Management of Tacrolimus-Induced Toxicity With Normal Serum Levels After Liver Transplant.

Drug-induced liver injury after liver transplant occurs in 1.7% of patients. Tacrolimus is an effective immunosuppressant that is used to treat acute rejection. Although rare, it can cause toxicity, which is demonstrated by cholestatic liver injury. Here, we present a case of a young male patient who was diagnosed with Wilson disease, had penicillaminechelating therapy, and underwent living related liver transplant. Within 1 month posttransplant, he developed deranged, predominantly cholestatic pattern liver function tests. Laboratory parameters showed total bilirubin of 1.12 mg/ dL, alanine aminotransferase of 553 IU/L, gammaglutamyltransferase of 624 IU/L, and tacrolimus level of 10.2 ng/mL. After thorough evaluation, a liver biopsy was performed. Liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. However, with normal level of tacrolimus, the biopsy was suggestive of drug-induced liver injury. Thus, tacrolimus dose was reduced, resulting in improved liver function tests and patient discharge from the hospital. Tacrolimus is an effective immunosuppressant after liver transplant and has the ability to treat early acute rejection. The patient's liver biopsy showed hepatocellular necrosis with centrilobular cholestasis without any evidence of graft rejection. Cholestatic liver injury after tacrolimus usually resolves after dose reduction or by switching to another agent. With demonstrated tacrolimus-induced toxicity in liver transplant recipients, despite normal serum levels, transplant physicians should keep high index of suspicion regarding toxicity in the posttransplant setting.

Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease.

Aim: Wilson's disease (WD) is a rare autosomal recessive disease, that can involve any organ of the body, the main ones being the liver and the brain. These patients can have varied presentations, ranging from having no symptoms to having neurological manifestations to features of chronic liver disease (CLD). Those patients that end up having CLD are prognosticated via the Child-Turcotte-Pugh (CTP) score and the Model for End-stage Liver Disease (MELD) score. However, two specific scores exist for prognostication in patients having WD, namely, the Nazar score and the Dhawan score. However, these are yet to be validated nor has their use been implemented in clinical practice. Materials and methods: Our study involved 65 patients with WD, comprising both the pediatric and the adult population. We aimed at evaluating the clinical manifestations the lab parameters and the management of these patients. Furthermore, we tried validating the Nazar and the Dhawan score and later compared them with the CTP and the MELD score, which are well-known prognostic tools in CLD. Results: Our patients were subdivided into the pediatric (more than 50%) and the adult group. The most common presenting complaint noted in both groups was abdominal distension. Values of the urine copper and serum ceruloplasmin did not defer between the pediatric and adult patients. Hepatic involvement is frequently seen in the pediatric age-group. Also, CTP class C was chiefly seen in pediatrics 17/33 (51.5%), while CTP class B was in adults 13/32 (40.6%). The mean Nazar score was 3 ± 3, while the mean Dhawan score was 5 ± 4. The main treatment offered for both groups was zinc along with penicillamine. Conclusion: Our study showed the Dhawan score was comparable to the CTP and the MELD score in terms of predicting the disease severity of WD in our patient population. How to cite this article: Majid Z, Abrar G, Laeeq SM, et al. Clinical Characteristics and Comparison of Different Prognostic Scores in Wilson's Disease. Euroasian J Hepato-Gastroenterol 2022;12(2):69-72.

The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan.

Variceal hemorrhage is a serious consequence of patients having chronic liver disease (CLD). Various scores exist that predict the outcome for non-variceal bleed. However, only a few scores evaluate patients with variceal bleed. We, in our study, evaluated 48 cirrhotics who presented with variceal gastrointestinal (GI) bleed over a period of 3 months. Majority of these were males and the most common etiology was hepatitis C infection. The main presenting complaints were hematemesis seen in 39.6% followed by hematemesis and melena in 31.25%. Most bleeding episodes were secured via banding in 62.5% followed by injection of histoacryl in 12.5%. Finally, Child-Turcotte-Pugh (CTP), model for end-stage liver disease (MELD), albumin-to-bilirubin (ALBI), and the ABC score were applied and none correlated with the presence of esophageal varices. However, the ALBI score did correlate with the presence of tachycardia in our study, a pertinent sign of upper GI bleed. How to cite this article: Majid Z, Khan SA, Akbar N, et al. The Use of Albumin-to-bilirubin Score in Predicting Variceal Bleed: A Pilot Study from Pakistan. Euroasian J Hepato-Gastroenterol 2022;12(2):77-80.

Non alcoholic fatty liver disease in a young male with celiac disease.

A young emaciated male, known case of celiac disease came with complaints of diarrhea along with 5kgs of weight loss in 3 months' time. He had severe electrolyte abnormalities along with low albumin, low calcium and a high phosphate with deranged liver function test. Ultrasound abdomen had shown fatty liver. Nutrition consult was sought and he was found to have a BMI of 6.8kg/m2. He was started on nutrition support along with supportive therapy, which resulted in weight gain and improvement in his condition.

Intestinal Spirocheteosis in a Patient with Celiac Disease.

A young girl presented to us with recurrent diarrhea along with a history of 5 kg weight loss in one year. On examination, she appeared pale, while her laboratory reports showed a low hemoglobin, mean corpuscular volume (MCV) and serum albumin. Her erythrocyte sedimentation rate (ESR) was slightly raised with her iron profile suggestive of iron deficiency anemia. Viral markers, human immunodeficiency virus (HIV) serology along with thyroid profile were all unremarkable. There was no history of tuberculosis, and purified protein derivative (PPD) skin test was also negative. Computed tomography (CT) abdomen showed thickening of the terminal ileum with multiple enlarged lymph nodes. An esophagogastroduodenoscopy (EGD) along with colonoscopy was done. Multiple biopsies were taken, which were suggestive of sprue along with intestinal spirochetosis. Her tissue transglutaminase (TTG) was negative while deamidated gliadin peptide (DGP) was positive. She was kept on gluten-free diet and started on tablet metronidazole. This case shows that intestinal spirochetosis should be kept in mind in patients belonging to lower socio-economic status, who present with chronic diarrhea symptoms.

Design & thermal modeling of solar panel module with embedded reconfigurable Air-Coil for micro-satellites.

Spacecrafts need to maneuver their solar panels towards the sun and antennas towards the ground station for maximum solar power harvesting and communication with the ground station. For tracking purpose, usually magnetorquer rods, reaction wheels and permanent magnets are used, but they are heavier, expensive, and occupy extra space on the spacecraft. Keeping in mind the dimension, budget and mass constraints of small satellites, a system compatible with small satellite is worth consideration. Consequently, this paper focuses on designing and analyzing a solar panel module with embedded Air-Coil. Such an Air-Coil is an innovative idea for the replacement of heavier, bulky and expensive attitude control systems. The proposed Air-Coil is integrated in the internal layers of an eight layers solar panel PCB module. Complete degradation analyses of the solar panel have been done to ensure that it will meet the satellite power requirements at BOL (beginning of life) and EOL (end of life). The proposed embedded Air-Coil has been analyzed for the generated magnetic moment, resultant torque, power consumption and temperature increase of the complete solar panel unit. A steady state thermal model is proposed to measure the thermal resistance between top and bottom layers of the solar panel module, which gives an idea about the heat trapped inside the solar panel module. The designed embedded Air-Coil is fully reconfigurable where coil in each layer can be operated as a separate coil. The four coils in different layers can be attached or detached through switches in different configurations i.e. single coil, four in series, four in parallel, and their hybrid combinations. The analyses of power consumption, heat dissipation, temperature rise, magnetic moment and torque generation by different configurations of the designed Air-Coil have been performed. The generated magnetic moment is very high i.e. around 12Am2, which is enough to rotate a microsatellite by 90° in 200s. The efficacy of the proposed module is significantly higher than the already available systems with respect to mass, price, power dissipation, heat generation, and dimension.

Efficacy Of Intravenous Lignocain Vs Sevoflurane In Prevention Of Coughing And Desaturation At Extubation In Children.

BACKGROUND: Inadvertent coughing and desaturation are the most commonly faced and feared respiratory complications in post-anaesthesia period. The study was done to compare the efficacy of intravenous lignocaine versus sevoflurane in prevention of coughing and desaturation at extubation in children less than 6 years of age. METHODS: This Randomized Control Trial was carried out from May 2013 to May 2016, at Combined Military Hospital Nowshera after obtaining approval from the hospital ethics committee (IREC-0003/5/13/Aneas). Children aged three months to six years undergoing surgical procedures requiring the placement of definitive airway were randomly assigned into two groups. Patients were anaesthetized by standardized balanced anaesthesia technique. In Group A (n=355), three minutes prior to extubation lignocaine 2% was used intravenously. In Group B (n=355), isoflurane was switched off, breathing circuit changed and sevoflurane started at minimum alveolar concentration (MAC 3-4%) for 3 minutes prior to extubation. Assessment for extubation was clinical. Oxygen saturation and severity of coughing were noted for 5 consecutive minutes, after extubation. RESULTS: In group-A, 156 patients were less than 2 years of age while in group-B, 135 patients were less than 2 years old. In group-A, 199 and in group-B, 220 children were 2-6 years of age respectively. Post stratification the p-value for weight was 0.17 (p-value >0.05) and t-statistic was 1.36. Post stratification p-value for gender was 0.12 (p-value>0.05) and chi square statistic was 2.49. Group A had more eventful extubation with 270 cases of cough (76%) as compared to group-B where it was noted in 199 cases (56%). Similarly, desaturation was observed in 85 cases in group-A (24%) as compared to 28 cases (8%) in group-B. The difference between the groups was statistically significant. CONCLUSIONS: Sevoflurane based anaesthetic vapours mixture causes statistical significant prevention from events like coughing episodes and desaturation in post-extubation in children less than six years of age undergoing elective surgery.

Hepatic Sarcodosis presenting as portal hypertension in a young boy.

A 13-year-old boy, known case renal stone disease came with the complaints of abdominal pain along with low grade fever. On examination, hepatosplenomegaly was noted while his lab reports showed a low hemoglobulin with a raised ESR. His blood and urine cultures showed no growth. Viral markers, autoimmune profile, C and p ANCA were all negative apart from a raised serum IgG level. Ultrasound abdomen showed a hyperechoic liver with an enlarged spleen along with splenic varices and minimum ascites. Ultrasound hepatic doppler was normal. Serum AFP levels were normal while workup for Wilson's disease was negative. Fibroscan showed F4 fibosis. CT scan abdomen showed an enlarged left lobe of the liver along with an enlarged spleen. His EGD revealed varices. So liver biopsy was done that was suggestive of chronic granulomatous disease with ZN stain testing negative for TB.PPD, urine for AFB were both negative. Serum ACE levels were raised. He started ATT therapy but his condition did not improve. So, on the suspicion of hepatic sarcoidosis, he started on steroids and had a drastic improvement in his condition.