Nonalcoholic Steatohepatitis: A Rapidly Increasing Indication for Liver Transplantation in India

Management of Portal Hypertension in the Older Patient

PURPOSE OF THIS REVIEW

Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease.

RECENT FINDINGS

Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.

Approach to Liver Transplantation: Is There a Difference between East and West?

Liver transplantation (LT) remains the only curative treatment for end-stage liver disease as well as acute liver failure. With the exponential increase in organ demand due to the increasing incidence and prevalence of liver diseases, the need to overcome the supply and demand mismatch has arisen. In this review, we discuss the current universal status of LT, emphasizing various LT practices worldwide.

Liver Transplantation Research from India During the Last 25 Years: 1998-2022

Background and aims

Liver transplant surgery has been performed in India for the last 25 years. We aimed to analyse the trends, characteristics, and key elements in the field of liver transplantation research from India.

Methods

On April 23, 2023, we conducted a search of the Scopus database for the literature on liver transplantation research, using a well-defined search strategy. MS Excel and VOS viewer software programs were used to examine the articles for organisation, author, journal, keywords, and high-cited literature.

Results

This analysis examined a total of 556 papers, which constituted only a 1.55% share of the global output. These papers involved 442 organizations, 1575 authors, and 147 journals. External funding was received in 4.13% and 23.56% were involved in international collaboration. Three Delhi-NCR organizations, namely the Medanta-The Medicity (n = 63), Institute of Liver & Biliary Sciences (n = 60), and Indraprastha Apollo Hospital (n = 48) led in publication productivity. M. Rela (n = 90) and A.S. Soin (n = 63) were the leading authors in publication productivity, while S. Sudhindran and P. Bhangui were the most impactful authors. Liver Transplantation (n = 96) and Journal of Clinical & Experimental Hepatology (n = 65) published the maximum number of these papers, whereas, Annals of Surgery and Journal of Hepatology led in the citation impact per paper. The most significant keywords were "Liver Transplantation" (n = 484), and "Living Donor" (n = 254). Only 1.80% (n = 10) of the papers were highly cited papers that received 50 to 142 citations and they together registered 69.9 citations per paper.

Conclusion

Although the number of publications on liver transplantation from India started growing recently, it forms only 1.55% of the global report. There is an unmet need to increase government-supported research and multicenter collaborative studies at national and international levels for high-quality patient care.

The Outcomes of Liver Transplantation in Severe Metabolic Dysfunction-Associated Steatotic Liver Disease Patients

The increasing prevalence of diabetes mellitus, obesity, and metabolic syndrome in the population can lead to metabolic dysfunction-associated steatohepatitis (MASH) and metabolic dysfunction-associated steatotic liver disease (MASLD). In Western industrialized countries, this has become a major problem with significant socioeconomic impacts. MASH is now a leading cause of liver transplantation (LT), especially in developed countries. However, the post-transplant outcomes of such patients are a major concern, and published data are limited and extremely variable. In this article, we discuss graft and patient survival after LT, complications, the recurrence of MASH, and MASH appearing de novo after transplantation. Recent studies suggest that patients with MASH have slightly worse short-term survival, potentially due to increased cardiovascular mortality. However, most studies found that longer-term outcomes for patients undergoing LT for MASH are similar or even better than those for other indications. Hepatocellular carcinoma due to MASH cirrhosis also has similar or even better outcomes after LT than other etiologies. In conclusion, we suggest questions and topics that require further research to enhance healthcare for this growing patient population.

Hepatocellular Carcinoma in Non-Alcoholic Fatty Liver Disease: From Epidemiology to Diagnostic Approach

Non-alcoholic fatty liver disease (NAFLD) is becoming the leading cause of liver morbidity worldwide and, as such, represents the pathogenic background for the increasing incidence of hepatocellular carcinoma (HCC). The annual incidence of NAFLD-related HCC is expected to increase by 45-130% by 2030. Diabetes mellitus is the most important risk factor for HCC development in NAFLD, with the risk further increased when associated with other metabolic traits, such as obesity, arterial hypertension and dyslipidemia. The highest risk of HCC exists in patients with advanced fibrosis or cirrhosis, although 20-50% of HCC cases arise in NAFLD patients with an absence of cirrhosis. This calls for further investigation of the pathogenic mechanisms that are involved in hepatocarcinogenesis, including genetics, metabolomics, the influence of the gut microbiota and immunological responses. Early identification of patients with or at risk of NAFLD is of utmost importance to improve outcomes. As NAFLD is highly prevalent in the community, the identification of cases should rely upon simple demographic and clinical characteristics. Once identified, these patients should then be evaluated for the presence of advanced fibrosis or cirrhosis and subsequently enter HCC surveillance programs if appropriate. A significant problem is the early recognition of non-cirrhotic NAFLD patients who will develop HCC, where new biomarkers and scores are potential solutions to tackle this issue.