HCV treatment Post BMT

[jwalia]

My daugher is a 14 year old exthalassemic who underwent BMT in November 2009.  She was found to be HCV positive prior to BMT and she underwent liver biopsy and HCV RNA Qualitative test.  The result of biopsy was Grade IV iron overload, mild portal and focal periportal fibrosis, and focal mild to moderate portal inflammation.(HCV positive).  The result of RNA qualitative was Not detected.During BMT she had moderate veno occlusive disease and she recovered. She was using Tab cyclosporin as immunosuppresant.  She had some anomalies in her SGOT and SGPT.  Last HCV RNA quantitative was done on March 30 2010 and the result was 12100000IU/ML. LFT results were as given below.

Date    total bilirubin  Direct bilirubin  Total protein  Serum albumin  SGOT/SGPT   Alk.phos      Cyclosporin dose
22.3.10    1.4              0.4                 6.3                4.6                  218/398                351            150/100 mg
01.4.10     1.2                                   6.3                3.6                  138/245               545             100/50 mg
15.4.10    0.9              0.1                 6.3                 4.0                  138/187               470             75/50  mg
29.4.10     0.7             0.1                 6.1                3.9                   186/318               444             50/50 mg
11.5.10    0.2              0.1                 5.8                4.3                    126/248              312             50/25  mg
27.5.10    0.6              0.05               6.3                4.4                   119/194               263             25/25  mg
17.6.10    0.6             0.2                  6.6                4.3                   139/252              249            25mg                
15.7.10    0.5              0.02               6.9                5.0                   154/232               240   25mg alternate day
23.8.10    0.7              0.02               6.8                4.5                   123/216               223        Stopped
30.9.10    0.37            0.08               6.6                3.8                    60/109               200

HCV quantitative done on 30.9.10 had a value of 1420000 IU/ML.  There was a decrease of 88% of virus load from the previously done report.  There is also marked decrease in SGOT and SGPT levels.  My question is if there is an decrease of this proportion without taking any extra medication, can her body recovers the remaining 12 %?  Should she opt for interferon therapy at this stage?  I will be very much obliged if somebody with experience in Post BMT hepatitis treatment can answer these queries.        

[eureka254]

Firstly, congratulations on the success of your daughters BMT.  It is unfortunate that a large population of blood product recipients also received hcv, but transfusions will now be a thing of the past for your daughter.  Excellent advice from Trinity -- getting her iron managed will be important in managing your daughter's hep c.  

Seeing fluctations in SGOT and SGPT and huge numerical variations in Viral Load is quite common in people with chronic hep c.  My husband's viral load has fluctuated between a million and 18 million, but those viral load numbers actually don't have much bearing the status of the disease unless being measured during treatment.  The biopsy shows mild damage, so it's important to investigate all options of management and treatment.  Much of what goes into that decision will depend on your daughter's hcv genotype, her state of health, and the progression of her liver fibrosis.  It would be well advised to seek the advice of a hepatologist who could work closely with your daughter's hemotologist and BMT doctors.  Hope that helps, and best wishes. ~eureka

[Trinity4]

According to what I read they discovered she was HCV positive in November of '09.  Almost 1 year has passed and despite the decrease in viral load (which fluctuates regularly) she is considered to have chronic HCV and the virus will remain active until she undergoes antiviral therapy.  Liver enzymes fluctuate with HCV as well.  It also looks like the damage to her liver is minimal at this time and it doesn't appear there is any urgency to treat right now.  I do not know what grade IV iron overload equates to but I'm assuming that is high.  Posttransplantation treatment of iron overload in ex-thalassemic patients is currently phlebotomy but they are studying  pharmacological treatments for iron overload which is showing the the drugs are well tolerated with reduction in serum ferritin levels and iron overload.  Having had elevated serum ferritin due to porphyria cutanea tarda myself, I was also tested for iron overload at biopsy and my Hepatic Iron Index was 0.4 umol/g/yr.  <1 is normal, inidicating no iron accumulation.  I was treated by phlebotomy over a period of 3 months, the ferritin levels returned to normal and the porphyria subsided.  

It looks like she has stopped taking the immunosuppresant and I assume the bone marrow transplant was a success.  You really should talk with a hepatolgist about your daughter's treatment options.  Much better drugs with higher odds of eradicating the hepc virus are expected to be released in 2011.  Regardless of the newer drugs, if minimal liver damage is present a watch and wait approach should be considered as long as your daughter is being monitored regularly.  A high iron level is a negative factor when initiating any type of antiviral treatment and can acclerate fibrosis so it is very important you consult with a hepatologist and thoroughly discuss your daugthers medical history.

My best to you both,
Trinity