Hepatology division of Endemic Medicine Department, Cairo University is the leader medical center in the provision of high quality comprehensive & multidisciplinary care to hepatology patients. Our faculty members are aiming to keep the leadership in diagnosing and treating the complete range of common and complex liver diseases. Our mission also aims to achieve high excellence educational and training programs for out academic candidates, residents and fellows. We are aiming to keep leadership in hepatology research through exploration of the latest diagnostic procedures, treatment options, and patient-centered outcomes for patients with liver diseases.

Sub-disciplines:

I. General Hepatology

i. Acute liver failure

ii. Chronic liver diseases

1. HCV

2. HBV

3. Complications of portal hypertension

4. Cholestatic Liver Disease

5. Vascular Liver Disease

6. Pregnancy-Associated Liver Disease

iii. Miscellaneous

II. Liver Tumors (Benign & Malignant/HCC)

III. NAFLD & Clinical Nutrition

IV. Liver Transplantation

Hepatology subunits:

1. HCC multidisciplinary clinic

2. Liver transplantation unit

3. Kasr alainy viral hepatitis center (KAVHC)

4. Diagnostic and interventional ultrasonography unit

5. Cairo university center of hepatic fibrosis (CUC-HF)

6. NAFLD multidisciplinary clinic

1. HCC multidisciplinary clinic:

HCC multidisciplinary clinic is a novel landmark and the first multidisciplinary ever in Kasr Elaini Hospital. It started its activity in Faculty of Medicine (Cairo University) since 2009. It is a peculiar clinic that succeeded through the last few years to prove itself and provide an exceptional unique service, as a first time in Egypt, to diagnose and manage a serious disease known as hepatocellular carcinoma in respect to international guidelines and in a multidisciplinary way. We managed more than 1500 patients during these years and we succeeded to archive their data for future researches.

Team members:

This clinic includes team members from:

· Tropical Medicine Department.

· Diagnostic and Interventional Radiology Department.

· Surgical Department specialized in hepatic surgeries.

· Oncology Department (Cesium department).

· Clinical Pathology Department.

These members attend a regular weekly meeting every Sunday to revise case by case the best modality line of treatment for HCC putting in consideration their hepatic status.

Aim of the clinic:

· Confirmation of diagnosis.

· Choice of best treatment modality according to worldwide applicable guidelines.

· Follow up of patients post management.

Clinical services provided by the clinic and lines of treatment:

Lines of management include:

· Percutaneous ablative techniques: Radiofrequency / microwave.

· Transarterial chemoembolization/ chemoperfusion.

· Surgical resection.

· Living donor liver transplantation.

· Sorafenib (First was within a clinical trial then out of trial and follow up of those patients as Sorafenib is not available in Kasr El Aini Hospital).

· Best supportive care if incurable.

In addition, as we are concerned with all points in relation to HCC, management of the primary cause of liver disease is part of our mission and so we manage HCV patients who develop HCC and achieved complete cure.

Scientific research is an integral part of the clinic:

As scientific research is extremely important at same time of management of patients, we prepared the clinic with a minus 80 freezer that allows keep of blood sampling of managed patients for future advanced research. Also, we kept a good line of contact for tissue sampling from patients who needed surgical intervention (such as resection and liver transplantation) with Pathology Department.

Otherwise, we succeeded to:

· Apply MSc and MD theses. This included doctors from Tropical Medicine Department, Clinical Laboratory Department, Radiology Department, Cesium Department, Biochemistry Department and National Research Center.

· Abstract publications in important International congresses such as EASL congress.

· Training programs: we twice organized international PATH programs in Egypt.

· National congresses. HCC multidisciplinary clinic is an integral part in Egyptian congresses concerned in managing HCC.

· Clinical trials (one concerned with sorafenib in collaboration with Cesium Department).

· A new project is starting related to genetic predisposition for HCC. This project is under guidance of STDF.

· Collaboration with other oncology centers such as National Cancer Institute as well as National Research Center.

· Cooperativity with ESLC (Egyptian Society of Liver Cancer) and consideration of our clinic as a good template to spread HCC multidisciplinary clinics nation wise.

· Recently, a new society is established as The Egyptian Society of Liver Tumors in Kasr Elaini to help and support liver cancer patients and research.

· International cooperation with great research areas such as:

i. MD Anderson (Huston – Texas).

ii. Sloan Katerin (New York).

iii. Mayo Clinic.

· Future plan: To upgrade the clinic to be a serving independent unit with a multidisciplinary board to strengthen the serving and research role of the clinic in the region.

2. Liver transplantation unit:

The Liver Transplantation Program for living donor liver transplantation at Kasr Al-Aini Hospital, Faculty of Medicine, Cairo University is dedicated to offering the best medical care to patients and providing excellent clinical outcomes acting on the highest standards of ethical practice in all aspects of individual and organizational functions.

The program has started at Kasr Al-Aini Hospital, Faculty of Medicine, Cairo University since 2004, providing state-of-the-art technology and leading-edge medical and surgical interventions to provide individualized, ongoing care for adult and pediatric patients with liver disease in addition to the dedicated efforts in training, education and research. The program is recognized as one of the nation's leading centers for pediatric and adult liver transplants; making it one of the largest referral governmental transplant centers in Egypt in addition to its international and regional reputation for living donor liver transplant.

Since 2004, Kasr Al-Aini Hospital has performed 202 living related liver transplants, with comparable national patient and liver survival rates at the one- and three-year marks after transplantation. The liver transplant program performs annually approx. 15-20 living donor liver transplants (adult and pediatric). The program provides complete treatment, transplant and management options for patients with acute or chronic liver disease, as well as patients with liver cancer from all over Egypt and Middle East Region in accordance with the latest international guidelines in the field of transplantation.

The program is run in an interdisciplinary organizational structure involving experienced highly-qualified staff members at Faculty of Medicine, Cairo University; surgeons and hepatologists, pediatricians, anesthesiologist, intensivists, radiologists, pathologists. Pre and post transplant coordinators who are fellows responsible for pre-operative preparation of liver transplant candidates and post-operative follow up under the supervision of the senior staff members.

Clinical services include inpatient (ward, intermediate care and intensive care unit) and outpatient activities (assessment, pre- and post-transplant clinics, day care unit). In addition; different diagnostic and interventional procedures are performed for possible candidates and liver transplant recipients, such as US, Doppler, liver biopsy, cholangiography, Transient Elastography.

In addition to patient management conferences such as weekly listing, there are several regular teaching events including weekly rounds and liver transplant seminars, as well as monthly hepatobiliay rounds.

3. Kasr Alainy viral hepatitis center (KAVHC):

Kasr Al - Aini Viral Hepatitis Center (KAVHC) is one of the most recent projects carried out by Kasr Al-Aini University Hospital, Department of Endemic Hepatology and Gastroenterology as part of our contribution to the well being of the Egyptian society. It was founded with the participation of the National Toxicology Center, Hepatic Schistosomiasis Unit and Cairo University Hospitals in October 2009. The Center was fully established and equipped by spontaneous efforts, where national pharmaceutical companies and charity foundations supplied the center with the required furniture and devices. Also the center was granted with the Science and Technology Development Fund (STDF) by the Academy of Scientific Research and Technology, which supported the Center with advanced equipment.

Adminstrative details:

The center was founded by Prof. Dr. Gamal Esmat (Former Vice President of Cairo University) and is directed by Prof. Dr. Rabab Fouad, Professor of endemic medicine, Cairo University.

Objectives:

1. Diagnosis and follow-up of patients with viral hepatitis, liver and digestive system diseases, providing treatment and vaccines for liver viruses and instruction on preventive measures.

2. Collaboration in scientific research, development of diagnostic tools in the field of liver disease, providing physicians with training and scientific knowlege.

KAVHC Units: HCV Unit – HBV Unit – Hepatic Fibrosis Unit – Liver Cancer Unit.

Activities and services

•Health care services:

1. Diagnosis of liver and digestive system diseases:

- Ultrasound: To diagnose various disorders and early detection of liver tumors.

- Fibroscan^®: This technology is used to determine the degree of liver fibrosis as a non-invasice alternative to liver biopsy. About 12100 patients were examined so far.

- Laboratory investigations: Including conventional tests and tumor markers.

2. Treatment of chronic hepatitis patients:

HCV patients are provided with the latest internationally approved drug regimens at very low prices in association with the National Committee for Combating Viral Hepatitis (NCCVH) and via support from the Egyptian pharmaceutical companies to eliminate waiting lists. Free of charge treatment was provided to those who cant even afford the discounted treatment; it was possible by the aid of donations from businessmen and NGOs. Also HBV patients are treated with the latest drugs available in the market at a discounted price.

3. Treatment project for Cairo University workers and students:

The Center is the main pillar of the Cairo University initiative labeled "Cairo University is free of HCV", where the center provides clinical examination and medical supervision free of charge for faculty members and their families, students and employees of Cairo University who were diagnosed with the virus.

4. Financial support of university hospitals and Cairo University (> 1Million LE)

Out of the Center's revenues and grants of research projects conducted within, more than one millions pounds were supplied to the University Hospital accounts. The National Center for Toxicology was also provided with 20% of the revenues of investigations done in the Center. Cairo University has also been supported by 20% of the research grants.

• Scientific and research activities:

Scientific research is one of the main objectives for which the Center has been established to evolute the management of viral hepatitis.

1. Research Projects:

Due to the academic and professional reputation of the Center, 14 research studies were conducted within, which have been serving nearly 1000 patients so far. For instance,

-Within the framework of funding from the STDF, several projects were conducted: “Predictor of fibrosis in chronic HCV”: a project to diagnose liver fibrosis by novel methods. Also the “Capacity bulding” project and other projects to identify methods of HCV infection and studying impact of hepatic schistosomiasis and HCV in Egypt.

-Treatment of HCV using the novel drug Sovaldi^® in cooperation with Gilead^© Sciences Pharmaceutical Company. This study was an essential nucleus in evaluating the drug before being approved by the Egyptian Ministry of Health for HCV treatment. Another study was conducted to evaluate the feasibility of Harvoni^® in cooperation with Gilead^©.

-Several clinical trials have been conducted to evaluate the safety and efficacy of the drugs used to treat chronic HCV patients such as the study of Qurevo^® in collaboration with Abbvie^© pharmaceutical, the study of Simeprevir^® in collaboration with Janssen^©, and the feasibility study of a new drug in collaboration with Pharco^© pharmaceuticals.

2. Supervising thesis of post-graduate studies:

So far, there have been 20 masters and 6 doctoral dissertations supervised in association with the Department of Endemic Diseases and other departments.

3. Scientific publishing and participation in scientific conferences:

Participated in international scientific conferences such as the American Society of Aesthetics (AASLD) and the European Society of Liver Diseases (EASL) Conferences. In addition, 17 peer reviewed publications have been published in international scientific journals with distinct impact factor and in the highest influential journals in the field of liver diseases.

• Social contribution Activities:

1. Screening and providing of medical convoys:

Sectors of patients, their families and a group of doctors were screened free of charge for early detection of viral hepatitis and hepatitis B and hepatitis A vaccines were provided. The center supplies the medical convoys carried out by the Faculty of Medicine - Cairo University in remote places with doctors and devices.

2. Training courses:

Lectures were given to specialized doctors, attended by almost 150 physicians and taught by faculty members. The Center also trained doctors in different governorates to use the Fibroscan device and analyze the results efficiently. Also in collaboration with the Middle East School of Hepatology, the Center organized a training course for doctors which included 45 doctors from different countries.

3. Awareness lectures:

Awareness lectures on the dangers of hepatitis viruses, methods of transmission, prevention and treatment were provided to families of patients with viral hepatitis and to patients who were treated to prevent recurrence. Lectures were also held to discuss HBV dangers and risks for 70 of patients in cooperation with GSK^© pharmaceutical company.

4. Diagnostic and interventional ultrasonography unit:

· The ultrasound unit of Endemic Medicine Department has three missions to be fulfilled:

1- Offering diagnostic and therapeutic interventional abdominal ultrasound for:

A. A-in-patients of our department, for patients referred from different departments of the hospital and from the emergency surgical department.

B. B-Out-patients referred from different governorates for highly specialized therapeutic services.

2-Educational services: Training of young doctors; post-graduate of Endemic medicine and Radiology Departments.

3-Research work.

· The weekly work schedule:

1- Interventional ultrasound unit:

-Twice/week, each for 8 hours.

-Types of intervention:

1- Ascitic fluid sampling and therapeutic tapping.

2-Aspiration of Hydatid cyst.

3- Aspiraration of intra-abdominal collections and abscesses and pig-tail insertion.

4-Liver biopsy and biopsy from other intra-abdominal organs.

5- Targeted biopsy of focal organ lesions, intra-abdominal lymphadenopathy.

6-Targeted biopsy of bowel and omental lesions.

5. Cairo University Center Of Hepatic Fibrosis (CUC-HF):

It was established in 2013 in Endemic Medicine Department, Faculty of Medicine, Cairo University as a STDF funded center of excellence.

Aim:

· Innovation of the first specialized centre in Egypt concerned about the diagnosis, prediction and prevention of long term complications of hepatic fibrosis especially portal hypertension.

· Creation of center of reference well equipped with the most available methods for non-invasive assessment of liver fibrosis using blood marker panels, serum serogates and ultrasound-based modalities as Fibroscan and ARFI devices instead of invasive liver biopsy.

· Development of bioinformatic infrastructure for data mining including the data of the patients studied, helpful for development of scoring system to validate hepatic fibrosis and prediction of fibrosis and related complications.

· Training of medical and paramedical staff on the new modalities of diagnosis, assessment and interpretation of the results specialized in the diagnosis of hepatic fibrosis and providing adequate patients education and medical care for patients with chronic liver disease. Transfer knowledge and experience to other investigators and different centers specialized in diagnosis and treatment of hepatic diseases among the nation.

· Establish a library for database related to liver diseases and fibrosis helpful in different epidemiological future researches by archiving patients’ data and samples which will be helpful for future researches in genetic and molecular diagnosis and treatment of hepatic fibrosis.

Team:

Director: Prof Ayman Yosry

Research advisor: Prof Mahasen Abdelrahman

Scientific manager: Prof Naglaa Zayed

Administrative manager: Dr. Ahmed Khairy

Bioinofmatic analysis: Engineer: Baker Awad

Achievements:

· Estalishment of database for more than 3000 chronic liver disease patients of different aetiologies mainly HCV, HBV, NASH, HCC, liver transplantation and cholestasis.

· Training of young doctors in Turkey and Germany on different imaging modalities, endoscopy and HVPG measurement.

· Establishment of international cooperation with ULM University in Germany.

· Active collaboration with Endemic medicine department, HCC clinic, clinical pathology department in faculty of medicine, Cairo university in addition national research institute.

· Sharing in more than 35 master and MD theses.

· Providing patient service such as diagnosis, treatment, follow up of patients with chronic liver disease, abdominal ultrasound, upper and lower GI endoscopy, EUS, functional hepatic reserve measurement, fibroscan, ARFI and HVPG measurement.

6. NAFLD multidisciplinary clinic:

· Program Items

§ Screening

§ Diagnosis

§ Management

§ Follow up

· General Objectives:

1- Building research capacity in Diagnosis and management of NAFLD patients (whole spectrum)

2- Integrating clinical nutrition concepts in clinical practice of Hepatogastroenterologists

3- Lowering prevalence of Malnutrition among patients with different Hepatogastroenterology illness

· Approach

o Any patient with one or more risk factors for NAFLD or malnutrition will be referred to the clinic to be evaluated as follow:

1- Proper history taking

2- Proper clinical examination with anthropometric measurements

3- Laboratory evaluation

4- Abdominal ultrasonography

Patients with negative (viral hepatitis markers & ANA) and bright liver on abdominal US will proceed for further evaluation as follows:

1. Liver biopsy

2. Blood storage

o Any patients admitted or presented to outpatient clinics with Hepatogastroenterology illness will be subjected to brief or detailed Nutritional assessment to allow further management.

· Infrastructure

Human Resources

i. Team members:

Hepatologist

Clinical Nutritionist

Clinical Dietician

Endocrinologist

Endoscopist

Bariatric surgeon

Pathologist

ii. Data Entry personnel

Collaborations:

National Nutrition Institute

Diabetes clinic

Other Disciplines

7.Pregnancy-Associated Liver Disease

Introduction: Liver diseases during pregnancy are not uncommon, they may have bad prognosis to both the mother and fetus so it is important to get a multi-disciplinary approach for early detection and management of such situations.

We usually face different scenarios; first one is related to liver diseases which occur in specific time throughout pregnancy, the second one is not specifically related to pregnancy and can occur at any time during pregnancy, the third one pregnancy occurring in pre- existing liver disease patients.

“Liver diseases in pregnant females” meeting was established in Endemic medicine department, Cairo University in September 2017.

It is a multidisciplinary team that include; hepatogastroenterologist, gynecology & obstetricians and pediatricitians.

We receive pregnant women (both inpatients & outpatients) who present with features of liver diseases, biliary diseases or infections (hepatotropic or non hepatotropic viruses), this occurs weekly every Monday at 12 pm at Kasr el Aini hospital outpatient clinic & for inpatients in endemic or obstetrics departments.

Our Goals:

· Early detection & management of new onset liver disease or biliary diseases during pregnancy.

· Screening for hepatotropic viruses vertically transmitted in pregnant women and offering therapy to the mother if needed during pregnancy.

· Follow up of pregnant women with pre-existing liver disease through pregnancy & after delivery.

· Ensure safe maternal & fetal outcome

· Offering treatment for new born from infected mothers.

Activities :

-Patients---> full history and physical examination & possible imaging.

-Screening for vertically transmitted hepatotropic viruses.

-Management of any liver disease with pregnancy and routine assessment by imaging or endoscopies (if possible).

-Follow up of pregnant women after delivery to assess maternal and fetal outcome.

-Patients counselling ---> For encouraging screening for hepatotropic viruses ( HCV, HBV, HIV) & non hepatotropic viruses (CMV & EBV) for their family member.

For the possibility and risk of recurrence of non-infectious disorders in future pregnancies

-Residents & Junior staff---> Training on how to manage pregnant women with any liver disease

-Meetings Participations in staff rounds with real cases presentation from the patients.

Participation in conferences & establishment of guidelines for liver diseases in pregnant females

-Researches -Screening for hepatotropic viruses ( HCV, HBV, HIV) & non hepatotropic viruses (CMV & EBV -Outcome post-delivery for pregnant women