Life-threatening thrombocytopenia and nephrotic syndrome due to focal segmental glomerulosclerosis associated with pegylated interferon alpha-2b and ribavirin treatment for hepatitis C

Ruxolitinib treatment in an infant with JAK2+ polycythaemia vera-associated Budd-Chiari syndrome

Budd-Chiari syndrome (BCS) is caused by hepatic venous outflow obstruction commonly seen with myeloproliferative neoplasms (MPNs). Polycythaemia vera (PV) is a very rare MPN in childhood. This is the youngest reported patient diagnosed with PV and BCS secondary to JAK V617F mutation.A 26-month-old girl was admitted with a 5-month history of abdominal distension, hepatosplenomegaly and ascites. Imaging studies revealed occlusion of the right hepatic vein and marked attenuation of the middle and left hepatic veins. BCS was diagnosed after excluding other causes of chronic liver disease. Mandatory prothrombotic workup revealed underlying PV.Partial recanalisation of hepatic veins occurred following anticoagulation therapy and PV was well controlled by pegylated interferon and hydroxycarbamide until she developed nephrotic syndrome, likely secondary to pegylated interferon. Therefore, treatment was modified to ruxolitinib, a novel-JAK-2 inhibitor; the therapy has been effective for almost 20 months with a good response and has no side effects.

Renal impairment in patients with chronic hepatitis C treated with first generation protease inhibitors

BACKGROUND

The incidence, course and risk factors associated with renal impairment (RI) in patients treated with triple therapy (TT) with pegylated interferon, ribavirin and telaprevir/boceprevir (PR/TVR/BOC) vs. dual therapy (DT) with PR were analyzed in this study. The association between RI and the decline of hemoglobin (Hb) was also examined.

METHODS

Retrospective analysis included 110 patients with genotype 1b chronic HCV infection, aged 18 - 80 years, who underwent TT (48TVR/14BOC) or DT (48 patients). The estimated glomerular filtration rate (eGFR), serum creatinine concentration (SCr) and Hb were measured at baseline, at weeks 4, 12, 24, 48 of treatment, and post-treatment week 24.

RESULTS

RI occurred in 9/62 (14.5%) patients who underwent TT, eight of whom were treated with TVR, one with BOC, and none treated with DT. The risk factors associated with RI were the following: TT (p = 0.0078), usage of nephrotoxic drugs (p = 0.0288), and older age (p < 0.0001). RI was reversible. A drop of Hb was associated with RI, older age and TT.

CONCLUSIONS

RI is not a rare but a reversible complication of TT. It is necessary to monitor SCr and eGFR, especially in patients with a potential risk factor of RI occurrence. The Hb drop is more severe in patients with RI than in those without it.

Severe immune thrombocytopenia after peg-interferon-alpha2a, ribavirin and telaprevir treatment completion: A case report and systematic review of literature

Mild to moderate autoimmune thrombocytopenia (AITP) is a common finding in patients receiving interferon-based antiviral treatment, due to bone marrow suppression. Here we report the case of a patient with chronic genotype 1b hepatitis C virus (HCV) infection treated with pegylated-interferon alpha-2a, ribavirin and telaprevir for 24 wk; the patient developed severe AITP three weeks after treatment withdrawal. We performed a systematic literature search in order to review all published cases of AITP related to HCV antiviral treatment. To our knowledge, this is the second case of AITP observed after antiviral treatment withdrawal. In most published cases AITP occurred during treatment; in fact, among 24 cases of AITP related to interferon-based antiviral treatment, only one occurred after discontinuation. Early diagnosis of AITP is a key factor in order to achieve an early interferon discontinuation; in the era of new direct antiviral agents those patients have to be considered for interferon-free treatment regimens. Prompt prescription of immuno-suppressant treatment (i.e., corticosteroids, immunoglobulin infusion and even rituximab for unresponsive cases) leads to favourable prognosis in most of cases. Physicians using interferon-based treatments should be aware that AITP can occur both during and after treatment, specially in the new era of interferon-free antiviral treatment. Finally, in the case of suspected AITP, presence of anti-platelet antibodies should be checked not only during treatment but also after discontinuation.

Acute tubular necrosis following interferon-based therapy for hepatitis C: case study with literature review

BACKGROUND/AIMS

Interferon treatment of malignant or viral diseases can be accompanied by various side-effects including nephro-toxicity.

METHODS

We report on a 68-year-old Caucasian male who received dual therapy with pegylated interferon 2a plus ribavirin for chronic hepatitis C.

RESULTS

After three months of antiviral therapy, the patient developed acute kidney failure (serum creatinine up to 6 mg/dL) with mild proteinuria (500 mg daily) and haematuria. Immediate immunosuppressive therapy with high-dose intravenous steroids did not improve kidney function. Kidney biopsy was consistent with acute tubular necrosis without glomerular abnormalities. He started long-term peritoneal dialysis (four regular exchanges) to provide both dialysis adequacy and ascites removal. Kidney function gradually improved over the following months (serum creatinine around 2 mg/dL) and peritoneal dialysis was continued with two exchanges daily. The temporal relationship between the administration of the drug and the occurrence of nephro-toxicity, and the absence of other obvious reasons for acute tubular necrosis support a causative role for pegylated interferon; benefit on kidney disease was noted after withdrawal of antiviral agents. An extensive review of the literature on acute tubular necrosis associated with interferon-based therapy, based on in vitro data and earlier case-reports, has been made. The proposed pathogenic mechanisms are reviewed.

CONCLUSIONS

Our case emphasizes the importance of monitoring renal function during treatment of chronic hepatitis C with antiviral combination therapy as treatment may precipitate kidney damage at tubular level.

Population pharmacokinetic-pharmacodynamic modeling and simulation of platelet decrease induced by peg-interferon-alpha 2a

Peg-interferon-alpha-2a (PEG-IFN) has been used all over the world including Japan as the standard of care for chronic hepatitis C (CHC). PEG-IFN causes platelet count decrease, while CHC patients with compensated liver cirrhosis have a low baseline of platelets. To use PEG-IFN more safely in these patients, we analyzed the effect of PEG-IFN on the longitudinal platelet profile with a pharmacokinetic-pharmacodynamic model. Platelet count and serum PEG-IFN concentration obtained from a Japanese clinical study on 40 patients were analyzed. The serum PEG-IFN concentration profile was fitted with an open 1-compartment model and the platelet profile was fitted with a turnover model. After the final model was fixed, the platelet profiles were simulated with various platelet baselines. The simulation revealed that according to PEG-IFN administration platelets decreased gradually and reached steady state within 12 weeks, and almost subjects would not have a lower platelet count than the criteria for discontinuation of the treatment. Once administration was discontinued, platelets recovered up to the baseline within several weeks. In conclusion, platelet count was predicted to be about a 30% (5th-95th percentiles in 1,000 simulation: 11-66%) decrease and to return to the baseline value in 4 to 8 weeks after the last administration of PEG-IFN.

Treatment with IFN-{alpha}, -{beta}, or -{gamma} is associated with collapsing focal segmental glomerulosclerosis

BACKGROUND AND OBJECTIVES

Treatment with IFN is rarely associated with nephrotic syndrome and renal biopsy findings of minimal-change disease or FSGS.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We report 11 cases of collapsing FSGS that developed during treatment with IFN and improved after discontinuation of therapy.

RESULTS

The cohort consists of seven women and four men with a mean age of 48.2 yr. Ten of the 11 patients were black. Six patients were receiving IFN-alpha for hepatitis C virus infection (n = 5) or malignant melanoma (n = 1), three were receiving IFN-beta for multiple sclerosis, and two were treated with IFN-gamma for idiopathic pulmonary fibrosis. After a median and mean [corrected] duration of therapy of 4.0 and 12.6 months, respectively, patients presented with acute renal failure (mean creatinine 3.5 mg/dl) and nephrotic-range proteinuria (mean 24-hour urine protein 9.7 g). Renal biopsy revealed collapsing FSGS with extensive foot process effacement and many endothelial tubuloreticular inclusions. Follow-up was available for 10 patients, all of whom discontinued IFN. At a mean of 23.6 months, nine of 10 patients had improvement in renal function, including one with complete remission and two with partial remission. Among the seven patients with available data, mean proteinuria declined from 9.9 to 3.0 g/d. Four of the seven patients were treated with immunosuppression, and there was no detectable benefit.

CONCLUSIONS

Collapsing FSGS may occur after treatment with IFN-alpha, -beta, or -gamma and is typically accompanied by the ultrastructural finding of endothelial tubuloreticular inclusions. Optimal therapy includes discontinuation of IFN.

Interferon-α induced severe thrombocytopenia: A case report and review of the literature

We report a case of severe thrombocytopenia following pegylated interferon-α 2a (Peg-IFN-α 2a) treatment of hepatitis C virus infection and summarize the clinical characteristics of 16 cases of IFN-α induced severe thrombocytopenia and its immune-mediated mechanism. Discontinuation of IFN-α and early administration of immunosuppressants are the effective therapy for IFN-α induced severe thrombocytopenia.

Autoimmune thrombocytopenic purpura during pegylated interferon α treatment for chronic hepatitis C

We describe a 72-year-old woman with chronic hepatitis C and autoimmune thrombocytopenic purpura (AITP) during pegylated interferon (PEG-IFN) alpha. Immunoglobulin G and antinuclear antibody were 2,113 mg/dL and 1,280 at the start, respectively. A liver biopsy negated autoimmune hepatitis. After a 48-week combination therapy with ribavirin, PEG-IFN alpha-2a was administered. At the 30th month, the platelet count was decreased to 1.1 x 10(4)/microL. Bone marrow biopsy disclosed normocellular marrow compatible with AITP. The platelet-associated IgG (PAIgG) titer rose to 500 ng/10(7) cells. Corticosteroid therapy was successful, and the platelet count and PAIgG titer reverted to 6.4 x 10(4)/microL and 57.3 ng/10(7) cells, respectively.

Outcome of patients with primary hepatic venous obstruction treated with anticoagulants alone

BACKGROUND

Outcome of patients with hepatic venous outflow tract obstruction (HVOTO) has improved with newer treatments, including anticoagulants, radiological interventions and liver transplant. In India, however, liver transplant and radiological interventions are costly and have limited availability. Hence, patients often opt for anticoagulation alone. We followed up a group of such patients to determine the clinical outcome with such treatment.

METHODS

Consecutive patients with HVOTO, treated with oral anticoagulation and supportive medical therapy but no radiological or surgical intervention, were followed up for at least 12 months. Diagnosis of HVOTO was based on color Doppler, and either angiography or magnetic resonance venography. Warfarin dose was adjusted to maintain international normalized ratio (INR) between 2.0 and 3.0. Patients with secondary HVOTO and those with baseline INR > or = 2.0 were excluded. Response was defined as absence of ascites and/or encephalopathy, normal AST/ALT, bilirubin <1.5 mg/dL, and no portal hypertension related bleed after starting therapy.

RESULTS

Of 43 patients (mean [SD] age=28.7 [8.4] years; 20 men), 26 (61%) had a response during a median follow up of 23 (range 15-33) months. The response first appeared within 2 months of the start of treatment in 18 patients and between 2 and 5 months from the start of treatment in eight patients. Seven patients died of progressive liver failure (6 patients) or GI bleed (1 patient). Nine patients had anticoagulation-related complications. On univariate analysis, short duration of symptoms, high serum albumin, low baseline INR, and low baseline Child-Pugh's (CP) or Clichy scores predicted response. Presence of hepatic encephalopathy, portal vein thrombosis, obstruction of all hepatic veins, low albumin, high INR, high serum bilirubin, high baseline CP score, Murad score and adverse Clichy index were associated with higher mortality rate. However, on multivariate analysis, only low CP score was associated with response, and no factor was found to predict death.

CONCLUSIONS

More than half of patients with HVOTO show response with only supportive medical therapy and anticoagulants. This occurs more often in patients with low CP score. Some patients may have delayed response.

Clinical features of 27 cases with interferon alpha- induced severe thrombocytopenia

AIM: To analyze clinical features of interferon alpha-induced severe thrombocytopenia.

METHODS: Twenty six cases with interferon alpha-induced severe thrombocytopenic purpu-ra were collected from Medline and CNKI and another case from our clinical practice, and all cases were classified into two groups: immune thrombocytopenic purpura group and throm-botic thrombocytopenic purpura group accord-ing to their mechanism. Clinical manifestations, results of laboratory examinations, treatment and prognosis of different groups were observed and analyzed.

RESULTS: Twenty four cases of ITP presented hemorrhagic tendency, severe thrombocytope-nia, elevated antiplatelet antibody or platelet related IgG, megacaryocyte hyperplasia. The platelet counts increased after discontinuation of IFNα and treatment with immune suppression agents for 1 or 2 weeks and the prognosis of ITP was good. Three cases of TTP presented fever, decreased platelet count, hemolytic anemia, neu-ropsychological symptoms and renal disorder. Plasma transfusion was the main therapy with poor prognosis and high mortality. ITP and TTP usually occurred in the process of anti- HCV treatment of IFNα.

CONCLUSION: Two kinds of IFNα-induced se-vere thrombocytopenia could occur during the process of anti-virus. Physicians should recog-nize and treat them in time correctly.

Drug-induced Kidney Disease – Pathology and Current Concepts

The kidneys can be damaged by a large number of therapeutic agents. The aim of this article is to discuss the pathological features of drug-induced renal disease as diagnosed by kidney biopsy. The literature is reviewed and cases seen by the authors that have a known drug association are analysed. Mechanisms of injury are varied and all renal structures may be affected. The tubulointerstitial compartment is most frequently involved, but glomerular and vascular lesions are seen in a significant proportion of cases. Key words: Drug, Kidney, Nephrotoxicity, Pathology