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It’s a bit of a dilemma: you can’t…
Date Recorded
July 31, 2014 Health Topics (The Scope Radio)
Family Health and Wellness Transcription
Interviewer: You have a patient with kidney failure, but you can't treat the kidney failure because the individual also has Hepatitis C. What do you do? You're going to find out how a creative group of doctors solved that problem next on "The Scope."
Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You are listening to the "The Scope."
Interviewer: It was a little bit of a puzzle, wasn't it? How to treat a patient that has Hepatitis C that also has kidney failure because you cannot use the new drugs for Hepatitis C on somebody that has kidney failure. We're with Dr. Jeffery Campsen. He's a transplant surgeon here at the University of Utah. Tell me about this cool new procedure that could really change the way we think about patients with kidney failure and Hepatitis C.
Dr. Jeffery Campsen: So it's very cool and it's a plan that we developed with our transplant group, and we're just now seeing the fruits come out of it. Basically we have patients that have kidney failure, but they also have an infection with Hepatitis C. There are deceased donors that die and are also infected with Hepatitis C. And those organs can't be used into people that have never been infected with Hepatitis C, but if you are already infected with Hepatitis C, you can accept an organ, a kidney from a donor that has Hepatitis C. And that's what we did.
We looked at our patients that had both, kidney failure and infection with Hepatitis C, and asked them if they would be willing to accept an organ from a Hepatitis C donor.
Interviewer: And I understand there is actually another advantage of somebody that has Hepatitis C being able to accept an infected organ. What is that?
Dr. Jeffery Campsen: Because that allows him to get transplanted sooner. Patients on the transplant list that are on dialysis have a shorter life expectancy. And so if we can get them off of dialysis, they actually increase the amount of time that they are allowed to stay alive. So other people can't accept the Hepatitis C donor because we would infect them with C, but because he could accept, because he already had the Hepatitis, he gets a transplant much sooner which then allows him to live longer.
Interviewer: But then you still have Hepatitis C.
Dr. Jeffery Campsen: That's right. And that's the very interesting part now. So recently there are new medications that have come out that are greater than 90% successful at curing Hepatitis C. However, they're not allowed to be used in patients with kidney failure. So what we decided to do as a group was commit to our patients with kidney failure and hepatitis, and basically saying, "If you get transplanted for your kidney and cured of your kidney disease, then we're willing at the university, after the transplant, to treat your Hepatitis C and cure you of Hepatitis C."
Interviewer: So this patient had kidney failure.
Dr. Jeffery Campsen: Correct.
Interviewer: Also had Hepatitis C.
Dr. Jeffery Campsen: Correct.
Interviewer: But could not get treated for that because of the kidney failure, could not use these brand drugs that have been developed over the past year until his kidney was healthy.
Dr. Jeffery Campsen: That's exactly right.
Interviewer: So we put the new kidney in. He has a healthy kidney. Now you can treat for the hepatitis. It's like a step by step thing.
Dr. Jeffery Campsen: That's exactly right. So we have a multidisciplinary team that looks at the entire health of the patient. And while his kidney disease was his main problem and that needed to be cured, we also have to make sure that after the transplant he lives a long time and protects that kidney. So if he has hepatitis, we also have to treat that.
So six months ago this man was on dialysis with renal failure and active Hepatitis C infection. Six months from now he is off of dialysis with a functioning kidney, cured of his renal failure, and cured of his Hepatitis C infection which will then allow him to live a long life with good quality.
Interviewer: That's amazing.
Dr. Jeffery Campsen: It's very cool and it's just something that with modern medicine that we've been able to put all of these techniques together into a care plan that our patients can benefit from.
Interviewer: Every time something new is invented after it's been invented or the procedure has been concepted, it's like, "Wow! Why didn't we think of this earlier?" Was this one of those deals or was this one of the deals where it was just very obvious that this would be the steps you would take?
Dr. Jeffery Campsen: No, it was something that when it all clicked together it was one of those ah-ha moments. And I think it was a group of transplant professionals sitting around during our selection committee saying, "You know what? I can treat his hepatitis if you guys cure him of his kidney disease." And then someone else says, "Well, he already has Hepatitis C. Can he get a Hepatitis C organ?" So there is a variety of input from multiple different disciplines that all come together and then allow for this very complicated medical plan to be conceived, and then pursued, and then be successful for the patient.
Interviewer: This individual now is going to have a quality of life that would have been unheard of even a couple of years ago.
Dr. Jeffery Campsen: Absolutely. We couldn't have done this a couple years ago and we could have done his transplants, we could have treated him for hepatitis, but the old medications had tons of side-effects and weren't very effective. And so now we took a variety of treatments and put them together with a variety of different physician groups, and allowed him to basically be cured of kidney failure, and cured of Hepatitis C infection allowing him to live a long life.
Announcer: We're your daily dose of science, conversation, medicine. This is "The Scope", University of Utah Health Sciences Radio.
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A combination of Hepatitis C and liver disease…
Date Recorded
July 08, 2014 Transcription
Dr. Campsen: There's a new treatment available for hepatitis C without the horrible side effects, and we are preventing the recurrence of hepatitis C and the need for retransplantation of the liver due to reinfection. I'm Dr. Jeffrey Campsen. I'm a liver transplant surgeon at the University of Utah, and that's next on The Scope.
Announcer: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Dr. Campsen: I'm here with . . .
Dr. Gallegos-Orozco: Dr. Juan Gallegos-Orozco. I'm an Assistant Professor of Medicine at the University of Utah School of Medicine, and I'm part of the liver transplant team.
Dr. Campsen: Juan, thanks for joining us today. The study that we're talking about today is a study that we're involved with for our patients that are receiving liver transplant for hepatitis C. What's exciting about it was that it's never been available, especially in the state of Utah, and its available now to our patients as a trial. The way that the trial is set up is that these patients are listed for liver transplant because of their cirrhosis, but they also have a Hepatitis C infection. They also probably have had a cellular cancer on top of it. They are then treated with the antivirals that you described, and hopefully the hepatitis C virus is cleared down to an undetectable level. At time of transplant, they receive their liver transplant and are given an immunoglobulin called Civacir that then continues after transplant. Hopefully, in combination of the antivirals before transplant, the liver transplant, and then the immunoglobulin after transplant will keep them from ever having hepatitis C again.
Dr. Gallegos-Orozco: Yes. This strategy is very exciting because following the footsteps of the hepatitis B immunoglobulin, which are antibodies against hepatitis B and was a big step forward in transplanting patients with hepatitis B, which is another kind of viral infection that can also cause chronic hepatitis, cirrhosis, and liver cancer. In hepatitis C, we're following this strategy, and our goal is to prevent the reinfection of the new or healthy liver that's being transplanted. The way we achieve that, like you mentioned, is not only with treatment before the transplant, but also with this immunoglobulin or antibodies against hepatitis C in an effort to neutralize any residual virus and, hence, preventing the reinfection of the transplanted liver. We hope that this strategy, in combination with the antiviral therapies, will ultimately lead us to prevent infection of hepatitis C, which, as you know, is a big problem in transplantation.
Dr. Campsen: It's a huge problem. So if you get a liver transplant and then the Hepatitis C comes back, it's basically a brand new infection in the liver transplant. It can really blossom to the point to where those patients won't survive the year after the liver transplant because the virus is so aggressive in how it comes back, which is demoralizing and tragic to everybody involved.
Dr. Gallegos-Orozco: I agree.
Dr. Campsen: Let's talk about this study. We started this study this past year, and we enrolled our first patient in the study. Can you tell us a little bit about him?
Dr. Gallegos-Orozco: Yes. This gentleman that we enrolled was a patient with chronic hepatitis C. He had developed cirrhosis and complications of his cirrhosis, and one of those complications was liver cancer. The patient was listed for liver transplant, and we followed him very closely during his course. We treated his liver cancer successfully, but he still required a liver transplantation. We knew that he had hepatitis C. He had the genotype one, which is one of the most difficult genotypes of hepatitis C to treat, and we were fortunate enough that we were able to get him through treatment with these new antivirals that did not require any interference. Just the combination of two pills that he took everyday for several weeks were good enough to decrease the amount of virus in his blood to basically undetectable levels.
At that time, a liver became available, and he was transplanted successfully with this healthy liver. Because of his participation in the trial, he also received this hepatitis C immunoglobulin or antibodies against hepatitis C, and he's completed the first six weeks of this treatment after transplant. So far, there's been no evidence of recurrence of hepatitis C in his blood, and his liver graft is doing very well.
Dr. Campsen: How exciting is that? Basically, what we did was we cured the hepatitis C if you can use that word. It's a strong word, but that's what I believe. We also cured him of his liver cancer, which is something that you probably couldn't have done a year ago.
Dr. Gallegos-Orozco: Correct. I agree, and I think that's a very exciting time, not only in the treatment of the hepatitis C overall, but certainly in the treatment of hepatitis C in our liver transplant patients.
Dr. Campsen: As with any medical procedure, there are concerns as to the safety of the procedure. Liver transplant in and of itself is a high-risk procedure. At the University of Utah, we have excellent outcomes, and our patients have done very well. However, when you add other new medications on top, there's a concern. Specifically for the Civacir trial, the hepatitis C immunoglobulin trial that we're speaking about today, I feel that it is a very low-risk procedure. How do you feel about it?
Dr. Gallegos-Orozco: I agree. So far, the evidence of the side effects from this clinical trial that we're participating in have shown that this procedure is safe and very well tolerated. It basically requires the patients that are participating to receive this immunoglobulin after an IV infusion, and they do that for several times during their first few weeks after liver transplant. So far, they've tolerated the procedure well. It hasn't been associated with any significant adverse events, and we feel that it's similar to the hepatitis B immunoglobulin and other types of antibodies that are used in medicine that overall it's a safe procedure. Of course, in the setting of the clinical trial, we're very vigilant about side effects, and we monitor our patients very, very closely.
Dr. Campsen: We're one of the centers that are involved in this trial. I think there's about 20 centers across the United States that are involved in the trial, and they're seeing very similar results to ours. Which are one, the safety profile of the drugs seems to be excellent, and then, two, the efficacy, meaning does it actually work, also seems to be very good. There are different arms of the study, but the study arms where the patients are actually getting the drug that we're talking about, no one's had a recurrence of the virus, which, I think, is an excellent result.
Dr. Gallegos-Orozco: I agree, and definitely, that's what we're wishing for with this, hepatitis C antibodies to prevent reinfection of the liver. So far, that's what the trial has shown.
Dr. Campsen: But with any study, it's the long-term follow-up that really makes the difference. So today we're talking about the early success of this, how excited we are to do something that we've never been able to do before, but, again, we're going to monitor it at a university setting along with our other universities that are involved and see if it truly is a therapy that will be used long-term.
Announcer: We're your daily dose of science, conversation, medicine. This is The Scope, the University of Utah Health Sciences Radio.
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Hepatitis C can be present in your system and…
Date Recorded
June 10, 2014 Health Topics (The Scope Radio)
Family Health and Wellness Transcription
Dr. Tom Miller: You're a Baby Boomer, and you should be screened for hepatitis C. That's coming up next on Scope Radio. This is Dr. Tom Miller.
Man: Medical news and research from the University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Dr. Tom Miller: Hi. I'm here with Dr. Juan Gallegos today, and he is a member of the Division of Gastroenterology, a specialist in liver diseases, and he is going to talk to us today about the recommendation for screening in Baby Boomers for the virus hepatitis C. Morning, Juan.
Dr. Juan Gallegos: Good morning, Tom. Thanks for the invitation.
Dr. Tom Miller: Should people be screened for hepatitis C? And, if so, why?
Dr. Juan Gallegos: The Centers for Disease Control in the United States came up with a broad recommendation in 2013, or last year, that states that people that were born between 1945 and 1965, that is, the Baby Boomer era persons, be screened at least once in their life for the hepatitis C virus. The reason behind that is that we know that the hepatitis C virus is a significant health problem in the United States. It is estimated that there's about 5 million people infected in the United States with hepatitis C.
Dr. Tom Miller: Most of them Baby Boomers?
Dr. Juan Gallegos: Most of them are Baby Boomers, and, unfortunately, most of them don't even know about the infection.
Dr. Tom Miller: Why is that?
Dr. Juan Gallegos: The fact is that the infection does not cause any specific symptoms, and it takes many years after acquiring the infection before there's any liver disease issues.
Dr. Tom Miller: So this is a little bit unlike hepatitis A where when you develop hepatitis A, you have the whole jaundice, yellow skin, feel terrible. Many times, I guess you're saying, when you have hepatitis C, you're infected, and you don't know it.
Dr. Juan Gallegos: That is true. You don't really know at the time of infection that you acquired this infection, and it's only when you start developing symptoms of liver disease that you come to your doctor, and then we uncover that fact that you've had hepatitis C probably for many years or decades.
Dr. Tom Miller: Unlike hepatitis A where you become very sick, you then clear the virus and you're done with it, hepatitis C is just kind of silently working away on the liver to destroy it. Is that right?
Dr. Juan Gallegos: That is correct. Most patients that get infected with hepatitis C will go onto develop chronic infection of their liver, and that's why we call this chronic hepatitis. And, ultimately, a percentage of them will go onto develop liver cirrhosis and even liver cancer. Hepatitis C is currently the main cause of liver cirrhosis and the need for liver transplants in the United States, and it's also the main cause for liver cancer in the United States.
Over the last 10 to 15 years, the number of cases of liver cancer has increased significantly in the country, and also of note is that over the last 5 years or so, the number of deaths attributed to hepatitis C and cirrhosis have overcome the number of deaths attributed to HIV or AIDS.
Dr. Tom Miller: That's a big deal. How does one become infected with this virus?
Dr. Juan Gallegos: Generally, the infection is transmitted through blood or contaminated blood. So, generally, people that have had blood transfusions or organ transplants prior to the 1990's, and that's when we started testing for this virus and screening for it, or people that have had a history of intravenous drug use. Even once, many, many years ago, that can be the sole source of infection.
Dr. Tom Miller: What about other causes of infection? Intercourse, multiple partners, brushing your teeth, even?
Dr. Juan Gallegos: For example, high-risk sexual behaviors have been attributed as a cause of infection or sharing other contaminated things in your homes like toothbrush or razor blades. But that is much less common than blood transfusions or intravenous drug use.
Dr. Tom Miller: But the bottom line from the CDC is get screened. So if that's the recommendation from the CDC, how does the screening take place, and where does one go to get the screening?
Dr. Juan Gallegos: The screening should be for everybody born between 1945 and 1965 regardless of any of the risk factors that we discussed because we know that a lot of patients with hepatitis C don't have any of these risk factors. Nonetheless, they do have the infection.
The way to be screened is basically to ask your doctor if you could be screened, and it's a simple blood test where we check for antibodies or chemicals that your body makes to defend yourself. If they're positive, that means that in the past, you've been exposed to the hepatitis C virus.
Now, that doesn't necessarily mean that, that person has hepatitis C at this time. But we do another confirmatory test to see if there's any hepatitis C virus in the blood at this time.
Dr. Tom Miller: I've had patients who I mentioned that they should be screened for hepatitis C in accordance with the CDC guidelines and they've said, "Look, doc, I live a clean life. I don't have any risk factors. I don't really need to be tested." What do you think about that?
Dr. Juan Gallegos: 75 percent of all patients infected with hepatitis C in the United States were born in the Baby Boomer era, and many of them did not have any of the typical risk factors that we associate. So what I tell my patients or what I would say to your patient is, "You know, regardless of the fact that you've lived a very clean life and very good for that, but you should be tested because we might find out that you do have hepatitis C regardless of the absence of any risk factors in the past."
Dr. Tom Miller: And if you have hepatitis C, there is now effective treatment for that?
Dr. Juan Gallegos: Yes, that's the most important part of it. It's that we can now change the natural course of the hepatitis C virus infection with very effective therapies.
Dr. Tom Miller: Preventing liver failure and the need for a liver transplant.
Dr. Juan Gallegos: Yes.
Dr. Tom Miller: That sounds like a great idea. Thank you very much.
Man: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.
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Without treatment, Hepatitis C can lead to liver…
Date Recorded
March 25, 2014 Health Topics (The Scope Radio)
Family Health and Wellness Transcription
Announcer: Medical news and research from University Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.
Kim: Hepatitis C virus is a liver disease that has become the forefront of health care attention and resources. The CDC has mandated that patients or baby boomers who were born from 1945-1965 should all get a single hepatitis C virus test because the preponderance of hepatitis C in that population of the United States is upwards of eight-fold or ten-fold larger just by virtue of the fact that those baby boomers were subjected to behaviors that were high risk. This mandate was brought up by the CDC in April this year. Our primary care providers are supposed to enact that mandate by testing our baby boomers once. And so this is a good time to talk about hepatitis C.
In addition, hepatitis C is a disease which research is developing huge gains in terms of managing in and so over the next few months we will see two new drugs, anti-viral drugs specifically designed to treat hepatitis C, and this is a huge difference in terms of hep C strategies that we didn't have.
Interviewer: So is it a lifestyle disease 100%? Meaning it was behaviors that caused it, meaning like needles and drug use. How does it get transferred, first of all? It transferred by a blood.
Kim: Yeah, the hepatitis C is a bloodborne pathogen. It's a virus, and once it resides, it gets access to your blood with a certain concentration and it will preferentially reside in the liver. And so hence the hepatitis portion of the virus name.
Interviewer: So hepatitis C, what are the symptoms? If I have hepatitis C am I going to notice anything?
Kim: The symptoms of hepatitis C upon first contraction may be general feelings of illness, almost like viral-type, flu-type symptoms. People do describe an upper abdominal pain on the right side, and that's likely due to the swelling that occurs when the hepatitis infects the liver. These are not necessarily common but these are things that would make you aware that something is going on. I think most people who, unless they were attune to the fact that they may have been exposed to blood, they wouldn't think too much of those types of symptoms.
Interviewer: All right. So the whole message here, there again, as a health care provider you're trying just to let people know, "You need to have this test." Is that accurate?
Kim: Absolutely. Knowing about this condition is the best way to treat it.
Interviewer: Is time of the essence in detecting hepatitis C?
Kim: Time is always important in any chronic diseases, and certainly chronic liver disease is another disease that would benefit from early detection because there are ways to decrease the end effects of hepatitis C in particular.
Interviewer: And one of the reasons somebody should be concerned about this is because-very startling statistic-85% of primary liver cancer is due to end-stage liver disease which could be caused by something like hepatitis C.
Kim: Cancer in general is a process where injury to tissues-and the liver is simply a tissue-results in the body creating unregulated growth in tumors. So hepatocellular cancer and also to a smaller degree bile duct cancer are cancers that are developed specifically in the liver in the setting of injury or cirrhosis.
If you were to contract hepatitis C on day zero about ten to fifteen years from then you will, unless you're treated, you will develop scarring of the liver or cirrhosis. From there on, we know that 85% of people over the course of 12 years will develop cancer in the liver. If detected early there are many therapies available to patients. However, if detected late, your options are far less.
Interviewer: Any final thoughts?
Kim: I think the end goal for centers like ours is to manage organ disease at all of its spectrum. So if we can in any way contribute to the early management or detection of liver disease then we're doing a service to the community. What we would like to try to avoid is folks who may be able to avoid the more rigorous and intense treatments of advanced organ failure such as cirrhosis, such as liver failure, because those are much more costly both socially to the patient and also financially to the community. If we can avoid that point that would be the ultimate goal.
Interviewer: So the old adage, an ounce of prevention is worth a pound of cure.
Kim: Absolutely.
Interviewer: Really does apply.
Announcer: We're your daily dose of science. Conversation. Medicine. This is The Scope. University of Utah Health Sciences Radio.
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