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Safety and efficacy of direct-acting antiviral drugs in the treatment of chronic hepatitis C virus infection in patients with thalassemia: a prospective study

Egyptian Liver Journal volume 11, Article number: 54 (2021) Cite this article

Abstract

Background

Hepatitis C virus (HCV) infection is a major cause of liver-related morbidity and mortality among thalassemic patients. Direct-acting antiviral agents (DAAs) are highly effective and well-tolerated by chronic HCV patients.

Results

The mean age of our patients was 29 years. Sustained virologic response (SVR) at 12 and 24 weeks was achieved in all patients (100%). The most common side effects were fatigue (18%), anemia (13.63%), and headache (4.5%). There was no statistically significant difference in the hemoglobin level before and after treatment (p = 0.48). There was a significant improvement in serum bilirubin and mean ALT levels after treatment compared to baseline data (p < 0.0005 each).

Conclusions

DAAs, namely, sofosbuvir plus daclatasvir or sofosbuvir plus ledipasvir, are effective and well-tolerated regimens in thalassemic patients with chronic HCV.

Background

Viral hepatitis, mainly the hepatitis C virus, is one of the common causes of post-transfusion hepatitis (PTH) in patients who need multiple blood transfusions [1]. Thalassemia is a hereditary disorder characterized by the synthesis of abnormal hemoglobin (genetic deficiency in the synthesis of beta-globin chains), resulting in hemolysis and anemia. Patients with β thalassemia major (BTM) usually require repeated blood transfusion, which keeps them at high-risk of HCV infection [2]. In spite of improvements in the screening of blood products in the last decades to minimize the risk of transmission of blood-borne diseases, viral hepatitis, especially HCV, remains an important problem in patients with β thalassemia [3, 4]. Post-transfusion HCV infection leads to chronic hepatitis with hepatocellular necrosis, fibrosis, and cirrhosis in patients with thalassemia with higher morbidity and mortality [5].

Chronic HCV infection (CHC) treatment in β thalassemia patients was challenging in the interferon (IFN)-based therapy era not only because of its modest efficacy [6,7,8,9,10] but also due to unfavorable safety and tolerability profiles, as it was necessary to be combined with ribavirin (RBV) considering subsequent hemolysis and increased need for blood transfusions, and, thereby, increased risk of iron overload [11].

With the introduction of the new IFN plus RBV free regimens in 2014, the management of all patients with chronic HCV infection, including those with β thalassemia, has dramatically improved. These drugs are direct-acting antivirals (DAAs) that act by targeting specific steps in the HCV life cycle and are used in combinations to treat CHC. In Egypt, depending on the genotype and the drug availability, the available DAAs combinations are the co-formulation of sofosbuvir (SOF) with ledipasvir (LDV) (one tablet of 400/90 mg once daily) and SOF plus daclatasvir (DCV) (in two tablets of 400/60 mg/day once daily). They are nucleotide analog NS5B polymerase inhibitor/NS5A inhibitor. According to guidelines, β thalassemia patients should be treated with IFN- and RBV-free regimens [12].

Different DAAs regimens have been reported to be safe and effective in the treatment of CHC patients in clinical practice [12]. Our thalassemia patients were followed up in a hematology clinic at Oncology Center, Mansoura University (OCMU). Such patients who are also infected with HCV could be a target population for “HCV micro-elimination” on the road toward global HCV elimination in our country.

Methods

Patients

This is a prospective study that included 88 treatment naïve patients with chronic HCV genotype 4 infection and beta-thalassemia major from attendees of Hematology Clinic at Oncology Center, Mansoura University, from January to December 2017. All included patients were transfusion-dependent and were using iron chelation therapy. Only four patients had concomitant hepatitis B virus (HBV) coinfection.

Inclusion criteria for DAAs

Patients of both genders included for DAAs therapy in the current study were diagnosed with Thalassemia major and were on regular transfusion and iron chelation therapy, aged 12 years and above, naïve chronic hepatitis C genotype 4 infection with detectable HCV-RNA by RT-PCR. No additional drugs were used.

Exclusion criteria

Patients were excluded from the study if they were infected with other HCV genotypes, had concomitant HIV infection, or had presence of liver cell failure.

Diagnosis of HCV and genotyping

Chronic HCV infection was diagnosed by positive RT-PCR RNA HCV with or without abnormal liver function tests and the presence of stigmata of chronic liver disease (flapping tremors, ascites, edema lower limb, and hepatic encephalopathy). HCV RNA was quantified by real-time PCR assay (COBAS AmpliPrep/COBAS TaqMan 48, Roche Molecular Diagnostics). The HCV genotype was detected by Versant HCV genotype 2.0 assays (LiPA-Siemens, Erlangen, Germany).

Laboratory assessment

The laboratory tests done included complete blood counts, liver enzymes (ALT, AST), serum bilirubin, serum creatinine, α fetoprotein, and INR. The liver fibrosis stage was assessed by a non-invasive tool known as the FIB-4 score [13].

Treatment protocols

At the Virology unit, Specialized Medical Hospital, Mansoura University, Egypt, all patients were evaluated for anti-HCV treatment. Two DAA regimens were used according to the guidelines of the National Committee for Control of Viral Hepatitis (NCCVH) in Egypt. We treated the patients with the following combinations: SOF(400 mg daily) plus DCV(60 mg daily) for the older age group and LDV(90 mg daily)-SOF in the younger age group (12–18 years) for 12 weeks. Only four patients were coinfected with HBV (diagnosed by the presence of detectable HBV DNA by PCR and all of them were HBeAg positive) and treated using LDV/SOF and lamivudine.

Endpoints of the treatment

The primary endpoint was assessed by the achievement of SVR at 12 weeks and at 24 weeks. The secondary endpoint was assessed by the recording of adverse events, increased transfusion requirements, or stoppage of treatment. All patients were on regular transfusion, and the median packed red blood cell units transfused was a unit per 21 days.

Patients’ follow up

Clinical and laboratory data were recorded at baseline and at 4, 8, 12, and 24 weeks of therapy.

Statistical analysis

Data were entered and statistically analyzed using the Statistical Package for Social Sciences (SPSS) version 17. Quantitative data were described as means (standard deviations) or medians (interquartile ranges), as appropriate. Comparisons between the different groups were performed using the Wilcoxon rank-sum test for variables that were not normally distributed. Qualitative data were presented as numbers and percentages and compared by using the chi-square test. A P value of less than 0.05 was considered statistically significant.

Results

Demographic and clinicolaboratory data

Table 1 shows the demographic, baseline clinical, and laboratory parameters for a total of 88 thalassemic patients with chronic HCV. The median age of our patients was 29 years and males represented 50% of our study participants. Hypertension was found in 13.63% of cases, osteoporosis in 13.63% of cases, and HBV in four cases. All patients were splenectomized. The median hemoglobin level, platelet count, and white blood cell counts were 8.25 gm/dl, 543 × 109/L, and 27.3 × 109/L respectively. The median AST, ALT, and serum bilirubin levels were 71.5 IU/L, 54,45 IU/L, and 2.9 mg/dl respectively. Serum ferritin levels were elevated with a median level of 2500 ng/ml. The median PCR for HCV RNA was 941757 IU/ml, with a median FIB-4 score of 0.52.

Table 1 Demographic, basal clinical and laboratory parameters
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Efficacy of treatment

All patients were treatment naïve. Overall, 64 (72.72%) patients were treated with a SOF plus DCV, and 24 (27.27%) patients received SOF plus LDV for 12 weeks. All patients achieved SVR at 12 weeks and 24 weeks. There was a significant improvement in the mean ALT values after treatment compared to baseline (42.45 ± 18.56 IU/L vs 57.29 ± 35.07 IU/L, p < 0.0005, Fig. 1). Also, there was a statistically significant decrease in serum bilirubin level after treatment (p < 0.0005, Fig. 2). There was no statistically significant difference in the hemoglobin level (Fig. 3), platelet count, and WBCs count before and after DAAs (the p values were 0.613, 0.092, and 0.284, respectively) (Table 2). Twelve patients reported increased blood transfusion requirements, although no significant difference was noticed between the mean HB level before and after DAAs.

Fig. 1
figure 1

ALT before and after treatment

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Fig. 2
figure 2

Serum level of bilirubin before and after treatment

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Fig. 3
figure 3

Hemoglobin level before and after treatment

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Table 2 Laboratory parameters before and after treatment with DAAs
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Safety of the treatment

No major side effects were reported and no patients discontinued the treatment. Only one case required treatment discontinuation (median time of 2 weeks) due to acute kidney injury after the prolonged use of NSAIDs and resumed DAAs after the decline of creatinine to the normal level. Twenty (22.72%) patients complained of mild symptoms. The most common side effects were fatigue (18%), anemia (13.63%), requiring blood transfusion (12 patients) in patients receiving SOF plus DCV, and, lastly, headache (4.5%). These side effects were more frequent among patients receiving SOF plus DCV, than in patients receiving SOF plus LDV; however, this difference in frequency was not statistically significant (60% vs. 40%, p = 0.58).

Discussion

HCV infection is considered a major clinical burden in β thalassemia patients. The prevalence of HCV is much higher among patients with beta-thalassemia, as these patients constitute a 4 high-risk group. A systematic review based on the literature database showed that the anti-HCV antibody among β thalassemia patients has been estimated at 18%, 45%, 63%, and 69% in Iran, Pakistan, Saudi Arabia, and Egypt, respectively [14]. Approximately 70–80% of those patients will progress to CHC and up to 20% will go on to cirrhosis [15]. It is also known that HCV infection is a risk factor for HCC, which has been considered as the second common cause of mortality in this population [16].

Herein, our study provides further proof that oral DAAs are highly effective and tolerable by β thalassemia patients with CHC. All enrolled patients achieved SVR at 12 weeks and at 24 weeks. Compared to the Italian cohort [17] and the Greek cohort [18], SVR was achieved in most of the patients (98% and 90%, respectively). Both studies included 57.1% vs. 78.7% and previously treated patients 42.9% vs. 75%. The achievement of 100% SVR in our study could be explained by the fact that all enrolled patients were treatment naïve and had no cirrhosis as the median FIB-4 score was 0.52. However, those patients should be monitored for the possibility of reinfection.

Hezode et al. [19] published a trial using a fixed combination of elbasvir and grazoprevir in patients with congenital blood disorders and CHC, including β thalassemic patients. Forty β thalassemia major patients received treatment for 12 weeks, and SVR was achieved in 97.6% of them. This study showed that treatment was well-tolerated by the patients, and hemoglobin levels were not affected by treatment. The most frequently reported side effects in this study were, e.g., headache, fatigue, nausea, and asthenia. However, this combination is not currently available in Egypt.

Also, in a case series of four β thalassemia patients with CHC associated with advanced hepatic fibrosis, treated with the LDV/SOF combination for 12 weeks, all patients achieved SVR with accepted drug safety and tolerability. The only reported adverse events were mild asthenia and headache. There were no changes in chelation therapy or transfusion requirements during the treatment period. Similar results were presented by Mangia et al. [20, 21].

In the present study, there were no major adverse events, and no discontinuation of treatment was reported. Only one case required temporary treatment discontinuation due to acute kidney injury after the prolonged use of NSAIDs then resumed DAAs after the decline of serum creatinine to the normal value. Mild symptoms occurred in approximately 22.72% of the patients. The most common side effects were fatigue (18%), anemia (13.63%), and headache (4.5%). This is in accordance with the published data from certain clinical trials [18, 22]. These side effects were more common among patients receiving SOF plus DCV than in patients receiving SOF plus LDV; however, this difference in the rates of occurrence of side effects was not statistically significant (p = 0.58). Also, no drug-drug interactions were observed.

There was a significant improvement of mean ALT values and a significant decrease in serum bilirubin after treatment. On the other hand, no statistically significant difference in the hemoglobin level, platelet count, and WBCs count were found before and after DAAs. Only 12 patients had increased blood transfusion requirements, despite a non-significant difference being noticed between the mean HB level before and after DAAs. The dose and type of iron-chelating therapy did not require any modifications during the treatment course.

A high hepatic iron concentration was proposed as a negative predictor of response to DAAs in different ethnic populations. There was no consensus on whether iron accumulation in the sinusoidal cells or hepatocytes and portal track macrophages was more significant for poor response to treatment [23].

Assessment of hepatic iron concentration was limited and mainly based on serum ferritin levels and non-invasive techniques without liver histology and the data of post-treatment assessment of hepatic iron overload were not obtainable during the study. So, we need further studies with larger samples and newer DAA combinations.

Conclusion

Direct-acting antiviral drugs (sofosbuvir plus daclatasvir or sofosbuvir plus ledipasvir) are safe, effective, and well-tolerated regimens for thalassemic patients with chronic HCV.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its supplementary information files] and readily available for sharing.

Abbreviations

HCV:

Hepatitis C virus

DAAs:

Direct-acting antivirals agents

SVR:

Sustained virologic response

PTH:

Post-transfusion hepatitis

BTM:

β thalassemia major

CHC:

Chronic HCV infection

IFN:

Interferon

RBV:

Ribavirin

SOF:

Sofosbuvir

LDV:

Ledipasvir

DCV:

Daclatasvir

OCMU:

Oncology Center, Mansoura University

HBV:

Hepatitis B virus

AST:

Aspartate aminotransferase

ALT:

Alanine aminotransferase

NCCVH:

National Committee for Control of Viral Hepatitis

HB:

Haemogloin

References

  1. Viral Hepatitis Prevention Board (1995) Hepatitis A, B and C: Defining workers at risk. Viral Hepat 3 Google Scholar

  2. Agarwal M, Malkan G, Bhave A, Vishwanathan C, Billa V, Dube S et al (1993) Antibody to hepatitis-C virus in multi-transfused thalassaemics--Indian experience. J Assoc Physicians India 41:195–197 [PubMed] [Google Scholar]

    CAS  PubMed  Google Scholar 

  3. Ocak S, Kaya H, Cetin M, Gali E, Ozturk M (2006) Sero-prevalence of hepatitis B and hepatitis C in patients with thalassemia and sickle cell anemia in a long-term follow-up. Arch Med Res 37:895–898 [PubMed] [Google Scholar]

    Article  Google Scholar 

  4. Prati D, Maggioni M, Milani S, Cerino M, Cianciulli P, Coggi G et al (2004) Clinical and histological characterization of liver disease in patients with transfusion-dependent beta-thalassemia. A multicenter study of 117 cases. Haematologica 89:1179–1186 [PubMed] [Google Scholar]

    PubMed  Google Scholar 

  5. Angelucci E, Pilo F (2008) Treatment of hepatitis C in patients with thalassemia. Haematologica 93:1121–1123 [PubMed] [Google Scholar]

    Article  CAS  Google Scholar 

  6. Casu S, Balestrieri C, Figorilli F, Onali S, Serra G, Chessa L, Lai ME (2014) P1155 safety and efficacy of PEG IFnA 2a and ribavirin for treatment of hepatitis C in sardinian adult patients with thalassemia major, a single centre real life experience. J Hepat. 60(1):468. https://doi.org/10.1016/s0168-8278(14)61315-5

    Article  Google Scholar 

  7. Paschos P, Vlachaki E, Pasvanti C, Sinakos E, Kalpaka A, Klonizakis P, Perifanis V (2011) Safety and efficacy of combination therapy with pegylated interferon alpha-2a and ribavirin in treating patients with chronic hepatitis C and beta-thalassaemia major: a Greek single-center experience. Acta Haematol. 126(4):231–233. https://doi.org/10.1159/000330516

    Article  PubMed  Google Scholar 

  8. Harmatz P, Jonas MM, Kwiatkowski JL, Wright EC, Fischer R, Vichinsky E, Giardina PJ, Neufeld EJ, Porter J, Olivieri N, for the Thalassemia Clinical Research Network (2008) Safety and efficacy of pegylated interferon alpha 2a and ribavirin for the treatment of hepatitis C in patients with thalassemia. Haematologica. 93(8):1247–1251. https://doi.org/10.3324/haematol.12352

    Article  CAS  PubMed  Google Scholar 

  9. Inati A, Taher A, Ghorra S, Koussa S, Taha M, Aoun E, Sharara AI (2005) Efficacy and tolerability of peginterferon alpha-2a with or without ribavirin in thalassaemia major patients with chronic hepatitis C virus infection. Br J Haematol. 130(4):644–646. https://doi.org/10.1111/j.1365-2141.2005.05645.x

    Article  CAS  PubMed  Google Scholar 

  10. Kamal SM, Fouly AH, Mohamed MK, Hochnikos BW, Lamont FT, Gohary IS, Koziel MJ, Afdhal NH, Sayed M, Rasenack JW (2006) 585 Peginterferon alpha 2b therapy with and without ribavirin in patients with thalassemia, a randomized study. J Hepatol. 44:217. https://doi.org/10.1016/s0168-8278(06)80585-4

    Article  Google Scholar 

  11. lavian SM, Tabatabaei SV. Treatment of chronic hepatitis C in polytransfused thalassaemic patients: a meta-analysis. J Viral Hepat. 2010; 17(4):236-244. doi: https://doi.org/10.1111/j.1365-2893.2009.01170.x.

  12. European Association for the Study of the Liver (2018) Electronic address EEE. EASL recommendations on treatment of hepatitis C. J Hepatol http://doi.org/10.1016/j

  13. Vallet-Pichard A, Mallet V, Nalpas B, Verkarre V, Nalpas A, Dhalluin-Venier V, Fontaine H, Pol S (2007) FIB-4: an inexpensive and accurate marker of fibrosis in HCV infection. comparison with liver biopsy and fibrotest. Hepatology 46(1):32–36. https://doi.org/10.1002/hep.21669

    Article  CAS  Google Scholar 

  14. Alavian S, Tabatabaei S, Lankarani K (2010) Epidemiology of HCV Infection among Thalassemia Patients in Eastern Mediterranean Countries: a Quantitative Review of Literature. Iran. Red. Crescent. Med. 12(4):365–376

    Google Scholar 

  15. Minola E, Prati D, Suter F, Maggiolo F, Caprioli F, Sonzogni A, Fraquelli M, Paggi S, Conte D (2002) Age at infection affects the long term outcome of transfusion associated chronic hepatitis C. Blood. 99(12):4588–4591. https://doi.org/10.1182/blood-2001-12-0192

    Article  CAS  PubMed  Google Scholar 

  16. Voskaridou E, Ladis V, Kattamis A, Hassapopoulou E, Economou M, Kourakli A et al (2012) A national registry of haemoglobinopathies in Greece: deducted demographics, trends in mortality and affected births. Ann Hematol. 91(9):1451–1458. https://doi.org/10.1007/s00277-012-1465-7

    Article  PubMed  Google Scholar 

  17. Onali S, Maida I, Balestrieri C, Arcadu F, Urru E, Porcu D, Serra G, Flore G, Dore E, Satta C, Paolo Bitti P, Grazia Sanna M, Serusi L, Casale M, Conti M, Loi M, Figorilli F, Cristina Pasetto M, Babudieri S, Chessa L (2018) Safety and efficacy of direct-acting antivirals in transfusion-dependent thalassemic patients with chronic hepatitis C. Hepat Mon. 18(1):e61453. https://doi.org/10.5812/hepatmon.61453

    Article  CAS  Google Scholar 

  18. Sinakos E, Kountouras D, Koskinas J, Zachou K, Karatapanis S, Triantos C, Vassiliadis T., Goulis I., Kourakli A., Vlachaki E., Toli B., Tampaki M., Arvaniti P., Tsiaoussis G., Bellou A., Kattamis A., Maragkos K., Petropoulou F., Dalekos G.N., Akriviadis E., Papatheodoridis G.V. Treatment of chronic hepatitis C with direct-acting antivirals in patients with beta thalassaemia major and advanced liver disease. Br J Haematol. 2017; 178(1):130-136. doi: https://doi.org/10.1111/bjh.14640. [PubMed: 28439915].

  19. Hezode C, Colombo M, Bourliere M, Spengler U, Ben-Ari Z, Strasser SI, et al. Elbasvir, grazoprevir for patients with hepatitis c virus infection and inherited blood disorders: a phase III study. Hepatology. 2017; 66(3):736-745. doi: https://doi.org/10.1002/hep.29139. [PubMed: 28256747].

  20. Biliotti E, Palazzo D, Serani M, Silvestri AM, Volpicelli L, Esvan R, Franchi C, Spaziante M, Sorrentino F, Taliani G Interferon free antiviral treatment of chronic hepatitis C in patients affected by beta-thalassemia major. Ann Hematol. 2017; 96(6):1043-1045. doi: https://doi.org/10.1007/s00277-017-2986-x. [PubMed: 28378040].

  21. Mangia A, Sarli R, Gamberini R, Piga A, Cenderello G, Piazzolla V, Santoro R, Caruso V, Quarta A, Ganga R, Copetti M, Forni G (2017) Randomised clinical trial: sofosbuvir and ledipasvir in patients with transfusion dependent thalassaemia and HCV genotype 1 or 4 infection. Aliment Pharmacol Ther. 46(4):424–431. https://doi.org/10.1111/apt.14197

    Article  CAS  PubMed  Google Scholar 

  22. European Association for the Study of the Liver. Electronic address EEE (2017) EASL recommendations on treatment of hepatitis C 2016. J Hepatol. 66(1):153–194. https://doi.org/10.1016/j.jhep.2016.09.001

    Article  Google Scholar 

  23. Ikura Y, Morimoto H, Johmura H, Fukui M, Sakurai M (1996) Relationship between hepatic iron deposits and response to interferon in chronic hepatitis C. Am. J. Gastroenterol. 91(7):1367–1373

    CAS  PubMed  Google Scholar 

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Acknowledgements

We are thankful to our colleagues in the hepato-gastroenterology and hematology departments, Mansoura University. We are also thankful for our patients for their contribution and trust.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Department of Internal Medicine, Hepatology & Gastroenterology Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Elsayed Ghoneem, Ahmed Saleh & Shahira Aly El-Etreby

  2. Department of Clinical Pathology, Hematology Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Metwaly Ibrahim Mortada & Mayada A. Ghannam

  3. Department of Clinical Hematology, Oncology Center Mansoura University (OCMU), Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Shaimaa El-Ashwah & Noha Eisa

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  1. Elsayed Ghoneem
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Contributions

The protocol of the study, study design, methodology, follow-up of the patients, collection of the data, data analysis, and writing—original draft preparation: SEA, NE, and EG. Lab investigation: MM and MG. Writing—review and editing: EG. Supervision: SEE and AS. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Ahmed Saleh.

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Ethics and approval consent to participate

The study has been approved by the ethics committee of our university (Mansoura Faculty of Medicine, Mansoura University, Institutional Review Board Code No R/17.12.71) and has been performed following the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Informed written consents approved by ethical committee of Mansoura Faculty of Medicine were obtained from all individual participants or their legal guardians if under 16 years.

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Ghoneem, E., Saleh, A., El-Etreby, S.A. et al. Safety and efficacy of direct-acting antiviral drugs in the treatment of chronic hepatitis C virus infection in patients with thalassemia: a prospective study. Egypt Liver Journal 11, 54 (2021). https://doi.org/10.1186/s43066-021-00124-5

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Keywords

  • Thalassemia
  • Chronic hepatitis C
  • Direct-acting antiviral drugs (DAAs)
  • Sustained virologic response (SVR)
  • Post-transfusion hepatitis (PTH)