81yr old Dad - Hep C Update/Questions

[HepDad]

Just a quick update on my dad - posted a few months back and had a couple of questions as well.
Here is my initial post:

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My dad is 81 yrs old - was in the hospital 2 months ago (Oct 2011).  He had a stroke a long time back (1981) and recently had some non-convulsive seizures. The docs put him on Sodium Valporate. While he was in the hospital, his LFT's were perfectly normal.
A few weeks ago (Jan 2012) he got all icteric, eyes were jaundiced and his urine was dark. Did an LFT and his enzymes were extremely high, ALT was 1160, AST was 1450. His neurologist immediately stopped the Sodium Valporate, and told us to see a hepatologist.
After a bunch of tests, my dads HCV RNA came back positive. The hepatologist suggested we wait for a few weeks and repeat an LFT, something about anti-bodies and the infection leaving the system.
Most recent LFT done today (FEb 20, 2012) showed a drop in Bilirubin to 1.4, ALT is 140, AST is 90, GGPT is 259.

Questions:
1. Does it make sense to consider the Interferon/Ribavarin treatment.
2. If he got the Hep C during his stay in the hospital, how long will it take before things get really bad for him.
3. How risky is it to wait and hot do anything.

Thanks for all comments and suggestions.

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Fastforward to Today:
We decided not to get on the Interferon/Riba treatment -
A few months have passed and my dad seems to be doing well - no real issues - Still a little slow, but he is 81. Not icteric at all. Urine is clear, almost white - Fairly active, no cognitive issues - still quite sharp.
Had a fall couple weeks back, and fractured his humerus bone in his left arm - Ortho suggested a sling and brace and no surgery. That seems to be healing well.
Blood work done 2 days after fall - just a coincidence. Had scheduled him for tests on Monday and unfortunately he fell on Sat nite.
The LFT results were slightly better, but still elevated.
Bilirubin: 1.94, Direct .48, Indirect 1.46.
ALT = 75
AST = 92
GGTP = 111
ALP = 101
Protein = 6.61
Albumin = 3.82

However, his Haemoglobin was low at 10.5, PCV was low at 31.6%, and RBC count was low at 3.52. Rest of the counts (WBC. Platelets etc etc ) were normal. All other tests for diabetes, kidneys, cholesterol etc were normal.
Serum Iron was 71.46, TIBC = 315.52, and Transferrin Saturation (TS) = 23%. Ferratin test was NOT done.

His GP said he was anemic and prescribed some iron tablets - and said his Haemoglobin would improve in a couple of months. His hepatologist is away on vacation. We did NOT take the iron tabs, since I read somewhere about Iron overload and Hep C replication due to iron overload.

Questions:
1. With his serum iron, TIBC, and TS being normal, does he really need more iron. Also, am I right in assuming these readings dont show any signs of iron overload.
2. Could his haemoglobin have fallen due to his fracture. It was a closed fracture and there was no external bleeding, but a lot of bruising, and blackish and blueish coloration on the arm and lower back area (This has now subsided - almost disappeared). Note the bloodwork was done 2 days after the fracture took place.
3.How do we get his haemoglobin back up without iron and without blood transfusions (he doesnt want to take any right now). Also, he shows no other signs of anemia. Not tired all the time, no breathlessness, no aches and pains, lips not chapped, tongue not pale, skin not pale, and blood pressure is normal --the only sign is pale nail beds sometimes during the day (could also be liver related).
4. Is there anything else we should look for to see how his Hep C is progressing/leaving/left - clinically, other than the pale nail beds he shows no signs. (Im sure this is with most Hep C patients).

Thanks guys for any and all suggestions. Any info would be appreciated. You all were awesome last time, and I thank you all.
Take care
..

[jules2551]

And yes my HGB was on the high side above 15.  Can't remember the exact number but my Ferritin was 3X the norm.

[jules2551]

No your Dad's HGB is a little low.  He might feel a little fatigued but other than that he sounds pretty good.  That is great that he got out for the 30 minute stroll.  

The Questions for all
      I never really had any symptoms of Hep C.  I had no clue that I had it.  I actually went to get my cholesteral checked HA!  That is when my LFT's came back elevated and everything just snowballed.  Looking back I would say the only symptom I had was some fatigue and headaches.  But that was probably due to the hemochromatosis.

[HepDad]

Idyllic: Thanks for responding:
As for your questions:

1. His Hgb used to be between 12 and 13.2. However at his 3 month check up for blood work it was down to 10.5
2. No biopsy was done - probably will not get it done.
3. Ultrasound done in January 2012 (when the jaundiced flared up) showed no major issues - just normal age related stuff.
4. No idea about stage of HCV - never did a Fibrosis. Since we decided not to go on the Interferon/Riba treatment, we have only been tracking it 'clinically'

Jules:
Thanks for responding - when your iron levels go into overload, does that automatically raise the HGb. - With 10.5 Hgb and 71.4 serum iron, doesn't it seem like there is no 'overload'!

Can-do-man:
Thanks for responding - and thanks for the encouragement. Yes, he seems to be in ok shape - just got back from a 30 min stroll. No aches, pains, breathing issues etc etc. But, I guess its a day to day thing.

Questions for all:
-- What other day to day symptoms to do Hep C patients demonstrate.
-- Is the urine always dark - (his is pale yellow, barely yellow at the darkest point)
---Are the eyes always jaundiced -- his seem clear most times  
--Is there any abdominal pain --- he says he feels no pain at all.
-- Does the appetite diminish -- his intake of food and fluids (water, lime juice, tomato juice, apple juice) is good - loves his fruits, plums, bananas etc etc  and eats well (he is vegetarian).

---Any other signs we should look for.
Thanks again guys and yes he has been taken off the Sodium Valporate since mid January.

Regards!
.Theo!

[can-do-man]

"Is there anything else we should look for to see how his Hep C is progressing/leaving/left - clinically, other than the pale nail beds he shows no signs. (Im sure this is with most Hep C patients)."

At your fathers age and since hes not going to treat I wouldn't want to risk a biopsy, besides is blood work shows no signs of serious trouble as you say his platelets are normal, same with the Albumin levels, Bilirubin is ok.

Double check with his GI but he very well could need some iron pills. Sounds like your father is in pretty good shape, everything should be fine.

Best to all of you.

[jules2551]

In my comment I did NOT mean to say over dosing.  !!!

[jules2551]

SODIUM VALPROATE

Indications: all forms of epilepsy

Cautions: monitor liver function before therapy and during first 6 months especially in patients most at risk (see also below), ensure no undue potential for bleeding before starting and before surgery; renal impairment (Appendix 3); pregnancy (important see notes above and Appendix 4 (neural tube screening)); breast-feeding; systemic lupus erythematosus; false-positive urine tests for ketones; avoid sudden withdrawal; see also notes above; interactions: see Interactions, section 4.8.1 and Appendix 1 (valproate)

LIVER TOXICITY. Liver dysfunction (including fatal hepatic failure) has occurred in association with valproate (especially in children under 3 years of age and those with metabolic or degenerative disorders, organic brain disease or severe seizure disorders associated with mental retardation) usually in the first 6 months of therapy and usually involving multiple antiepileptic therapy (monotherapy preferred). Raised liver enzymes are not uncommon during valproate treatment and are usually transient but patients should be reassessed clinically and liver function (including prothrombin time) monitored until return to normal—an abnormally prolonged prothrombin time (particularly in association with other relevant abnormalities) requires discontinuation of treatment. Any concomitant use of salicylates should be stopped.

[jules2551]

Effect of sodium valproate on subcellular fraction enzymes in rat liver.

Cotariu D, Evans S, Zaidman JL.


Abstract

Previous observations that valproic acid (VPA) causes hepatic damage prompted us to investigate the effect of large doses of the drug (0.6, 1.2 and 1.8 mmol/kg/day) on a number of liver enzymes located on different subcellular fractions. In mitochondria, glutamate dehydrogenase, aspartate aminotransferase and ornithine carbamoyltransferase were significantly increased (1.8 mmol/kg/day). In microsomes, gamma-glutamyltransferase activity increased significantly (1.8 mmol/kg) and cytochrome P-450 content decreased significantly (1.2 and 1.8 mmol/kg). In cytosol, both aspartate and alanine aminotransferase activities were increased at all dose levels. These results indicate that VPA induces dose-dependent changes in some liver enzyme activities.

     ************************************************************************

I have to agree with Idyllic on the over dosing of the Sodium Valporate.  Could be the reason for the increase in ALT/AST.  Wait for the Hepa Dr to discuss taking the Iron.  Personally I would not take them unless he says otherwise.  I have Hemochromatosis and have had numerous phlebotomies to reduce my iron levels.  I would think a transfusion would be better for him IMO.

Have a great day!
Jules

[Idyllic]

Sorry no one is answering your post. There are not many folks on line today. Double sorry about your fathers fall. I hope he is OK.  Was the Sodium Valporate causing the his liver enzymes to elevate?

1. Not knowing more of the facts, it makes sense to hold off on the iron pills given the values of your father's current iron panel. I would consult and/or coordinate with his Hepatologist first.

2. What was your father's Hgb before it dropped to the 10.5?

3. I am so glad your father is being followed by a Hepatologist.   I am not sure what Hgb level would be for a man your father's age and physical condition so I cannot really speak to that.

4. I am not entirely certain I follow how you are currently following your father's HCV progress let alone other ways you could do do it. I hate to ask you to reiterate what you may have said already but what stage of Fibrosis was his last biopsy? Could he withstand a biopsy? How about an ultrasound?


I am sorry I offered little info or insight into your father's condition. Hopefully someone with more knowledge and experience than I have will come along and make sense of the liver/hepatological related aspects of your post. I am glad you are there for him and that he is being followed by a Hepatologist.