1
|
El Kassas M, Eltabbakh M, Elbadry M, Tawheed A, Elbaz T. Establishing a research production line in real-life settings: the case of Hepatitis C management in a viral hepatitis specialized Egyptian center. Curr Med Res Opin 2022; 38:553-563. [PMID: 35118916 DOI: 10.1080/03007995.2022.2038489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Efforts toward eradicating the Hepatitis C virus (HCV) have advanced rapidly, due to the development of direct-acting antivirals (DAAs), especially with the appearance of pan-genotypic combinations. Real-world studies, in particular, have verified the efficacy and safety of DAA combinations documented in registration trials. This review documents the results of using DAA combinations in real-life settings in everyday clinical practice in Egypt, the country with the highest prevalence of HCV. The significant number of treated patients in Egypt, which exceeded four million allowed tremendous data about the results of HCV management in real-life settings for different treatment regimens and disease conditions. DAA combinations have resulted in high sustained virologic response rates (SVR12) and few adverse reactions in real-life settings. SVR12 rates ranged from 90% to 100%, depending on the combination of drugs used, the HCV genotype, and the stage of liver disease. Most adverse reactions reported in real-world settings were mild and resulted in treatment discontinuation in only a minority of cases. Data from real-life studies covered most aspects of HCV management that were lacking after initial approval studies. More research is needed to tailor treatment and produce generic HCV combinations to overcome the residual limitations of the currently available DAAs.
Collapse
Affiliation(s)
- Mohamed El Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Eltabbakh
- Tropical Medicine department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed Elbadry
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Ahmed Tawheed
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Tamer Elbaz
- Endemic Medicine and Hepatogastroenterology, Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| |
Collapse
|
2
|
El Kassas M, Alboraie M, El Badry M, Youssef N, Omar H, El Sheemy RY, Al Balakosy A, Ashraf Ahmed Mohamed O, Gamal Naguib Meleak G, Dabbous H, Hassan Ahmed Fouad M, Wifi MN, Zaky S, Tahoon M, El Tahan A, El-Raey F, Ezzat S, Doss W. Retreatment of chronic hepatitis C patients who failed previous therapy with directly acting antivirals: A multicenter study. Int J Infect Dis 2020; 96:367-370. [PMID: 32325275 DOI: 10.1016/j.ijid.2020.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022] Open
Abstract
AIM OF THE STUDY The current study aimed to evaluate the efficacy of different DAAs regimens in the treatment of chronic hepatitis C (CHC) Egyptian patients who failed to achieve SVR after their treatment with SOF-based regimens. METHODS This was a retrospective observational multicenter study that included CHC patients that failed to achieve cure on SOF-based regimens who were re-treated using different DAAs regimen and were allocated according to national guidelines for the treatment of hepatitis C. Primary outcome was to assess the SVR12 rate among prior non-responders after retreatment with a second course of DAAs. RESULTS Our study included 172 patients who failed to achieve SVR after treatment with SOF-based treatment regimen [age: 51.2 ± 11.3, 58.7% men]. Included patients were retreated using SOF/DCV/RBV, SOF/ r/PAR /OMB /RBV, SOF/DCV/SIM, SOF/LDV ± RBV or SIM/SOF. SVR12 was successfully attained in 95.35% (164/172) of the included non-responders. CONCLUSION The current multicenter study proved the efficacy of various DAAs regimens issued by the National Committee for Control of Viral Hepatitis for retreatment of relapsed CHC Egyptian patients.
Collapse
Affiliation(s)
- Mohamed El Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Alboraie
- Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed El Badry
- Tropical Medicine and Gastroenterology Department, Faculty of Medicine, Aswan University, Aswan, Egypt
| | - Naglaa Youssef
- Medical Surgical Nursing Department, Faculty of Nursing, Cairo University, Cairo, Egypt; Collage of Nursing, Princess Nourah Bint Abdulrahman University, KSA
| | - Heba Omar
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt.
| | - Reem Y El Sheemy
- Tropical Medicine Department, Faculty of Medicine, Minia University, Egypt
| | | | | | | | - Hany Dabbous
- Tropical Medicine Department, Faculty of Medicine, Ain Shams University, Egypt
| | | | - Mohamed-Naguib Wifi
- Internal Medicine Department, Hepatogastroenterology Unit, Kasr Al-Ainy School Of Medicine, Cairo University, Cairo, Egypt
| | - Samy Zaky
- Heptogastroenterology and Infectious Diseases Al-Azhar University, Egypt
| | - Marwa Tahoon
- Epidemiology and Preventive Medicine, National Liver Institute, Menoufia University, Egypt
| | - Adel El Tahan
- New Cairo Viral Hepatitis Treatment Unit, NCCVH, Egypt
| | - Fathiya El-Raey
- Hepatogastroenterology and Infectious Diseases Department, Damietta Faculty of Medicine Al-Azhar university, Egypt
| | - Sameera Ezzat
- Epidemiology and Preventive Medicine, National Liver Institute, Menoufia University, Egypt
| | - Wahid Doss
- Endemic Medicine and Hepatology Department, Faculty of Medicine, Cairo University, Egypt
| |
Collapse
|
3
|
Inflammasome Genes' Polymorphisms in Egyptian Chronic Hepatitis C Patients: Influence on Vulnerability to Infection and Response to Treatment. Mediators Inflamm 2019; 2019:3273645. [PMID: 30728751 PMCID: PMC6343134 DOI: 10.1155/2019/3273645] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 12/09/2018] [Indexed: 12/12/2022] Open
Abstract
Chronic inflammation is a pivotal contributor to the liver damage mediated by hepatitis C virus (HCV). The NOD-like receptor, pyrin domain-containing 3 (NLRP3) inflammasome is activated by HCV in both hepatocytes and Kupffer cells. The aim of our study was to investigate the association of nine single-nucleotide polymorphisms in four inflammasome genes (NLRP3, CARD8, IL-1β, and IL-18) with the susceptibility to HCV infection and outcome of interferon treatment in 201 Egyptian chronic hepatitis C patients and 95 healthy controls. The genotyping was conducted using TaqMan predesigned SNP assay. In the comparative analysis, the CC genotype of the NLRP3 rs1539019 was found to be associated with the lower risk to chronic HCV infection (OR: 0.33, 95% CI: 0.17-0.62). This association was also found for the CA genotype and the A allele of the NLRP3 rs35829419 (OR: 0.18 and 0.22, respectively), in addition to the GG genotype and G allele of IL-18 rs1946518 (OR: 0.55 and 0.61, respectively). In contrast, the AA genotype of the IL-1β rs1143629 was significantly more frequent in HCV patients (OR: 1.7, 95% CI: 1-2.86). Notably, the frequency of the AA genotype of NLRP3 rs1539019 was significantly higher in patients with lack of response (NR) to the interferon treatment (OR: 1.95, 95% CI: 1-3.7). A similar association was found for both the CC genotype and C allele of the NLRP3 rs35829419 (OR: 2.78 and 2.73, respectively) and for the TT genotype and T allele of CARD8 rs2043211 (OR: 2.64 and 1.54, respectively). Yet, the IL-1β (rs1143629, rs1143634) and IL-18 (rs187238, rs1946518) polymorphisms did not show any significant association with response to interferon treatment. In conclusion, this study reports, for the first time, the association of genetic variations in NLRP3 with hepatitis C susceptibility and response to treatment in Egyptian patients. However, further large-scale studies are recommended to confirm our findings.
Collapse
|
4
|
Frias M, Rivero-Juárez A, López-López P, Rivero A. Pharmacogenetics and the treatment of HIV-/HCV-coinfected patients. Pharmacogenomics 2018; 19:979-995. [PMID: 29992850 DOI: 10.2217/pgs-2018-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
This review will summarize the role of pharmacogenetics in the natural history of hepatitis C, particularly in patients with HIV/HCV and will take the perspective of pharmacogenetics and its influence on the response to antiviral therapy and the susceptibility to develop adverse effects. This review will also devote a section to host genetics in other clinical situations, such as disease progression and acute HCV infection, which may determine whether treatment of HIV-/HCV-coinfected patients is implemented or deferred.
Collapse
Affiliation(s)
- Mario Frias
- Department of Clinical Virology & Zooneses, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba. Córdoba, 14004, Spain
| | - Antonio Rivero-Juárez
- Department of Clinical Virology & Zooneses, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba. Córdoba, 14004, Spain
| | - Pedro López-López
- Department of Clinical Virology & Zooneses, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba. Córdoba, 14004, Spain
| | - Antonio Rivero
- Department of Clinical Virology & Zooneses, Hospital Universitario Reina Sofía de Córdoba, Instituto Maimonides de Investigación Biomédica de Córdoba (IMIBIC), Universidad de Córdoba. Córdoba, 14004, Spain
| |
Collapse
|
5
|
Vidal LL, Soares MA, Santos AF. NS3 protease polymorphisms and genetic barrier to drug resistance of distinct hepatitis C virus genotypes from worldwide treatment-naïve subjects. J Viral Hepat 2016; 23:840-849. [PMID: 26775769 DOI: 10.1111/jvh.12503] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Accepted: 12/02/2015] [Indexed: 12/26/2022]
Abstract
Hepatitis C virus (HCV) NS3 protease inhibitors have been primarily designed against genotype 1, the one with the lowest response to dual therapy. However, less evidence of their efficacy on non-1 genotypes is available, and any such information is mostly concentrated on genotypes 2-4. This study evaluated HCV protease resistance profiles in the major six HCV genotypes and identified genetic barrier (GB) profiles to each available protease inhibitor across HCV strains from different locations worldwide. We obtained 15 099 HCV sequences from treatment-naïve subjects retrieved at the Los Alamos HCV Sequence Database. The wild-type codons of different HCV genotypes were used to analyse the smallest number of nucleotide substitution steps required for changing that codon to the closest one associated with drug resistance. The 36L and 175L RAVs were found as genetic signatures of genotypes 2-5, while the 80K RAV was found in all genotype 5 sequences. Genotypes 4 and 6 showed a higher GB to RAV mutations conferring resistance to telaprevir, while genotypes 2-5 presented baseline resistance to that drug, carrying the 36L mutation. Genotype 4 had a higher GB to simeprevir resistance, requiring three substitutions to acquire the 155K mutation. Subtype 1b showed a higher GB than subtype 1a to resistance for most PIs, with RAVs at codons 36 and 155. Geographic disparities were also found in frequencies of certain RAVs in genotypes 2 and 3. Under a scenario of unprecedented evolution of anti-HCV direct-acting agents, the genetic composition of the circulating HCV sequences should be evaluated worldwide to choose the most appropriate/feasible therapeutic schemes with the highest genetic barriers to resistance.
Collapse
Affiliation(s)
- L L Vidal
- Departamento de Genética, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - M A Soares
- Departamento de Genética, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.,Programa de Genética, Instituto Nacional do Câncer, Rio de Janeiro, Brazil
| | - A F Santos
- Departamento de Genética, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
| |
Collapse
|
6
|
Hézode C, Asselah T, Reddy KR, Hassanein T, Berenguer M, Fleischer-Stepniewska K, Marcellin P, Hall C, Schnell G, Pilot-Matias T, Mobashery N, Redman R, Vilchez RA, Pol S. Ombitasvir plus paritaprevir plus ritonavir with or without ribavirin in treatment-naive and treatment-experienced patients with genotype 4 chronic hepatitis C virus infection (PEARL-I): a randomised, open-label trial. Lancet 2015; 385:2502-9. [PMID: 25837829 DOI: 10.1016/s0140-6736(15)60159-3] [Citation(s) in RCA: 191] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Hepatitis C virus (HCV) genotype 4 accounts for about 13% of global HCV infections. Because interferon-containing treatments for genotype 4 infection have low efficacy and poor tolerability, an unmet need exists for effective all-oral regimens. We examined the efficacy and safety of an all-oral interferon-free regimen of ombitasvir, an NS5A inhibitor, and paritaprevir (ABT-450), an NS3/4A protease inhibitor dosed with ritonavir (ombitasvir plus paritaprevir plus ritonavir), given with or without ribavirin. METHODS In this multicentre ongoing phase 2b, randomised, open-label combination trial (PEARL-I), patients were recruited from academic, public, and private hospitals and clinics in France, Hungary, Italy, Poland, Romania, Spain, Turkey, and the USA. Eligible participants were aged 18-70 years with non-cirrhotic, chronic HCV genotype 4 infection (documented ≥6 months before screening) and plasma HCV RNA levels higher than 10,000 IU/mL. Previously untreated (treatment-naive) patients were randomly assigned (1:1) by computer-generated randomisation lists to receive once-daily ombitasvir (25 mg) plus paritaprevir (150 mg) plus ritonavir (100 mg) with or without weight-based ribavirin for 12 weeks. Previously treated (treatment-experienced) patients who had received pegylated interferon plus ribavirin all received the ribavirin-containing regimen. The primary endpoint was a sustained virological response (HCV RNA <25 IU/mL) 12 weeks after the end of treatment (SVR12). Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT01685203. FINDINGS Between Aug 14, 2012, and Nov 19, 2013, 467 patients with HCV infection were screened, of whom 174 were infected with genotype 4. 135 patients were randomly assigned to treatment and received at least one dose of study medication; 86 patients were treatment-naive, of whom 44 received ombitasvir plus paritaprevir plus ritonavir and 42 received ombitasvir plus paritaprevir plus ritonavir with ribavirin, and 49 treatment-experienced patients received the ribavirin-containing regimen. In previously untreated patients, SVR12 rates were 100% (42/42 [95% CI 91·6-100]) in the ribavirin-containing regimen and 90·9% (40/44 [95% CI 78·3-97·5]) in the ribavirin-free regimen. No statistically significant differences in SVR12 rates were noted between the treatment-naive groups (mean difference -9·16% [95% CI -19·61 to 1·29]; p=0·086). All treatment-experienced patients achieved SVR12 (49/49; 100% [95% CI 92·7-100]). In the ribavirin-free group, two (5%) of 42 treatment-naive patients had virological relapse, and one (2%) of 44 had virological breakthrough; no virological failures were recorded in the ribavirin-containing regimen. The most common adverse event was headache (14 [29%] of 49 treatment-experienced patients and 14 [33%] of 42 treatment-naive patients). No adverse event-related discontinuations or dose interruptions of study medications, including ribavirin, were noted, and only four patients (4%) of 91 receiving ribavirin required dose modification for haemoglobin less than 100 g/L or anaemia. INTERPRETATION An interferon-free regimen of ombitasvir plus paritaprevir plus ritonavir with or without ribavirin achieved high sustained virological response rates at 12 weeks after the end of treatment and was generally well tolerated, with low rates of anaemia and treatment discontinuation in non-cirrhotic previously untreated and previously treated patients with HCV genotype 4 infection. FUNDING AbbVie.
Collapse
Affiliation(s)
- Christophe Hézode
- Department of Hepatology and Gastroenterology, Hôpital Henri Mondor, AP-HP, Université Paris-Est, Inserm, Créteil, France.
| | - Tarik Asselah
- Centre de Recherche sur l'Inflammation (CRI), Inserm UMR, Université Paris Diderot, Service d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Tarek Hassanein
- Southern California Liver Centers and Southern California Research Center, Coronado, CA, USA
| | - Marina Berenguer
- Hepatology Unit, Hospital Universitario La Fe, Universidad de Valencia and Ciberehd, Valencia, Spain
| | - Katarzyna Fleischer-Stepniewska
- Department of Infectious Disease, Liver Diseases and Acquired Immune Deficiencies, Wroclaw Medical University, Wroclaw, Poland
| | | | | | | | | | | | | | | | - Stanislas Pol
- Groupe Hospitalier Cochin-Saint Vincent De Paul, Université Paris Descartes, Inserm, Institut Pasteur, Paris, France
| |
Collapse
|
7
|
Efficacy and safety of simeprevir with PegIFN/ribavirin in naïve or experienced patients infected with chronic HCV genotype 4. J Hepatol 2015; 62:1047-55. [PMID: 25596313 DOI: 10.1016/j.jhep.2014.12.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 12/19/2014] [Accepted: 12/22/2014] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS Simeprevir (SMV) is a once-daily (QD), oral hepatitis C virus (HCV) NS3/4A protease inhibitor approved for treatment of genotype (GT) 1 and GT4 infection. This Phase III, open-label, single-arm study (RESTORE; NCT01567735) evaluated efficacy/safety of SMV with peginterferon-α-2a/ribavirin (PR) in patients with chronic HCV GT4 infection. METHODS 107 patients were included. Treatment-naïve (n=35) and prior relapse patients (n=22) received SMV 150mg QD+PR (12 weeks), followed by PR alone (12 or 36 weeks, response-guided [HCV RNA <25IU/ml detectable/undetectable at week 4 and <25IU/ml undetectable at week 12]). Prior non-responders (partial, n=10; null, n=40) received SMV/PR (12 weeks), followed by PR for 36 weeks. The primary endpoint was sustained virologic response 12 weeks after end of treatment (SVR12). RESULTS Median age: 49.0years; 28.0% Black/African; 7.5% IL28B CC; 28.8% METAVIR F4. Overall, 65.4% (70/107) of patients achieved SVR12 (82.9% [29/35] treatment-naïve; 86.4% [19/22] prior relapsers; 60.0% [6/10] prior partial responders; 40.0% [16/40] prior null responders). In treatment-naïve and prior relapser patients fulfilling response-guided criteria for 24 weeks of treatment (88.6% [31/35] and 90.9% [20/22]), SVR12 rates were high: 93.5% [29/31] and 95.0% [19/20], respectively. Overall on-treatment failure and relapse rates were 23.4% (25/107) and 14.6% (12/82), respectively. Adverse events (AEs) were mainly grade 1/2; serious AEs were infrequent (4.7%) and considered unrelated to SMV. CONCLUSIONS Efficacy and safety of SMV 150mg QD for 12 weeks with PR in treatment-naïve or -experienced patients with chronic HCV GT4 infection were in line with previous reports for HCV GT1 infection.
Collapse
|
8
|
El-Raziky MS, Halawa EF, Draz IH, Ali MS. Natural history and response to treatment of HCV infection among Egyptian survivors of childhood malignancy. Pediatr Hematol Oncol 2015; 32:138-45. [PMID: 25264733 DOI: 10.3109/08880018.2014.958885] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Children with cancer are at a high risk for hepatitis C virus infection due to immunosuppression secondry to chemotherapy and multiple transfusions of blood products. We aim to evaluate the presence of HCV infection in children with malignant diseases, risk factors, clinical course, laboratory, histopathological findings, and response to HCV treatment. METHOD We described 31 patients referred to the pediatric hepatology clinic at Cairo University pediatric hospital and presenting with postmalignant virus C infection. Data collected included that of medical history, physical examination, and periodic evaluation clinically, laboratory, and histopathologically during their follow up. RESULTS The mean age at diagnosis of HCV infection was 8 ± 3.3 years, the period of follow up of the patients in the hepatology clinic ranged from 0.3 to 15 years with a mean of 2.6 ± 2.3 years. Risk factors for HCV acquisition were chemotherapy in 93.5%, blood transfusions in 83.9%, and operations in 64.5%. Out of the 31 cases, 51.6% had leukemia. At first presentation, serum ALT level was elevated in 83.9% and AST level was elevated in 80.6%. Liver biopsy was performed in 26 cases; 96.1% had mild to moderate activity, 32% had no fibrosis, and 68% had mild to moderate fibrosis. Eighteen cases received HCV treatment. The response to HCV treatment was 27.7%. Although hepatitis C infection acquired by childhood cancer survivors was presented initially with high rate of elevated liver enzymes and PCR positivity, it seems to have a relatively benign clinical course with mild to moderate chronic hepatitis.
Collapse
|
9
|
Gekonge B, Bardin MC, Montaner LJ. Short communication: Nitazoxanide inhibits HIV viral replication in monocyte-derived macrophages. AIDS Res Hum Retroviruses 2015; 31:237-41. [PMID: 25303025 PMCID: PMC4313412 DOI: 10.1089/aid.2014.0015] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We document the anti-HIV activity of nitazoxanide (NTZ), the first member of the thiazolide class of antiinfective drugs, originally effective against enteritis caused by Cryptosporidium parvum and Giardia lamblia. NTZ has been administered extensively worldwide, with no severe toxicities associated with its use. Here, we show for the first time that NTZ decreases HIV-1 replication in monocyte-derived macrophages (MDM) if present before or during HIV-1 infection. This NTZ effect is associated with downregulation of HIV-1 receptors CD4 and CCR5, and increasing gene expression of host cell anti-HIV resistance factors APOBEC3A/3G and tetherin. As NTZ is already in clinical use for other conditions, this newly described anti-HIV activity in MDM may facilitate innovative intensification strategies against HIV-1 when combined with current antiretroviral drug regimens.
Collapse
Affiliation(s)
- Bethsebah Gekonge
- HIV Immunopathogenesis Laboratory, Wistar Institute, Philadelphia, Pennsylvania
| | | | - Luis J. Montaner
- HIV Immunopathogenesis Laboratory, Wistar Institute, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Esmat G, El Raziky M, Elsharkawy A, Sabry D, Hassany M, Ahmed A, Assem N, El Kassas M, Doss W. Impact of vitamin D supplementation on sustained virological response in chronic hepatitis C genotype 4 patients treated by pegylated interferon/ribavirin. J Interferon Cytokine Res 2014; 35:49-54. [PMID: 25061714 DOI: 10.1089/jir.2014.0060] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current standard of care therapy (SOC) for chronic HCV is pegylated interferon/ribavirin (Peg-IFN/RBV). Many reports showed the possible role of vitamin D supplementation in augmenting the response to SOC. The aim of this study was to assess the role of vitamin D supplementation on the response to treatment in chronic HCV genotype 4 patients. One hundred and one chronic HCV patients were classified into two groups (Group 1): 51 patients received the SOC therapy consisting of Peg-interferon alfa-2b plus ribavirin, (Group 2): 50 patients received the SOC therapy+vitamin D3 (Cholecalciferol) in a dose of 15,000 IU/week during the treatment course. Vitamin D deficiency was found in 95% of patients. No correlation was found between vitamin D levels and stage of fibrosis in the whole population. Vitamin D supplementation had no positive impact on treatment outcome where sustained virological response (SVR) was achieved in 51.2% in group 2 and 71.4% in group 1 by per-protocol analysis and in 44% in group 2 and in 68.6% in group 1 by intention to treat analysis (P value 0.22 and 0.220 respectively). Despite its role in other genotypes, vitamin D supplementation has no significant impact on SVR in HCV Genotype 4 patient. No correlation was found between vitamin D levels and stage of liver fibrosis.
Collapse
Affiliation(s)
- Gamal Esmat
- 1 Department of Endemic Medicine and Hepatology, Faculty of Medicine, Cairo University , Cairo, Egypt
| | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Youssef SS, Abbas EAER, Mostafa A, Omran MH, Barakat A, Seif SM. IL28B rs 12979860 predicts response to treatment in Egyptian hepatitis C virus genotype 4 patients and alpha fetoprotein increases its predictive strength. J Interferon Cytokine Res 2014; 34:505-9. [PMID: 24660823 DOI: 10.1089/jir.2013.0115] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
To assess the role of IL28B rs 12979860 polymorphism in predicting response to treatment in genotype 4 (G4) Egyptian patients, and to evaluate the role of alpha fetoprotein (AFP) in increasing the predictive strength of IL28B rs 12979860 polymorphism to predict response to treatment. One hundred thirty 7 HCV patients were genotyped for IL28B rs 12979860 by polymerase chain reaction--restriction fragment length polymorphism technique. The presence of the C allele of IL28B rs 12979860 was associated with response to treatment, while the T allele was associated with failure of response to treatment. AFP is associated with IL28B rs 12979860 SNP genotypes at cut off 2.68 and 4.5 ng/mL individually. Response rate was 1.3 and 1.6, 3 times higher in CC, CT, and TT respectively in patients below AFP 4.5 ng/mL than in patients above it. IL28B rs 12979860 polymorphism is strongly associated with treatment induced response to treatment. AFP (cut off 4.5 mg/mL) increases the predictive power of IL28B in response to treatment.
Collapse
Affiliation(s)
- Samar Samir Youssef
- 1 Microbial Biotechnology Department, National Research Center , Cairo, Egypt
| | | | | | | | | | | |
Collapse
|
12
|
Bahgat MM. Interaction Between the Neglected Tropical Disease Human Schistosomiasis and HCV Infection in Egypt: a Puzzling Relationship. J Clin Transl Hepatol 2014; 2:134-9. [PMID: 26356794 PMCID: PMC4521266 DOI: 10.14218/jcth.2013.00028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Revised: 02/21/2014] [Accepted: 02/26/2014] [Indexed: 02/06/2023] Open
Abstract
Egypt has the highest prevalence of chronic hepatitis C virus (HCV) infection and seropositivity worldwide, and it has been proposed that this enhanced susceptibility to HCV is related to coinfection with schistosomiasis. Although currently, there are no studies regarding the actual prevalence of both human schistosomiasis and schistosomiasis/HCV coinfection evidences strongly support that eliminating human schistosomiasis from Egypt is necessary to reduce both HCV prevalence and liver pathology. The present review highlights the significant impact of the neglected tropical disease human schistosomiasis on both susceptibility of Egyptians to HCV coinfection, severity of the resulting liver pathology, and poor response to antiviral therapy. The immune evasion mechanisms exerted by the HCV-NS3/4A protease domain, and the possible impact of immune evasion mechanisms exerted by proteases of larval, worm and egg stages of the parasite Schistosoma on human susceptibility to HCV infection are discussed. In addition, schistosome immune evasion mechanisms may include immunosuppression that in turn prevents clearance of HCV viremia and leads to relapsing HCV infection and severe liver pathology. I propose the generation of a replicon system from the most prevailing genotype (HCV-4a) in Egypt and establishing its replication on hepatoplastoma or immune cells in presence of bilharzial antigens. Finally, the use of a humanized small animal model that can acquire both HCV and S. mansoni infections will be important to further understand in real time the impact of coinfection on both the immune system and liver pathology.
Collapse
Affiliation(s)
- Mahmoud M. Bahgat
- Immunology and Infectious Diseases Group, Therapeutic Chemistry Department, the Centre of Excellence for Advanced Sciences, the National Research Centre, Dokki, Cairo, Egypt
- Research Group of Biomarkers for Infection and Immunity, Institute of Experimental Infection Research, TWINCORE Centre for Experimental and Clinical Infection Research, Hannover, Germany
| |
Collapse
|
13
|
Trimbitas RD, Serghini FZ, Lazaar F, Baha W, Foullous A, Essalhi M, El Malki A, Meziane Bellefquih A, Bennani A. The "hidden" epidemic: a snapshot of Moroccan intravenous drug users. Virol J 2014; 11:43. [PMID: 24602336 PMCID: PMC3995948 DOI: 10.1186/1743-422x-11-43] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Accepted: 02/24/2014] [Indexed: 12/21/2022] Open
Abstract
Background Hepatitis C virus is a persistent epidemiological problem, with an estimated 170 million individuals infected worldwide, and the leading cause of asymptomatic chronic infection, liver cirrhosis and hepatocellular carcinoma. Injection drug users (IDUs) have the highest seroprevalence as compared to chronic hemodialysis and transfusion patients, and this cohort remains the most under-studied high-risk group in North Africa to date. This study first sought to characterize the demographic, epidemiological, and genotypic profile of a total sample size of 211 chronically-infected IDUs living in the Tangier region of Northern Morocco, and secondly to contrast this to other chronically-infected patients, in order to uncover possible discrepancies. Results The general ‘profile’ of local IDUs marks a stark contrast to chronically-infected HCV Moroccan patients, other African countries, and neighboring European countries. The majority of Moroccan drug users were found to be middle-aged and celibate. A relatively high seroprevalence was found among drug users (60%), and this increased with age. The majority of drug users shared their needles and this hold implications for transmission, as seropositive status was significantly different between those users that shared vs. those that did not share their needles. In addition, IDUs exhibited genotypes 1a and 3a predominantly, as compared to the predominant 1b and 2a/2c genotypes found in chronically HCV-infected patients. The IDU genotypic profile closely matches the one in other European countries (Portugal, Spain, France, and Italy), which are invariably speculated as the potential source of currently-circulating genotypes in Moroccan IDUs. Conclusion These findings have implications for disease prevention, transmission and treatment, as this distinct IDU subgroup cannot be collectively pooled along with other HCV-positive high-risk groups. Local government, practitioners, and health institutions should take this into account when treating, prescribing antiviral therapy, and designing preventative public health campaigns.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Abdelouaheb Bennani
- Pasteur Institute of Morocco, Place Louis Pasteur, 20360 Casablanca, Morocco.
| |
Collapse
|
14
|
Deneke M, Dranoff J, Duarte-Rojo A. Successful eradication of genotype 4 HCV with telaprevir-based triple antiviral therapy. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2014. [DOI: 10.1016/j.rgmxen.2014.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
15
|
Sira MM, Behairy BE, Abd-Elaziz AM, Abd Elnaby SA, Eltahan EE. Serum Inter-Alpha-Trypsin Inhibitor Heavy Chain 4 (ITIH4) in Children with Chronic Hepatitis C: Relation to Liver Fibrosis and Viremia. HEPATITIS RESEARCH AND TREATMENT 2014; 2014:307942. [PMID: 25295185 PMCID: PMC4177773 DOI: 10.1155/2014/307942] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 02/07/2023]
Abstract
Liver fibrosis and viremia are determinant factors for the treatment policy and its outcome in chronic hepatitis C virus (HCV) infection. We aimed to investigate serum level of inter-alpha-trypsin inhibitor heavy chain 4 (ITIH4) and its relation to liver fibrosis and viremia in children with chronic HCV. ITIH4 was measured by ELISA in 33 treatment-naive children with proved chronic HCV and compared according to different clinical, laboratory and histopathological parameters. Liver histopathological changes were assessed using Ishak score and compared with aspartate transaminase-to-platelet ratio (APRI) and FIB-4 indices as simple noninvasive markers of fibrosis. ITIH4 was measured in a group of 30 age- and sex-matched healthy controls. ITIH4 was significantly higher in patients than in controls (54.2 ± 30.78 pg/mL versus 37.21 ± 5.39 pg/mL; P = 0.021). ITIH4, but not APRI or FIB-4, had a significant direct correlation with fibrosis stage (P = 0.015, 0.961, and 0.389, resp.), whereas, the negative correlation of ITIH4 with HCV viremia was of marginal significance (P = 0.071). In conclusion, ITIH4 significantly correlated with higher stages of fibrosis indicating a possible relation to liver fibrogenesis. The trend of higher ITIH4 with lower viremia points out a potential antiviral properties and further studies in this regard are worthwhile.
Collapse
Affiliation(s)
- Mostafa M. Sira
- 1Department of Pediatric Hepatology, National Liver Institute, Menofiya University, Shebin El-koom, Menofiya 32511, Egypt
- *Mostafa M. Sira:
| | - Behairy E. Behairy
- 1Department of Pediatric Hepatology, National Liver Institute, Menofiya University, Shebin El-koom, Menofiya 32511, Egypt
| | - Azza M. Abd-Elaziz
- 2Department of Microbiology and Immunology, National Liver Institute, Menofiya University, Shebin El-koom, Menofiya 32511, Egypt
| | - Sameh A. Abd Elnaby
- 3Department of Pediatrics, Faculty of Medicine, Menofiya University, Shebin El-koom, Menofiya 32511, Egypt
| | - Ehab E. Eltahan
- 3Department of Pediatrics, Faculty of Medicine, Menofiya University, Shebin El-koom, Menofiya 32511, Egypt
| |
Collapse
|
16
|
Deneke MG, Dranoff JA, Duarte-Rojo A. [Successful eradication of genotype 4 HCV with telaprevir-based triple antiviral therapy]. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2014; 79:64-66. [PMID: 24679642 DOI: 10.1016/j.rgmx.2013.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2013] [Revised: 09/03/2013] [Accepted: 09/04/2013] [Indexed: 06/03/2023]
Affiliation(s)
- M G Deneke
- División de Gastroenterología y Hepatología, Universidad de Arkansas para las Ciencias Médicas, Little Rock, AR, EE. UU
| | - J A Dranoff
- División de Gastroenterología y Hepatología, Universidad de Arkansas para las Ciencias Médicas, Little Rock, AR, EE. UU.; Servicio de Investigación, Servicio de Salud Veterans Affairs de Arkansas Central, Little Rock, AR, EE. UU
| | - A Duarte-Rojo
- División de Gastroenterología y Hepatología, Universidad de Arkansas para las Ciencias Médicas, Little Rock, AR, EE. UU..
| |
Collapse
|
17
|
Sede M, Laufer N, Ojeda D, Gun A, Cahn P, Quarleri J. Analysis of sequences of hepatitis C virus NS5A genotype 1 in HIV-coinfected patients with a null response to nitazoxanide or peg-interferon plus ribavirin. Arch Virol 2013; 158:1907-15. [DOI: 10.1007/s00705-013-1687-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/22/2013] [Indexed: 02/06/2023]
|
18
|
Esmat G, El Kassas M, Hassany M, Gamil ME, El Raziky M. How to optimize HCV therapy in genotype 4 patients. Liver Int 2013; 33 Suppl 1:41-5. [PMID: 23286845 DOI: 10.1111/liv.12059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
HCV is a worldwide disease with an estimated prevalence by WHO of 3%. Hepatitis C virus 4 is prevalent in Africa and the Middle East, especially Egypt. The treatment of HCV4 is affected by many factors, related to the virus itself (genotype, pretreatment viral load and prevalent quasispecies), to the host (genetic factors, age, ethnicity and liver histology), to the presence of comorbidities (obesity, insulin resistance and co-infections) and to the therapeutic drugs (type, dose and duration). Optimizing treatment is the goal of daily practice to obtain the best results for the patient.
Collapse
Affiliation(s)
- Gamal Esmat
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | | | | | | |
Collapse
|
19
|
Abstract
Worldwide eradication of hepatitis C virus (HCV) is possible through a combination of prevention education, universal clinical and targeted community screening, effective linkage to care and treatment with promising new direct-acting antiviral drug regimens. Universal screening should be offered in all healthcare visits, and parallel community screening efforts should prioritize high-prevalence, high-transmission populations including injection drug users, prison inmates and those with HIV/HCV co-infection. Increasing awareness of HCV infection through screening, improving treatment uptake and cure rates by providing linkage to care and more effective treatment, and ultimately combining education efforts with vaccination campaigns to prevent transmission and reinfection can slow and eventually stop the 'silent epidemic'.
Collapse
Affiliation(s)
- Liesl M. Hagan
- Center for AIDS Research; Emory University School of Medicine and Veterans Affairs Medical Center; Decatur GA USA
| | - Raymond F. Schinazi
- Center for AIDS Research; Emory University School of Medicine and Veterans Affairs Medical Center; Decatur GA USA
| |
Collapse
|
20
|
Derbala M, Rizk N, Shebl F, Alkaabi S, Eldweik N, John A, Sharma M, Yaqoob R, Almohanadi M, Butt M, Alejji K. Interleukin-28 and hepatitis C virus genotype-4: treatment-induced clearance and liver fibrosis. World J Gastroenterol 2012; 18:7003-8. [PMID: 23323000 PMCID: PMC3531686 DOI: 10.3748/wjg.v18.i47.7003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 05/31/2012] [Accepted: 06/08/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the association between interleukin-28B (IL28B) genotype and response to treatment and hepatic fibrosis in patients with hepatitis C virus (HCV) genotype 4. METHODS Two hundred and one HCV-genotype 4 patients were included. All patients were treated with Peginterferon alph2a/Ribavirin for 48 wk. End of treatment response (ETR) was defined as loss of detectable serum HCV RNA at the end of treatment. Sustained viral response (SVR) was defined as loss of detectable serum HCV RNA at the end of 24 wk follow up. Genotyping of IL28B rs12979860 was performed using the TaqMan assay. We used logistic regression to estimate the adjusted odds ratio (aOR) and 95%CI. RESULTS The study included 201 HCV-genotype 4 patients. The majority of patients were men (89.6%), with a median age of 47 years, inter-quartile range (40-51). Approximately 62.5% of patients had ETR, and 49.6% had SVR. Individuals who achieved SVR were more likely to be younger (χ(2) = 4.91, P = 0.027), and less likely to have fibrosis (χ(2) = 15.54, P < 0.0001), or inflammation (χ(2) = 7.58, P = 0.006). The genotype distribution of rs12979860 was 36.2%, 49.0% and 14.8% for genotypes CC, CT, and TT, respectively. In these participants, rs12979860 genotype distribution did not differ by gender (P = 0.466), pretreatment viral load (P = 0.600), inflammation (P = 0.435), or fibrosis (P = 0.291). The frequencies of IL28B rs12979860 genotypes were TT (14.8%), CT (49.0%), and CC (36.2%). Compared to rs12979860 genotype TT, aORs (95%CI) for ETR and SVR were: CC genotype, [17.55 (5.34-57.69) and 5.92 (2.09-16.76), respectively]; CT genotype, [5.15 (1.80-14.78) and 2.48 (0.94-6.52), respectively]. In the current study, the patients who did not achieve ETR or SVR had a lower prevalence of rs12979860 CC (17.4% and 23.3%, respectively) than individuals who had ETR or SVR (47.9% and 47.2%, respectively). Individuals with rs12979860 CC genotype had approximately 6 times the odds of SVR compared to individuals with TT genotype (aOR = 5.92; 95%CI: 2.09-16.76). Similarly, patients with CT genotype had SVR more often than patients with TT genotype (aOR = 2.48; 95%CI: 0.94-6.52). Carrying at least one copy of the C allele (genotypes CT and CC) had almost 8 times the probability of ETR compared to those with genotype rs12979860 TT (aOR = 7.87; 95%CI: 2.84-21.82), and approximately 3 times the odds of SVR compared to those with genotype rs12979860 TT (aOR = 3.46; 95%CI: 1.37-8.74). In addition, data were consistent with a significant gene-dose relationship (aOR = 4.05/allele; 95%CI: 2.27-7.22). The association between rs12979860 genotype and SVR was similar among those who achieved and those who did not achieve SVR. CONCLUSION In HCV-genotype 4 patients, rs12979860 is a sensitive predictor of viral clearance, independent of viral load, age, gender or fibrosis, with no similar relation to severity of fibrosis.
Collapse
|
21
|
Ye Y, Yan YS, Chen G, Yan PP, Zheng WX, Deng YQ, Yang XH, Wu SL, Zhang ZS. Molecular epidemiology of hepatitis C virus among different groups of people in the province of Fujian, China. Arch Virol 2012; 158:611-8. [PMID: 23132411 DOI: 10.1007/s00705-012-1513-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Accepted: 09/10/2012] [Indexed: 12/19/2022]
Abstract
Genotyping of hepatitis C virus (HCV) can provide valuable information for prognosis and treatment duration prediction. To explore the genetic diversity of HCV in Fujian Province, China, 112, 104 and 48 anti-HCV-positive serum samples were collected from volunteer blood donors, IDUs and patients, respectively, from Jan 2008 to Dec 2008 and were genotyped through sequence analysis, followed by phylogenetic analysis in the C/E1 and NS5B regions. Genotypes could be determined for 85.61 and 84.85 % of samples in the C/E1 and NS5B region, respectively. 6a was the most prevalent subtype, which accounted for 42.04 and 43.75 % in the C/E1 and NS5B region, respectively. Mixed infection and potential recombination were detected in this study. Kappa tests indicated that similar results were obtained by two genotyping methods targeting the C/E1 and NS5B regions. The differences in the main prevalent subtype between the three target groups suggest diversity of HCV prevalence in different populations.
Collapse
Affiliation(s)
- Ying Ye
- Department of Pathogenic Biology, School of Basic Medical, Fujian Medical University, No. 88, Jiaotong Road, Fuzhou, 350004 Fujian, People's Republic of China
| | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Aituov B, Duisembekova A, Bulenova A, Alibek K. Pathogen-driven gastrointestinal cancers: Time for a change in treatment paradigm? Infect Agent Cancer 2012; 7:18. [PMID: 22873119 PMCID: PMC3508868 DOI: 10.1186/1750-9378-7-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 07/27/2012] [Indexed: 02/06/2023] Open
Abstract
The regulation of cancerous tumor development is converged upon by multiple pathways and factors. Besides environmental factors, gastrointestinal (GI) tract cancer can be caused by chronic inflammation, which is generally induced by bacteria, viruses, and parasites. The role of these inducers in cancer development, cell differentiation and transformation, cell cycle deregulation, and in the expression of tumor-associated genes cannot be ignored. Although Helicobacter pylori activates many oncogenic pathways, particularly those in gastric and colorectal cancers, the role of viruses in tumor development is also significant. Viruses possess significant oncogenic potential to interfere with normal cell cycle control and genome stability, stimulating the growth of deregulated cells. An increasing amount of recent data also implies the association of GI cancers with bacterial colonization and viruses. This review focuses on host-cell interactions that facilitate primary mechanisms of tumorigenesis and provides new insights into novel GI cancer treatments.
Collapse
Affiliation(s)
- Bauyrzhan Aituov
- Nazarbayev University, 53 Kabanbay Batyr Avenue, Astana 010000, Kazakhstan
| | - Assem Duisembekova
- Nazarbayev University, 53 Kabanbay Batyr Avenue, Astana 010000, Kazakhstan
| | - Assel Bulenova
- Nazarbayev University, 53 Kabanbay Batyr Avenue, Astana 010000, Kazakhstan
| | - Kenneth Alibek
- Nazarbayev University, 53 Kabanbay Batyr Avenue, Astana 010000, Kazakhstan
- Republican Scientific Center for Emergency Care, 3 Kerey and Zhanibek Khan Street, Astana 010000, Kazakhstan
| |
Collapse
|