LIVER

COVE

RST

ORY

(

(

APRI

L20

14+

DO

CN

DO

C31

Respon

sibleforu

pto

500

oddfunctio

nsinhu

man

body,liveris

also

vulnerab

leto

severalm

etab

olic,

toxic,microbial,circulatoryan

dcancerou

sinsults.D

ocNDoc

looksa

tsomekeyprob

lemso

fliveran

dtheir

treatm

ents,and

recent

prog

ressin

term

softran

splantationan

dresearch.The

fivespecialists

sharetheirexperiences

ontackling

liverdiseases,estab

lishing

Indiaas

alow-costlivertran

splant

destinationforthe

world,

hepa

totoxicityresearch

andwaysto

preventrisingliverdiseases

Ital

lde

pend

son

the

fen

ce.W

ith

the

acce

pta

nce

of

bra

ind

eath

,it

bec

ame

po

ssib

leto

no

to

nly

un

der

take

kid

ney

tran

spla

nta

-ti

on

s,b

ut

also

star

to

ther

solid

org

antr

ansp

lan

tssu

chas

of

liver

,h

eart

,lu

ng

san

dp

ancr

eas.

Ijo

ined

Sir

Gan

ga

Ram

Ho

spit

alan

dse

tu

pa

liver

tran

spla

nta

tio

nu

nit

alo

ng

wit

hD

rS

Nu

nd

y.T

he

de-

part

men

tco

nd

uct

edth

efi

rst

liver

tran

spla

nt

in20

01.

Th

isw

asa

de-

ceas

edd

on

or

liver

tran

spla

nt.

Alo

ng

wit

hD

rN

un

dy,

Ista

rted

livin

gd

on

or

liver

tran

spla

nta

tio

nas

the

pre

do

m-

inan

tfo

rmof

liver

tran

spla

nta

tio

n.

In20

04

,we

wer

ed

oin

gab

ou

t10

to12

tran

spla

nts

aye

ar,b

ut

mo

stpa

-ti

ents

wer

en

ot

keen

tog

oth

rou

gh

the

pro

cess

.Usu

ally

,th

ese

case

sw

ere

atth

ela

stst

age,

and

had

no

op

tio

nb

ut

tran

spla

nta

tio

n.B

ein

gla

stst

age

case

s,th

esu

rger

yre

sult

sal

sova

ried

.In

200

5,I

left

for

Ho

ng

Ko

ng

,th

ep

ion

eer

inth

esp

ecia

lisa-

tio

n.I

cam

eba

ckan

djo

ined

Ap

ollo

Ho

spit

als

in20

06

.In

dia

has

com

eah

ead

sin

ce,b

ut

the

jou

rney

had

alo

tof

hu

rdle

s.L

ike,

tho

ug

hth

eB

illw

asin

pla

cean

dth

ere

was

ah

ug

en

eed

ofo

rgan

do

no

rs,s

oci

ety

cou

ldn

ot

be

mo

ti-

vate

dto

do

nat

eo

rgan

s.T

hen

,in

case

sof

paed

iatr

ictr

ansp

lan

ts,t

ill19

97,

on

lyad

ult

sco

uld

giv

ea

po

r-

tio

nof

thei

rliv

erto

child

ren

.Oth

erco

un

trie

sw

ere

rep

ort

ing

bre

ak-

thro

ug

htr

ansp

lan

tsu

rger

ies,

soth

ere

was

know

led

ge.

Bu

tth

ere

was

also

am

ind

set

that

inh

ibit

edp

eop

leto

do

nat

eo

rgan

s.A

tA

po

llo,w

hat

we

hav

ed

on

ed

iffe

ren

tly

islo

w-c

ost

tran

spla

nta

-ti

on

.Th

eco

stof

aliv

ertr

ansp

lan

tis

less

erat

CL

BS

than

oth

erh

osp

ital

s.W

em

ade

chan

ges

inth

em

edic

a-ti

on

s.In

itia

lly,t

he

med

icin

esw

ere

exp

ensi

ve.W

ech

ang

edth

eman

dp

resc

rib

edpa

tien

tssi

mp

lem

edi-

cin

es.W

eal

soim

ple

men

ted

som

ete

chn

ical

chan

ges

and

trai

ned

cen

-tr

esac

ross

the

wo

rld

.Rig

ht

fro

mte

ams

inP

akis

tan

and

Ban

gla

des

hto

tho

sein

Ind

ia,w

eh

ave

trai

ned

man

yh

osp

ital

so

ntr

ansp

lan

tca

ses.

�W

hat

’syo

ur

tip

too

the

rh

osp

i-ta

ls,e

spe

cial

lyth

ose

inth

ep

ub

licse

cto

r?T

he

pu

blic

sect

or

ho

spit

als

nee

dto

take

mo

reca

ses.

Th

eyn

eed

toco

l-la

bo

rate

wit

ha

gro

up

that

isw

elle

s-ta

blis

hed

intr

ansp

lan

tati

on

.Bu

tev

ery

ho

spit

aln

eed

sto

un

der

stan

dth

attr

ansp

lan

tati

on

ish

ard

wo

rk.A

tti

mes

,tra

nsp

lan

tsu

rger

ies

star

tin

the

mo

rnin

gan

dfi

nis

hin

the

nig

ht.

Th

ete

amn

eed

sfo

cus,

ded

icat

ion

and

har

dw

ork

tom

ake

tran

spla

nta

-ti

on

succ

essf

ul.

�W

hat

pe

rce

nta

ge

of

you

rto

tal

case

sco

mes

fro

mab

road

?T

he

case

sth

atco

me

her

efo

rtr

ans-

pla

nta

tio

nca

nn

ot

be

pu

tu

nd

erth

eh

ead

ofm

edic

alto

uri

sm.T

he

peo

ple

that

com

eto

us

are

fro

mP

akis

tan

,B

ang

lad

esh

and

Nep

al,a

nd

they

are

her

eb

ecau

seof

wo

rdof

mo

uth

.T

hey

reco

gn

ise

the

go

od

wo

rkw

eh

ave

do

ne.

Tod

ay,a

bo

ut

80

per

cen

tof

ou

rca

ses

com

esfr

om

the

Ind

ian

sub

con

tin

ent.

Th

ere

st,t

hat

is20

per

cen

t,co

mes

fro

mju

stan

y-w

her

e,es

pec

ially

fro

mco

un

trie

sw

her

eth

ere

isn

oo

pti

on

oftr

ans-

�Te

llu

sab

ou

tyo

ur

jou

rney

asa

live

rtr

ansp

lan

tsu

rge

on

.In

the

199

0s,

wh

enIw

astr

ain

ing

inA

llIn

dia

Inst

itu

teof

Med

ical

Sci

-en

ces

(AIIM

S),

New

Del

hi,

we

had

ave

ryac

tive

liver

un

it.B

ut

mo

stpa

-ti

ents

wh

oh

adliv

erfa

ilure

,unf

ort

u-

nat

ely,

kep

td

yin

g.T

he

case

sof

cad

aver

liver

tran

spla

nts

wer

eb

ein

gre

po

rted

abro

ad,b

ut

tran

spla

nta

-ti

on

was

no

tp

oss

ible

inIn

dia

.At

that

tim

e,at

the

beh

est

ofR

ajiv

Gan

dh

i,th

eca

sew

asp

icke

du

p,an

dit

was

real

ised

that

ther

ew

asn

ore

cog

nit

ion

ofb

rain

dea

thca

ses

inIn

dia

.Bra

ind

eath

isth

eco

mp

lete

and

irre

vers

ible

loss

ofb

rain

fun

c-ti

on

(in

clu

din

gin

volu

nta

ryac

tivi

tyn

eces

sary

tosu

stai

nlif

e).S

uch

pa-

tien

tsco

uld

sup

ply

org

ans

toth

ose

wh

on

eed

edth

em.

Ou

rte

am,w

hic

hin

clu

ded

emi-

nen

tsu

rgic

alg

astr

oen

tero

log

ist

Dr

SN

un

dy,

did

ast

rin

go

fm

eeti

ng

sal

love

rIn

dia

,wit

hth

eo

bje

ctiv

eto

bri

ng

reco

gn

itio

nto

bra

ind

eath

case

s.In

199

4,t

he

Tran

spla

nta

tio

no

fH

um

anO

rgan

Act

was

pas

sed

inIn

dia

tost

ream

line

org

and

on

atio

nan

dtr

ansp

lan

tati

on

acti

viti

es.

Bro

adly

,th

eA

ctac

cep

ted

bra

ind

eath

asa

form

of

dea

than

dm

ade

the

sale

of

org

ans

ap

un

ish

able

of-

APRI

L20

14+

DO

CN

DO

C33

32D

OC

ND

OC+

APRI

L20

14

“L

iver

tran

spla

ntat

ion

isha

rdw

ork”

Know

nalloverthe

worldforh

islead

ingworkinlivertran

splantationintheIndian

subcon

tinent,

DrS

ubashGup

ta’steam

atCe

ntreforLiveran

dBiliarySciences

(CLBS),Ind

raprasthaAp

olloHospital,

New

Delhi,successfully

cond

ucted300livingdo

norlivertran

splantsin2013

.The

land

mark

makes

thecentreon

eof

thebu

siestlivertran

splantationhu

bs.Inan

interviewwith

JyotiV

ermaof

Doc

NDoc

,the

senior

consultant,livertran

splant

andga

strosurgery,shares

hise

xperiences

onlivertran

splantationan

dchalleng

esitfaces.Excerpts:

Interview

“At

Apo

llo,

wha

tw

eha

vedo

nedi

ffer

ently

islo

w-c

ost

tran

spla

ntat

ion.

We

have

also

mad

ech

ange

sin

med

icat

ions

and

have

trai

ned

cent

res

inha

ndling

tran

spla

ntca

ses”

pla

nt,

du

eto

vari

ou

sre

aso

ns.

�W

hat

issu

esd

oes

live

rtr

ans-

pla

nta

tio

nfa

ceto

day

?T

her

ear

em

any

issu

es.P

rim

arily

,Ib

elie

ve,i

tis

leg

isla

tio

nfo

rliv

ertr

ansp

lan

tati

on

and

kid

ney

tran

s-p

lan

tati

on

,wh

ich

has

bee

np

ut

inth

eh

and

sof

anau

tho

risa

tio

nb

od

y.M

any

ati

me,

the

com

mit

tee

isn

ot

sen

siti

veto

the

nee

ds

ofth

epa

-ti

ents

.Fo

rex

amp

le,i

nso

me

case

s,w

hen

the

do

no

ris

un

rela

ted

and

ifd

on

or

and

/or

reci

pie

nt

bel

on

gto

ast

ate/

un

ion

terr

ito

ry,o

ther

than

the

stat

e/u

nio

nte

rrit

ory

wh

ere

the

tran

spla

nta

tio

nis

pro

po

sed

tob

eu

nd

erta

ken

,a‘n

oo

bje

ctio

nce

rtif

i-ca

te’f

rom

the

stat

e/u

nio

nte

rrit

ory

ofd

om

icile

ofd

on

or

and

/or

reci

pi-

ent

isre

qu

ired

.Su

chre

qu

irem

ents

ofte

nd

elay

the

mat

ter,

lead

ing

topa

tien

t’s

dea

th.

For

case

sco

min

gfr

om

abo

ard

,w

eal

son

eed

tod

oa

lot.

Ifyo

uar

ein

cou

ntr

ylik

eS

ing

apo

re,w

her

evi

sas

for

med

ical

case

sg

eta

sin

gle

win

do

wap

pro

ach

,cas

esco

min

gto

Ind

iafa

cem

any

has

sles

.In

som

eca

ses,

peo

ple

stru

gg

leto

reac

hri

gh

th

osp

ital

s.T

he

Ind

ian

go

vern

-m

ent

mu

stad

dre

sssu

chis

sues

and

stre

amlin

eth

ep

roce

ss.

Wh

ileth

ere

isan

imm

ense

bu

r-d

enof

liver

dis

ease

sin

the

cou

ntr

y,w

eh

ave

limit

edm

edic

alp

rofe

ssio

n-al

sto

atte

nd

toth

eca

ses.

We

also

face

the

issu

eof

bel

ief.

We,

asa

so-

ciet

y,ar

en

owaw

are

ofo

rgan

do

na-

tio

n,b

ut

bel

ieve

that

such

anin

cid

ent

will

no

th

app

ento

us

or

anyo

ne

ino

ur

fam

ily.H

ere,

com

mu

-n

icat

ion

pla

ysan

imp

ort

ant

role

.Ath

ird

part

yin

volv

emen

t,lik

ea

hea

lth

insu

ran

cefi

rm,t

ob

uild

ast

and

,wh

ere

anin

div

idu

alis

com

-fo

rtab

lean

dco

nfid

ent

tod

on

ate

or-

gan

ssh

ou

ldb

efo

cuse

do

n.

Ind

iaal

son

eed

sto

hav

ea

go

od

,o

rgan

ised

hea

lth

care

syst

em,w

hic

hin

tere

stin

gly

exis

tsev

enin

smal

ler

cou

ntr

ies

like

Sri

Lan

kaan

dC

uba

.T

he

syst

emis

wh

ere

ever

yon

ein

the

soci

ety

has

acce

ssto

hea

lth

care

faci

litie

s.

�Te

llu

sab

ou

tth

ew

ho

lep

roce

ss,a

nd

how

CL

BS

has

mad

eit

smo

oth

and

succ

essf

ul.

Th

ela

nd

mar

kn

um

ber

oftr

ansp

lan

tsu

rger

ies

byth

ece

ntr

eis

bec

ause

ofth

eat

ten

tio

nw

eh

ave

giv

ento

ever

yd

etai

lof

the

pro

cess

.Iw

ill

beg

inw

ith

pla

nn

ing

,wh

ich

isve

ryim

po

rtan

t.Im

ust

tell

you

agai

nth

atth

epa

tien

tsth

atco

me

tou

sar

eb

e-ca

use

ofw

ord

ofm

ou

th.N

ot

just

be-

fore

the

op

erat

ion

,bu

taf

ter

itto

o,w

ed

ore

gu

lar

follo

w-u

pso

npa

-ti

ents

’hea

lth

and

reco

rdth

eir

re-

cove

ry.W

ear

ein

con

sist

ent

tou

chw

ith

them

and

thei

rfa

mili

es.W

een

-co

ura

ge

them

toke

epse

nd

ing

thei

rm

edic

alre

po

rts

even

ifth

eyar

ed

oin

gw

ell.

We

see

toit

that

pati

ents

do

n’t

take

thei

rh

ealt

hlig

htl

yan

dav

oid

med

icin

alsi

de

effe

cts

and

late

nt

dis

ease

s.P

ost

op

erat

ion

,th

ere

isa

seri

esof

test

sto

mo

nit

or

infe

ctio

ns,

reje

c-ti

on

and

nu

trit

ion

.Des

pit

eth

ese,

unf

ort

un

atel

y,ab

ou

t9

0p

erce

nt

(at

on

eye

ar)

ofth

eca

ses

turn

ou

tto

be

succ

essf

ul.

Th

ela

gis

du

eto

tech

nic

alre

aso

ns

(any

gap

insu

r-g

ery,

etc.

),im

mu

no

log

ical

and

re-

late

dto

infe

ctio

ns.

We

ensu

reth

atw

ep

resc

rib

ean

ti-r

ejec

tio

nm

edi-

cin

eso

rim

mu

no

sup

pre

ssiv

ed

rug

so

nly

asm

uch

asth

eo

rgan

allo

ws.

�S

har

ew

ith

us

som

eca

sest

ud

ies.

An

inte

rest

ing

case

was

atr

ansp

lan

to

na

five

-mo

nth

-old

baby

in20

07.

Th

eca

sew

asal

sow

idel

yre

po

rted

.T

he

fath

erw

asth

ed

on

or

inth

isca

se.T

hen

,rec

entl

y,w

eh

ada

case

wh

ere

the

pati

ent

had

afa

cto

rIX

def

icie

ncy

,wh

ich

isa

ble

edin

gd

is-

ord

erca

use

dby

ala

ckof

blo

od

clo

t-ti

ng

fact

or

IX.I

tw

asa

livin

gd

on

or

tran

spla

nt.

Th

eca

ses

show

that

ever

yd

ayis

un

iqu

efo

ru

s.W

em

ust

also

avo

idliv

erp

rob

-le

ms

(hep

atit

is,n

on

-alc

oh

olic

fatt

yliv

erd

isea

se,c

irrh

osi

san

dliv

erca

n-

cer)

and

op

tfo

rsa

feva

ccin

atio

nan

da

hea

lthy

lifes

tyle

.Th

eliv

er,i

nco

mb

inat

ion

wit

ho

ther

syst

ems

and

org

ans,

isth

ou

gh

tto

be

resp

on

sib

lefo

ru

pto

50

0se

para

tefu

nct

ion

s.W

en

eed

tore

spec

tit

toliv

eh

ealt

hyan

dfo

rlo

ng

.� APRI

L20

14+

DO

CN

DO

C35

34D

OC

ND

OC+

APRI

L20

14

“Despite

imm

ense

burd

enof

live

rdi

seas

es,In

dia

has

lim

ited

spec

ialist

sto

hand

leth

eca

ses.

As

aso

ciet

y,w

ear

eaw

are

ofor

gan

dona

tion

,bu

tbe

liev

eth

atsu

cha

case

will

notha

ppen

tous

”

DrSu

bhashGup

tawithProf(Dr)SKSarin,

Director,Instituteof

Liveran

dBiliarySciences,N

ewDelhi

size

and

mak

eit

apt

toth

ew

eig

ht

and

nee

ds

ofth

ech

ild.T

his

isca

lled

red

uce

dg

raft

.

�P

re-t

ran

spla

nt

eval

uat

ion

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tw

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term

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din

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re?

Wel

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term

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ess,

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uld

adm

itth

atw

ela

ckri

gh

tfr

om

hep

atit

isB

vacc

inat

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tore

gu

lar

chec

k-u

ps,

asm

ost

of

the

pat

ien

tsw

ed

iag

no

sear

ein

the

adva

nce

dst

age

of

the

dis

ease

.Bes

ides

,th

elif

esty

le,g

enet

icfa

cto

rsar

ere

spo

nsi

ble

for

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dis

ease

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ple

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rtu

nat

ely,

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eto

know

abo

ut

itat

ala

ter

stag

ean

dat

tim

esat

the

failu

rest

age.

Th

isis

anar

eao

fco

nce

rn.

Mo

sto

fth

eliv

erca

nce

rca

ses

can

be

pre

ven

ted

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op

tin

gsi

m-

ple

lifes

tyle

chan

ges

such

asre

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uce

dal

coh

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on

sum

pti

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tin

gh

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itis

Bva

ccin

atio

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dp

ro-

tect

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x.H

owev

er,s

om

efa

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fam

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isto

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ge

and

race

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bey

on

do

ur

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tro

l.

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nw

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rin

gd

own

the

cost

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er

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cer

trea

tme

nt?

Du

rin

gth

ep

ast

ten

yea

rs,I

nd

iah

asb

eco

me

aso

ug

ht-

afte

rd

esti

-n

atio

nfo

rp

ati

en

tsse

eki

ng

live

rtr

ansp

lan

td

ue

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igh

succ

ess

rate

of

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eri

esa

nd

aff

ord

ab

leco

st,

wh

ich

sta

nd

sa

ta

bo

ut

on

esi

xth

of

the

tota

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ced

ura

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en

ses

ava

ilab

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bro

ad

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on

sid

eri

ng

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pro

ced

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lon

gh

osp

ita

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de

dic

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am

of

pro

fess

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do

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ra

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ted

exp

en

ses,

the

cost

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eb

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gh

td

ow

nb

eyo

nd

asp

eci

fic

limit

.In

aco

rpo

rate

ho

spit

al,

the

cost

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rtr

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lan

tis

abo

ut`2

1-2

5la

kh,w

hile

ina

cha

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ble

org

an

isa

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nsu

cha

sS

GR

Hit

is`1

7.75

lakh

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he

bes

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on

isto

go

for

pre

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nti

veh

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resu

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reg

ula

rh

ealt

hch

eck-

ups

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atit

isB

vacc

i-n

atio

n,p

rote

cted

sex

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ah

ealt

hylif

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le.L

iver

can

cer

isa

tick

ing

tim

eb

om

b,as

the

situ

atio

naf

ter

10to

20ye

ars

isg

oin

gto

be

wo

rse.

�

“In

Indi

a,le

ssth

an5

per

cent

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ecia

list

sar

epe

rfor

min

gla

paro

scop

icG

Ica

ncer

surg

erie

s,w

hich

isqu

ite

less

com

pare

dto

the

num

ber

ofpa

tien

tsre

gist

erin

gfo

rth

epr

oced

ure”

PROGENITORCELLSCAUSIN

GLIV

ERTUMOURSISOLATED

AU

niv

ersi

tyof

Cal

ifo

rnia

rese

arch

team

,wh

ich

incl

ud

esan

Ind

ian

-ori

gin

scie

nti

st,h

asis

ola

ted

and

char

acte

rise

dth

ep

rog

enit

or

cells

that

giv

eri

seto

mal

ign

ant

hep

ato

cellu

lar

carc

ino

ma

(HC

C)

tum

ou

rs—

the

mo

stco

mm

on

form

ofliv

erca

nce

r—sa

ysa

rep

ort

.Th

est

ud

y’s

lead

auth

or

Mic

hae

lK

arin

,Ph

D,p

rofe

sso

rof

ph

arm

aco

log

yan

dpa

tho

log

y,an

dco

lleag

ues

rep

ort

edth

atH

CC

pro

gen

ito

rce

lls(H

cPC

)ta

kefo

rmw

ith

ind

ysp

last

ico

rab

no

rmal

lesi

on

sof

ten

fou

nd

ind

amag

edo

rci

rrh

oti

cliv

ers.

Stu

dy

co-a

uth

or

Deb

anja

nD

har

said

that

thei

rst

ud

ysh

owed

that

HcP

Car

elik

ely

der

ived

fro

md

ysp

last

icle

sio

ns,

can

pro

gre

ssto

mal

ign

ant

tum

ou

rsan

dfu

rth

erd

emo

nst

rate

that

thei

rm

alig

nan

tp

rog

ress

ion

toca

nce

rd

epen

ds

up

on

the

envi

ron

men

tth

atsu

rro

un

ds

them

.

Non

-alc

oh

olic

fatt

yliv

erdi

s-ea

se(N

AFL

D)

isth

em

ost

fre-

quen

tliv

er-r

elat

eddi

seas

ew

orl

dwid

ean

dis

beco

min

ga

publ

ich

ealt

his

sue

beca

use

ofit

sin

-cr

ease

dpr

eval

ence

.Th

isis

beca

use

ofo

besi

ty(1

5-3

0pe

rce

nt)

and

in-

sulin

resi

stan

ce/t

ype-

2di

abet

es(7

-15

per

cen

t)in

mos

tin

dust

rial

ised

cou

n-

trie

s.N

AFL

Dis

asp

ectr

um

ofdi

s-ea

sew

hic

hra

nge

sfr

om

thos

ew

ith

sim

ple

fat

accu

mu

lati

on

inth

eliv

er(f

atty

liver

)to

infl

amm

atio

nal

on

gw

ith

fat

(no

n-a

lco

ho

licst

eato

hep

ati-

tis

or

NA

SH

)to

full-

blow

nci

rrh

osis

(sca

rrin

gof

liver

).T

his

liver

dise

ase

occ

urs

inth

ose

wh

odr

ink

littl

eo

rn

oal

coh

ol( (

See

fig

ure

) .P

reva

lenc

e of

NA

FLD

is a

bout

15-

30 p

er c

ent

in t

he W

este

rn p

opul

a-ti

on, a

bout

58

per

cen

t in

ove

rwei

ght

subj

ects

, and

abo

ut 7

5-9

8 p

er c

ent

inth

ose

who

are

obe

se o

r no

n-di

abet

ican

d ob

ese.

The

exa

ct p

reva

lenc

e of

NA

SH

is d

iffi

cult

to

repo

rt a

s it

re-

quir

es a

n in

vasi

ve t

est

in t

he f

orm

of

a liv

er b

iops

y fo

r di

agno

sis.

How

ever

,it

is a

ppro

xim

atel

y 10

-15

per

cen

t of

thos

e w

ith

NA

FLD

. Abo

ut 2

5 p

er c

ent

of t

hose

wit

h N

AS

H p

rogr

ess

to d

e-ve

lop

fibr

osis

(ear

ly s

carr

ing)

and

abou

t 25

per

cen

t of

the

m p

rogr

ess

to d

evel

op c

irrh

osis

. A m

inor

ity

ofth

ese

pati

ents

wit

h ci

rrho

sis

(tw

o to

thre

e pe

r ce

nt)

prog

ress

es t

o en

dst

age

liver

dis

ease

and

live

r fa

ilure

.P

atie

nts

wit

h N

AS

H c

an d

evel

op h

e-pa

toce

llula

r ca

rcin

oma

(liv

er c

ance

r)in

less

tha

n th

ree

per

cent

(rep

orte

don

20

yea

rs f

ollo

w-u

p) w

itho

utde

velo

ping

cir

rhos

is a

nd in

tho

sew

ith

cirr

hosi

s du

e to

NA

SH

the

risk

is a

ppro

xim

atel

y tw

o to

thr

eepe

r ce

nt e

very

yea

r.

�P

rob

lem

s in

dia

gn

osi

sP

atie

nts

wh

o h

ave

fatt

y liv

er a

lon

ear

e ge

ner

ally

asy

mpt

om

atic

an

d th

epr

obl

em is

inci

den

tally

dia

gnos

ed o

nim

agin

g (u

ltra

sou

nd/

com

pute

d to

-m

ogr

aphy

sca

n/m

agn

etic

res

on

ance

imag

ing)

. Th

ese

pati

ents

wh

en s

ub-

ject

ed t

o li

ver

fun

ctio

n t

ests

are

fou

nd

to b

e ab

no

rmal

. Pat

ien

ts w

ith

NA

SH

an

d ea

rly

cirr

hos

is (

fibr

osis

)ar

e al

so ‘s

ilen

t’; i

t is

on

ly in

th

e ad

-va

nce

d st

age

of c

irrh

osis

th

at p

a-ti

ents

sh

ow s

ympt

om

s of

wea

knes

s,w

eigh

t lo

ss, f

luid

acc

um

ula

tio

n in

th

etu

mm

y, s

wel

ling

of f

eet,

loss

of

mu

s-cl

e m

ass,

jau

ndi

ce, b

loo

d vo

mit

ing,

etc.

It is

impo

rtan

t to

dia

gnos

e th

ese

pati

ents

in t

he

earl

y st

age

wh

en t

he

dise

ase

is r

ever

sibl

e (f

atty

live

r,N

AS

H a

nd

fibr

osis

), b

ut

on

ce t

her

e is

cirr

hos

is o

r liv

er c

ance

r, th

e ca

se b

e-co

mes

irre

vers

ible

an

d ad

van

ced,

mak

ing

the

trea

tmen

t di

ffic

ult

.O

ne

also

nee

ds

to r

ule

ou

t se

c-o

nd

ary

cau

ses

of f

atty

live

r (e

xces

-si

ve a

lco

ho

l co

nsu

mp

tio

n, c

erta

inm

edic

atio

ns,

nu

trit

ion

pro

ble

ms,

ex-

cess

ive

wei

gh

t lo

ss, s

tarv

atio

n, p

ar-

ente

ral n

utr

itio

n, t

oxin

s, e

tc.)

.

�D

iag

no

sis

Ris

k fa

cto

rs:T

he

exac

t ca

use

fo

rN

AFL

D is

dif

ficu

lt t

o p

inpo

int,

how

-ev

er, i

t is

ass

oci

ated

wit

h c

erta

inm

edic

al d

iso

rder

s. O

verw

eigh

t, o

be-

sity

, hig

h b

ody

mas

s in

dex

(abo

ve30

), t

ype-

2 d

iabe

tes,

car

diov

ascu

lar

diso

rder

, an

d pa

tien

ts w

ho

hav

e

APRI

L 20

14+

DO

C N

DO

C47

46D

OC

N D

OC+

APRI

L 20

14

met

abo

lic s

yndr

om

e ar

e m

ore

like

lyto

hav

e N

AFL

D. M

etab

olic

syn

dro

me

is d

iagn

osed

wh

en a

ny t

hre

e of

th

eri

sk f

acto

rs a

re p

rese

nt.

Th

e in

ci-

den

ce is

on

th

e ri

se b

ecau

se o

f m

od-

ern

Wes

tern

nu

trit

ion

, sed

enta

rylif

esty

le a

nd

gen

etic

pre

disp

osit

ion

.In

itia

lly, t

her

e w

as s

om

e o

bser

vati

on

that

NA

FLD

was

mo

re p

reva

len

t in

urb

an a

s co

mpa

red

to r

ura

l po

pula

-ti

on

, how

ever

, th

is is

no

t tr

ue

alw

ays.

Blo

od

tes

ts:L

iver

fu

nct

ion

test

s w

ill r

evea

l ab

no

rmal

itie

s(r

aise

d li

ver

enzy

mes

).Im

agin

g:U

ltra

son

og

rap

hy, C

T s

can

and

MR

I of

the

abd

om

en w

ill r

evea

lp

rese

nce

of

fat

in t

he

liver

, dia

gn

ose

cirr

ho

sis,

live

r ca

nce

r w

ith

cir

rho

sis

in t

he

adva

nce

d s

tag

e of

th

e d

is-

ease

sp

ectr

um

. Th

ere

are

ind

ices

for

dia

gn

osi

ng

fat

ty li

ver.

Oth

er

mo

dal

itie

s: F

atty

Liv

er In

dex

is a

sco

re b

ased

on

fo

ur

para

met

ers

(BM

I, w

aist

cir

cum

fere

nce

, tri

gly

c-er

ides

an

d g

amm

a g

luta

myl

tran

s-fe

rase

-a li

ver

enzy

me)

an

d is

calc

ula

ted

to

co

nfir

m o

r to

ru

le o

ut

the

pre

sen

ce o

f N

AFL

D.

Liv

er b

iops

y is

th

e g

old

sta

nd

ard

for

dia

gn

osi

ng

th

e w

ho

le s

pec

tru

mof

live

r d

isea

ses

asso

ciat

ed w

ith

NA

FLD

. Th

e in

vasi

ve n

atu

re o

f th

ep

roce

du

re is

a d

isad

van

tag

e th

ou

gh

.

�S

tag

ing

of

NA

FL

DN

AFL

D f

ibro

sis

sco

re (

NFS

) u

tilis

essi

x fa

cto

rs: a

ge,

blo

od

su

gar

leve

l,

BM

I, p

late

let

cou

nt,

ser

um

alb

um

in(a

fo

rm o

f p

rote

in),

an

d t

he

liver

en

-zy

mes

rat

io (

AS

T/A

LT).

It r

ule

s o

ut

adva

nce

d f

ibro

sis/

scar

rin

g w

hic

h is

irre

vers

ible

; th

is h

elps

in p

lan

nin

gth

e tr

eatm

ent.

Fib

roM

eter

is u

sed

to

co

nfir

m a

d-

van

ced

sta

ge

of f

ibro

sis/

scar

rin

g.

Th

is is

bas

ed o

n t

he

anal

ysis

of

seve

n p

aram

eter

s (a

ge,

wei

gh

t, f

ast-

ing

su

gar

, liv

er e

nzy

mes

–AS

T a

nd

ALT

, fer

riti

n-m

easu

re o

f ir

on

sto

rein

th

e b

od

y, a

nd

pla

tele

t co

un

t).

Fib

rosc

an is

an

oth

er n

on

-inv

a-si

ve t

oo

l to

det

erm

ine

the

liver

sti

ff-

nes

s/st

age

of f

ibro

sis/

scar

rin

g.

All

thes

e n

on

-inv

asiv

e m

easu

res

to a

sses

s liv

er f

ibro

sis

are

use

ful b

e-fo

re p

lan

nin

g f

or

a liv

er b

iops

y,w

hic

h is

per

form

ed o

nly

in t

hos

e pa

-ti

ents

wh

ere

the

test

is a

mbi

guo

us.

�Tr

eatm

ent

Th

e g

oal

s o

f tr

eatm

ent

in p

atie

nts

wit

h N

AFL

D a

re t

o r

ever

se a

nd

im-

pro

ve f

atty

ch

ang

e an

d p

reve

nt

fi-

bro

sis/

scar

rin

g. T

his

is a

chie

ved

by

lifes

tyle

mo

dif

icat

ion

s an

d m

edic

altr

eatm

ent.

Lif

esty

le m

od

ific

atio

ns

incl

ud

e w

eig

ht

red

uct

ion

(ab

ou

t 7-

10 p

er c

ent

wei

gh

t lo

ss)

by p

hysi

cal

exer

cise

an

d d

ieta

ry c

han

ges

(pla

nt-

bas

ed d

iet

rich

in f

ruit

s, v

eg-

etab

les,

wh

ole

gra

ins

and

hea

lthy

fat)

. Th

is im

pro

ves

the

liver

en

-zy

mes

, glu

cose

co

ntr

ol i

s b

ette

r in

dia

bet

ics,

an

d o

n li

ver

bio

psy

th

e in

-

flam

mat

ion

als

o r

egre

sses

.M

edic

al t

reat

men

t is

req

uir

ed in

a su

bse

t o

f p

atie

nts

wit

h N

AFL

D in

the

form

of

anti

-oxi

dan

ts v

itam

in E

and

C (

pre

ven

ts p

rog

ress

ion

of

fi-

bro

sis)

, an

d d

rug

s u

sed

to

tre

at d

ia-

bet

es (

imp

rove

s in

sulin

sen

siti

vity

and

live

r fu

nct

ion

s). H

owev

er, t

he

trea

tmen

t n

eed

s to

be

giv

en w

ith

cau

tio

n a

s th

ere

are

con

flic

tin

g r

e-p

ort

s (i

mp

rove

men

t ve

rsu

s ri

sks)

asso

ciat

ed w

ith

th

eir

con

sum

pti

on

.

Oth

er t

her

apie

s in

clu

de

usi

ng

bile

sal

ts, o

meg

a-3

po

lyu

nsa

tura

ted

fatt

y ac

ids,

ch

ole

ster

ol l

ower

ing

agen

ts (

stat

ins)

, pre

bio

tics

(n

on

-di-

ges

tib

le c

arb

ohy

dra

tes)

an

d p

rob

i-o

tics

(liv

er m

icro

-org

anis

ms)

. Th

ese

hel

p in

tak

ing

car

e of

ob

esit

y, d

ys-

lipid

emia

, car

dia

c p

rob

lem

s, in

sulin

resi

stan

ce a

nd

inte

stin

al m

icro

flo

ra.

Bar

iatr

ic s

urg

ery

is u

sed

to

tre

atm

orb

idly

ob

ese

pati

ents

(B

MI>

40

or

BM

I>35

wit

h c

om

orb

idit

ies)

. It

im-

pro

ves

the

fatt

y ch

ang

e an

d t

he

in-

flam

mat

ion

(N

AS

H)

in t

he

liver

.S

urg

ical

tre

atm

ent

in p

atie

nts

wit

h N

AFL

D is

a c

hal

len

ge

and

re-

qu

ires

go

od

per

iop

erat

ive

care

to

pre

ven

t ca

rdia

c an

d c

hes

t co

mp

lica-

tio

ns,

wh

ich

is v

ery

com

mo

n in

thes

e o

bes

e pa

tien

ts. D

efin

itiv

etr

eatm

ent

in t

he

form

of

liver

tra

ns-

pla

nta

tio

n is

req

uir

ed in

pat

ien

tsw

ith

ad

van

ced

cir

rho

sis

lead

ing

to

liver

fai

lure

or

wh

en t

her

e is

live

rtu

mo

ur

in a

cir

rho

tic

liver

. �

“T

he e

xact

caus

e of

NA

FL

D is

hard

to

pinp

oint

”

Column

Fatt

y Li

ver

NASH

Fobr

osis

Cirr

hosi

s

Hepa

toce

llula

r ca

rcin

oma

~15

-30%

of p

opul

atio

n

~10

-15%

pro

gres

s~

25%

pro

gres

s~

2-5%

/yea

r pr

ogre

ss~

2-3%

/yea

r pr

ogre

ss

Prog

ress

pos

sibl

e ?%

Non

-alc

ohol

ic fa

tty

liver

dis

ease

is q

uiet

ly o

n th

e ris

e am

ong

the

adul

t pop

ulat

ion,

writ

es D

r Vib

ha V

arm

a, c

onsu

ltant

,liv

er tr

ansp

lant

, hep

ato-

bilia

ry a

nd p

ancr

eatic

surg

ery,

Koki

labh

en D

hiru

bhai

Am

bani

Hos

pita

l