed: –Liver ultrasound: normal –Auto-antibodies: negativos –Thyroid hormones: normal –HBV serology & viral load: negative –CMV viral load: negative –Viral load HCV: > UI/ml Recurrent hepatitis C Antiviral therapy (9 month postLT) -Peg-alfa-2b 100µg/día -Ribavirin 1000mg/día

Time postLTFirst month3d month5th-6th month Biochemical RYesYes (normal) Viral RViral load decreaseYes (84 IU/m)Yes (< 50 IU/ml) AEs* Headache *Anxiety (alprazolam) * Irritability/depression (escitalopram) * Headache * Improvement of depression * Headache * Asthenia *Hand-shaking (D/C nifedipine, propranolol) 3 hospital admissions Laboratory abnormalities * Anemia *Neutropenia *Low platelets * Anemia (EPO) *Neutropenia *Low platelets * Anemia (EPO) *Neutropenia *Low platelets Clinical course during IFN-therapy

Third amission (6 months on treatment) Confusion, instability, disorientation, memory loss, urinary incontinence, headache, episodes of unconsciousness with hypertony No fever, no agitation at night, good sleep MRI: normotensive hydrocephaly + Periventricular leucoaraiosis LUMBAR PUNCTURE: Pressure 33 cm H2O, Glu 26 mg/dl, cells 15 (100% MN), proteins: 4,9 g/dl Micro: yeast (criptolatex positive) LOWENSTEIN: Cryptococcus neoformans BURRI Stain: capsulated yests compatible with Cryptococcus ANFOTERICIN B + STOP antiviral therapy

-Fibroscan 2011:=6,1 Kpa --Fibroscan 2012 = 15,1 Kpa - Fibrscan 2013: 35 Kpa - Liver biopsy 2014: Cirrhosis with moderate necro-inflammation + macrosteatosis - Gastroscopy: mild esophageal varices Child A 6 Cirrhosis, Meld 14 Baseline viremia: IU/mL Week 2 viremia: 152 IU/mL Week 4 to 24: undetectable SVR-4 and SVR12 Follow-up Recurrent hepatitis C 24 week- therapy with SOF+DCL+RBV