michelle b. moreno, m.d.. 1. to present a case of a young patient with hypertension 2. to discuss...
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Michelle B. Moreno, M.D.
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1. To present a case of a young patient with hypertension
2. To discuss hepatitis C, its prevalence, diagnosis, evaluation, prevention and extrahepatic manifestations
3. To present the treatment option for this case
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G.P. 29 year old male Filipino Elevated blood pressure
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4 months PTA Hypertension Imidapril + HCTZ 10/12.5
ODwith good compliance
BP persistently elevated (150/80 – 180/90)
Admission
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No headache, blurring of visionNo skin lesionsNo chest pain, palpitations, difficulty of
breathing, easy fatigabilityNo cough, colds, fever, night sweatsNo abdominal pain, dysuria(+) grade 2 bipedal edema 3 weeks ago
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No Diabetes MellitusNo Asthma(+) Allergy to IbuprofenNo previous surgery or hospitalizationNo history of blood transfusion
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(+) Hypertension – motherNo Diabetes MellitusNo AsthmaNo hepatitis
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Smoker 7 pack yearsAt present, consumes 8-10 sticks per day
Occasional alcoholic drinker1 sexual partner(+) tattoo on left leg and arm x 1 yearNo illicit drug use
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Conscious, coherent, not in respiratory distress
BP 160/110 HR 86 RR 17 T 36.9Good skin turgor, no skin lesions, Anicteric sclerae, pink palpebral
conjunctivae, no lymphadenopathy, no masses, no neck vein distention, JVP 8, no carotid bruit
Symmetrical chest expansion, no intercostal retractions, clear breath sounds
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Adynamic precordium, PMI at 5th ICS LMCL, no heaves, no thrills, normal rate, regular rhythm, distinct S1 and S2, no murmurs, no S3, no S4
Flat, normoactive bowel sounds, no bruit, soft, no tenderness, no organomegaly, no masses,
Pulses full and equal, no edema, (+) tattoo on left leg and arm
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29,M uncontrolled blood pressure Known Hypertensive BP 160/110 HR 86 (+) grade 2 bipedal edema 3 weeks ago
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Hypertension stage IIR/O Secondary causes
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Secondary Hypertension Renal artery stenosis Primary renal disease Pheochromocytoma Primary Aldosteronism Coarctation of aorta Hypothyroidism Primary Hyperparathyroidism
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BP 160/110 150/80 Clonidine (Catapres) 75 mcg SL Normal CBC, chest xray
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Urinalysis 11/14Color Yellow
Transparency Hazy
pH 6.0
Specific gravity 1.025
Sugar Negative
Protein +3Ketones Negative
Nitrites Negative
Leucocyte esterase Negative
Blood +3RBC 19WBC 4
Epithelial cells 6
Bacteria 9
Uric acid crystals moderate
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11/14Na 141K 3.3Ca 8.18Corrected Ca 10.02SGOT 40SGPT 55Alk phos 78Total bili 0.30Uric acid 7.0Total protein 5.3Albumin 1.7Cholesterol 245.87
BUN 28.99Creatinine 2.8Glucose 97.01Globulin 3.6A/G Ratio 0.47HDL 42.95Triglycerides 186.2LDL 147.41
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Proteinuria, HypoalbuminemiaHyperlipidemiaActive urinary sedimentsHistory of edema
Nephrology referralImpression: Nephrotic syndrome
Acute GN vs chronic GN R/O RPGN
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KUB ultrasound24 hour urine collectionESR, CRP, ASO, ANA, C3, HbsAg, Anti Hbs, Anti HCV, anti HIV
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• KUB Ultrasound: Bilateral renal parenchymal disease. Normal urinary bladder.
• 24 hour urine collectionUrine Creatinine: 105.4 mgs% = 1370.20
mgs/24hrsUrine protein: 740.2 mgs% = 9622.60
mgs/24hrsTotal volume 1300ml/24hrsSp.gr. 1.020
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ESR 60 CRP negative ASO less than 200 ANA negative C3 normal Anti HIV negative
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CT scan guided kidney biopsy (+) Anti HCV GI referral Ultrasound of upper abdomen
Minimal ascites. Gallbladder polyp. Normal liver, biliary tree, pancreas and spleen.
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RNA virus
WHO, the global prevalence averages 3%, 170M worldwide
6 genotypes ◦ Genotype 1: longer
duration of treatment
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Intravenous drug use / needle stick injury Blood transfusion Intranasal cocaine use Hemodialysis HCV-positive mother Sexual transmission History of tattooing and/or body
piercing
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HCV genotype
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Exposure
Acute Infection
Chronic hepatitis C(50-80%)
Spontaneous resolution(20-50%)
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Chronic hepatitis C
Cirrhosis Extrahepatic
Hepatocellular carcinoma(1-4% per
year)
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Extrahepatic
Hematologic
diseases
Diabetes Mellitus
Dermatologiccondition
Autoimmune
disordersRenal disease
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There is a strong and likely causal association between chronic hepatitis C virus (HCV) infection and glomerular disease
3 types: Mixed Cryoglobulinemia Membranoproliferative glomerulonephritis
(MPGN) Membranous nephropathy
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Discharged Pending kidney biopsy, HCV RNA, and HCV
genotype results Home meds:
Atorvastatin 20 mg daily at bedtimeAmlodipine 10 mg dailyPrednisone 10 mg 3 x day
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BP 140/90 (+) grade 2 bipedal edema Repeat SGPT: normal Creatinine 2.3 Proteinuria +3, Hematuria +3 HCV RNA: 9,737,233 IU/mL HCV genotype: genotype 1
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The presence of subepithelial electron-dense deposits and tubuloreticular structure in this biopsy with strong C1q staining in glomeruli suggests a diagnosis of lupus nephritis. Other conditions with tubuloreticular structures include viral infections (hepatitis and HIV) and alpha-interferon treatment.
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(1) Membranous Glomerulopathy, stage I(2) Acute and chronic tubulointerstitial nephritis
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29, M Hypertension Hepatitis C glomerulonephritis HCV RNA: 9,737,233 IU/mL HCV genotype: genotype 1 Normal SGPT Estimated creatinine clearance 31 ml/min
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Ribavirin anemia gout nasal congestion itchiness
Pegylated Interferon influenza like
symptoms thrombocytopenia leukopenia depression thyroiditis
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Goal: viral clearance
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Pegylation refers to the cross-linking of polyethylene glycol (PEG) molecules to the interferon molecule, which delays renal clearance.
Advantage of pegylation is that it permits less frequent dosing (once weekly versus three times a week with non-pegylated interferon)
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Nucleoside analog which has a broad spectrum of antiviral activity.
It inhibits the replication of RNA viruses in cell culture. It appears to decrease hepatitis C virus infectivity in a dose-dependent manner
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Pt M 29 GN, NS Negative
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Pt Membranous nephropathy
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Pt 1 Peginf-alfa-2b + ribavirin
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6 patients became HCV RNA PCR negative and 4 of 7 have maintained both virological and renal remission. 1 of 7 has maintained virological and partial renal
remission 1 patient did not tolerate interferon, but is in
renal remission with low dose ribavirin
Bruchfeld, A. et al. Interferon and ribavirin treatment in patients with hepatitis C-associated renal disease and renal insufficiency. Nephrol Dial Transplant (2003) 18: 1573-1580
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1 vasculitis patient responded with complete remission but relapsed virologically and had a minor vasculitic flare after 9 months
1 patient with vasculitis had low dose immunosuppresion in addition to antiviral therapy
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serum HCV RNA HCV genotype Baseline liver biochemistry, renal function,
CBC, thyroid function Psychiatric evaluation Pregnancy test
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Blood counts and aminotransferases: weeks 1, 2, and 4 and at 4- to 8-week intervals thereafter.
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At 24 weeks: aminotransferase levels and HCV RNA. If HCV RNA still present, stop therapy. In patients with genotype 1, stop therapy if HCV
RNA is still positive. Continue therapy for a total of 48 weeks if HCV RNA is negative, and retesting for HCV RNA at the end of treatment.
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strict birth control during therapy and for 6 months thereafter.
thyroid-stimulating hormone levels every 3 to 6 months
End of therapy: HCV RNA
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• aminotransferases every 2 months for 6 months.• Six months after stopping therapy, test for HCV RNA by PCR.
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Peg Intron (peginterferon alfa-2b
Pegasys(peginterferon alfa-2a)
P 730,200Rebetol (Ribavirin) 1200mg dailyP 890,050
PEG-Intron plus Rebetol
(peginterferon alfa-2b + ribavirin)
P 1,620,250
P 698,400Copegus (Ribavirin)1200 mg dailyP 510,400
Pegasys plus Copegus
(peginterferon alfa-2a + ribavirin)
P 1,208,800
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No vaccine or immune globulin products available
Screening and testing of blood, plasma, organ, tissue and semen donors
Adequate sterilization of reusable material such as surgical or dental instruments
Needle and syringe exchange programs
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Centers for Disease Control and Prevention (CDCP)◦ Ever injected illegal drugs◦ Received clotting factors made before 1987◦ Received blood/organs before July 1992◦ Were ever on chronic hemodialysis◦ Have evidence of liver disease
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National Institutes of Health (NIH)◦ multiple sexual partners◦ spouses or household contacts of HCV-infected
patients◦ those who share instruments for intranasal
cocaine use
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Hepatitis C related GlomerulonephritisHypertension stage IIDyslipidemias/p kidney biopsy
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