MR Elastography can assess whole liver while fibro scan has some limitations-Prof. Altaf Alam

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PSSLD conference proceedings-II

MR Elastography can assess whole liver while 
fibro scan has some limitations-Prof. Altaf Alam

Prescription is not everything, treating physicians must spend
some time with patients to educate them-Wasim Jafri

ISLAMABAD: Dr. Masood Siddiq along with Prof. Khalid Mahmood chaired the first scientific session during the PSSLD’s 11th annual conference held here from December 8-10, 2017. Dr. Altaf Alam from Lahore was the first speaker who talked about diagnosis of liver diseases Noninvasive vs. Liver biopsy. He pointed out that it is essential to look at prognosis, making decision on treatment besides monitoring the disease progression. We also wish to assess liver fibrosis. During the last ten years liver biopsy, he sated, has decreased because of contra indications and complications. We do not like it and the patients also do not like it. Repeated procedures and biopsy in HCV has gone down considerably. Since now safe and potent drugs are available, liver biopsy is also not needed. However, you wish to know everything about our patient and other co-morbidities, liver biopsy is still indicated.


Prof. Masood Siddiq along with Prof. Khalid Mahmood and Dr. Junaid 
chairing a session during the PSSLD conference held at Islamabad recently.

Continuing Prof. Altaf Alam said that in HBV we aim at viral suppression and not eradication because treatment cost and compliance problems and other difficulties. It is essential to start treatment in time. Biopsy is done for staging fibrosis, predicting prognosis and we usually recommend liver biopsy after three to five years. He also talked about non-invasive methods for assessment of fibrosis. Patented tests, he stated, are very expensive. MR Elastography can assess whole liver while fibro scan has some limitations. That is why it is preferred in different liver diseases. He also referred to false positive, liver stiffness/elasticity. Class-I biomarkers of fibrosis is a test not available in Pakistan. Its kits have to be imported. He was of the view that one can combine fibrosis and fibro test to get good results. Soon we will have the facility of non-invasive tests for fibrosis at our clinic, he remarked.

Prof. Javed Iqbal Farooqi from Peshawar discussed NASH progression-Basic Mechanisms and Targets. He first discussed the spectrum of NAFLD and its outcome in detail. NASH, he said is same today and tomorrow and it is going to be a problem before it leads to cirrhosis, liver metabolism and insulin resistance. How NASH starts was also discussed in detail. He mentioned high fat diet, limited exercise which leads to insulin resistance. Central obesity also leads to insulin resistance. He also briefly referred to lipo toxicity and oxidative stress, necrosis and apoptosis besides speaking about the difference between the two. He then highlighted the target of treatment drugs for each phase. At present we have many drugs and the treatment outcome is very bright though it is a complex disease, he added.

During the discussion Prof. Wasim Jafri stated that it is going to be a major epidemic. We need to lay emphasis on life style modification. Reduction in weight will be much better. He further stated that prescription is not everything, but it is the outcome which matters the most. He urged his colleagues to spend some time with patients and ask them on life style modifications. Prof. Khalid Mahmood remarked that we have not yet controlled HBV and HCV and the NASH will be the next epidemic. Diabetes mellitus, obesity, dyslipidemias are all related. It is difficult to say which patient is going to develop NASH, these patients should be followed up. Those having family history of diabetes mellitus are more likely to develop NASH, he remarked.

Dr. Mark Thursz made a presentation on NASH- Current and Emerging Therapies. He pointed out that NAFLD occurs with metabolic syndrome, it is also associated with cardiovascular diseases. Biopsy is not always necessary as non-invasive diagnosis of NASH like fibrosis markers are useful. Prognosis depends on fibrosis stage. He further stated that they use fibro scan extensively and it needs additional procedures. Speaking about therapeutic targets, he mentioned weight loss, control of metabolic syndrome, prevention of progression of fibrosis, life style modifications, reduce caloric intake and increase exercise. We hold combined clinics with diabetologists and dieticians. It is the dietician nurse which spends lot of time with the patient. He also highlighted the importance of behaviour therapy, having clear targets, positive feedback. Even 5% weight loss will help the patients tremendously. Regular exercise will improve the liver outcome. Treatment of obesity, use of appropriate supplements, slowing absorption are also helpful. Bariatric surgery is yet another treatment modality but it is very expensive and has some complications as well. Metformin, Vitamin E, insulin sensitizer, anti-fibrotic are also helpful. There are reports that metformin also reduces the liver cancer. Use of Vitamin E is associated with prostate cancer and hemorrhagic stroke that is why it not much used. He disclosed that now many Fix Dose combinations are undergoing trials and they offer lot of hope.


Prof Wasim Jafri along with Prof. Nusrutullah Chaudhry and Prof. Siddik Memon 
chairing a Session during the PSSLD conference held at Islamabad.

Dr. Mark Thursz concluded his presentation by stating that NAFLD is not a benign disease. It increases liver mortality. It requires full assessment, evaluation of fibrosis. Management must focus on weight loss, cardiovascular risk factors and drug therapy. During the discussion it was stated that not all patients will go for liver biopsy. At present we do not have good pharmacotherapy, and we do not give it either. Efficacy of some of the agents is not proven. One must identify all manifestations, ALT, ultrasound is not done by diabetologists and most of them go on treating patients with abnormal liver function tests. We need to invite diabetologists to have combined clinics. It that is not possible go to their place and discuss the patients with them. One of the participants from overseas stated that they use clinical nurse specialists as they have lot of knowledge and they can spend more time with the patient.

Dr. Zhongping Duan was the next speaker and his presentation was on Progress and prospects of the prevalence of Non-Viral Liver Diseases in China. He pointed out that globally almost 25% of deaths are related to alcohol attribute and its prevalence is between 4.3 to 6.5%. Treatment consists of abstinence and other strategies. NAFLD is an important chronic liver disease in China. He then discussed the standardized treatment, drug induced liver injuries and also stated that self-medication was quite common in China which also leads to drug related liver injuries. He concluded his presentation by stating that in China HBV vaccine is decreasing the prevalence of HBV but ALD and NAFLD are increasing. Now more and more inherited metabolic liver diseases are being diagnosed, he remarked.

The next session was chaired by Prof. Wasim Jafri along with Prof. Nusrat Ullah Chaudhry. Dr. Graham Foster was the first speaker whose presentation was on how we should manage Treatment Failures of HCV Genotype 3. He pointed out that in case of Peg and Riba failure, one should add Sofosobuvir and it will give good results. In case of SOF plus DECl and Ribavirin, continue the treatment for twelve to sixteen weeks. SOF plus VL gives 90% response rate. In case of hard to cure patients, one should extend the therapy to twenty four weeks. Patients treated earlier if treated with SOF plus VEL and VOX, the results are usually very good. He then referred to triple therapy i.e. Grazopevir plus Flbasvir plus SOF in G-3 cirrhosis. He also referred to eight weeks treatment with G/P Glacapivir plus Pebrentavir in G-3 cirrhosis. However, he hastened to add that avoiding treatment failure is the best option. We can rescue the patient. Failure takes place because they do not ensure compliance with therapy. If they do not take drugs first time, they will develop resistance.

Responding to question during the discussion Dr.Graham Foster said that relapses are always there but it is rare but 10% relapse reported from Pakistan is very high. There may be re-infection and some relapses. Prof. Zaigham Abbas remarked that taking 400mg twice a day and then adding with it Ribavirin, it is very difficult for the patient to take it. They need careful follow up and these patients must be handled by specialists not GPs.

Dr. Mario Mondelli’s presentation was on Residual problems after Hepatitis –C cure. He pointed out that HCV risks remains very high even after SVR with Peg Interferon and Ribavirin treatment. HCC risk remains high in cirrhotic. Diabetes is a risk factor for HCC after HCV cure. Scale of HCV therapy will also require surveillance. His conclusions were that clinical knowledge is of limited benefit of a SVR in DAA treated patients. Residual HCC risk persists in cirrhotic patients. These patients should be offered treatment before fibrosis occurs. During the discussion it was sated that there is another stud which showed that HCC decreased after SVR.

Dr. Rong Kuan Li from China talked about hopes for elimination of HCV. He pointed out that in 1992, the prevalence of HCV in the world was 3.3% and in China it was 3.2%. From 2004-2013 the number of HCV cases increased manifold. In 2013, the total number of new HCV cases in China were 203155. Prevalence of HCV was 52%, HBV 25%, HAV 23% and all infectious diseases accounted for 23%. In China there were ten million HCV patients. Before the DAA became available we used to treat patients with Peg Interferon and Ribavirin. Then Government provided funding and financial support for HCV patients through Health Insurance policies. Now the patient pays one fourth of the cost of treatment. Now Interferon free therapy is available to the patients. DAAs prices are now reduced in China. We use Declatasvir combined with AsumaPrevir. Drugs for HCV get immediate approval. It is planned that five hundred seventy thousand patients will be treated annually. It is very hard work to do, so far less than two hundred thousand patients have been treated. Treatment cost is very high, resources are scare but we are determined to achieve our goals with hard work, he remarked. During the discussion it was stated that HCV patients in cities have better chances of treatment as compared to those in rural areas. It was also stated that China exports cheap DAAs material all over the world, hence it should not be much difficult to reduce its prices locally.

Dr. M.Salih discussed managing HCV in post-transplant scenario. He pointed out that the goal should be cure after recent re-infection. One must use appropriate DAAs against HCV but the problem is that we have very few drugs available. After transplant, usually there is 100% response rate but one must be mindful of drug-drug interactions in these patients. Responding to a question Dr. Wasim Jafri remarked that HBV positive patients can be a donor but cirrhotic cannot be donors for liver transplant.

Prof. Masao Omata discussed Cure of HCV and HCC. He pointed out that deaths due to HCC started declining in Japan in 2004. He then gave details of his own five hundred patients which he had treated with 100% cure. Now there is no wait list with me, he remarked.