1. Please tell me about yourself and your choice of becoming a Hepatologist and liver diseases expert. How long have you been in the field?
I have done my training in Internal Medicine and Gastroenterology from the Postgraduate Institute of Medical Education and Research in Chandigarh, India. We had a very strong hepatology (liver disease) department in the institute, which is quite renowned. A number of original research takes place in the department, which get published in leading medical journals regularly. After getting trained as a Gastroenterologist, I worked in Abu Dhabi for 5 years from 2003 to 2008. I realized that there is a huge burden of liver disease in UAE. There were lots of doctors taking care of patients with liver disease but there were no facilities that could offer comprehensive state of the art care for all aspects of liver disease. I decided to do further training in advanced liver diseases and with a good recommendation from the Hepatology department in Chandigarh, India, I was able to get into the prestigious Mount Sinai Medical Centre in New York, the United States for a one year fellowship in advanced liver diseases and transplant hepatology. I completed that in 2009 and since the last 8 years I have been practicing Hepatology. I kept working between UAE and India and established an Integrated Liver Care (ILC) Team in Bangalore, India, which is a professional group of Hepatologists, hepatobiliary surgeons, liver transplant surgeons, interventional radiologists and liver intensive care experts. Our professional group, the ILC has been working since the past three years with the Aster DM Healthcare Group in India and we have our advanced liver centers at Aster Medcity in Kochi and Aster CMI Hospital in Bangalore, India, where we offer the complete range of medical and surgical care related to all forms of liver diseases, liver, pancreas and biliary tract cancers and multi-organ transplantation. We aim to bring the Aster Integrated Liver Care Program to the UAE so that we can offer cutting-edge, comprehensive care to patients suffering from liver diseases.
2. What causes liver diseases?
The first thing that comes to people’s minds when they think of liver disease is excess alcohol consumption. But in fact, many other liver diseases are more common than an alcoholic liver disease. By far the most common cause of liver disease is fatty liver, which happens in individuals who are overweight, have sedentary lifestyles, diabetes and high triglyceride levels in the blood. Most people assume that fatty liver is an innocuous problem but now we understand that a subset of patients have a progressive form of fatty liver that can damage the liver seriously. There are hepatitis viruses such as Viral Hepatitis A, B, C, D and E, which cause both acute (short lasting) and chronic (long standing) liver disease. Patients with chronic viral hepatitis usually do not have any symptoms and therefore are unaware of the problem. It is important to screen for viral hepatitis so that it can be detected and effectively treated at an early age. Some individuals have a condition called autoimmune liver disease in which their own body’s immune system starts damaging the liver. Excess accumulation of iron or copper in the body can also affect the liver. Children and young adults can suffer from a wide variety of metabolic and genetic liver diseases that may present in infancy or in adulthood. Various forms of cancers either arising from the liver or spread from other organs can also involve the liver.
3. Are there variations of liver disease? If so, what are these?
In general, liver disease patterns are the same all over the world. But there are variations such as the age of presentation. Patients with chronic viral hepatitis remain undetected for longer periods of time in Asia, Middle East and Africa since people do not get screened regularly. Hence they may present at a more advanced stage of the disease. People from Africa are in particular more prone to develop liver cancer from hepatitis B at a younger age. Hepatitis D virus, which is uncommon in most parts of the world, is common in central Asia and some areas of Middle East. Patients with chronic hepatitis C have a more rapid progression of liver disease in Asia compared to the Western world.
4. If there were variations of liver disease, what are the most common or most prevalent on the global scale, in the Middle East and North Africa, in the UAE?
On a global scale the most prevalent liver disease is non-alcoholic fatty liver disease followed by alcoholic liver disease and chronic viral hepatitis due to hepatitis B and C infections. In the MENA region, including UAE, non-alcoholic fatty liver is still the most common cause of liver disease due to high prevalence of obesity and diabetes with which this disease is linked. Chronic hepatitis B and C is quite common but largely undiagnosed.
5. How different are liver diseases in children compared to those among adults?
Children usually have a different spectrum of liver disease. Newborns and infants may develop liver disease as a result of serious metabolic and genetic defects. They usually present with yellowing of the skin and eyes (jaundice) and poor growth. These conditions can lead to liver failure quite early in the first few years of life. Such kids require liver transplantation. An important cause of liver disease in the first year of life is extrahepatic biliary atresia. In this condition the bile ducts inside the liver do not develop properly during the development of the baby. This leads to progressive jaundice right from the time of birth. This condition needs to be recognized within the first few weeks of life so that a special corrective surgery known as Kasai’s operation can be done. Else the child goes on to develop liver failure and requires a liver transplant. Children in their first decade of life can suffer from autoimmune liver disease as well as a condition called Wilson’s disease, which is a state of excess copper accumulation in liver due to a genetic defect. Once again early recognition of this problem can lead to proper medications to remove excess copper from the body before the liver gets irreversibly damaged. Children also develop liver cancers, which are quite different from liver cancers in adults. These are aggressive tumors but their response to chemotherapy and surgery is quite good. Some kids with a liver cancer need a liver transplantation.
6. How young is your youngest liver disease patient? Has he survived it? How?
We have treated children as young as one month with liver disease. These are usually children with extrahepatic biliary atresia requiring surgery. There are newborn kids who develop liver disease due to a correctable metabolic defect. For example there was a one-month-old girl with
a condition called galactsemia in which the child cannot metabolize the sugar called galactose in the milk. A simple treatment was exclusion of all forms of milk and milk products.
7. How old is your oldest liver disease patient? Has he survived it? How?
There are a large number of old patients above the age of 75-80 years with liver disease. Most of these patients have liver cirrhosis with liver failure. A lot of these patients develop liver cancer as well due to the long standing nature of liver diseases. Most of these patients are challenging because they are often too old and have other coexistent medical problems that preclude liver transplantation or major liver surgery. There was a 79-year-old Emirati gentleman who had liver cirrhosis and liver cancer and underwent a successful liver transplantation in 2006. He is 89 years old now and continues to be on my follow up care. Having said so, in general liver transplant is not offered above the age of 70 years.
8. What is the worst liver condition or disease, which you have encountered in your career? Please tell me about this and about the patient.
The worst liver condition is usually advanced liver cancer presenting with liver failure. In these cases, often no treatment is possible and patient survival is limited to a few months. We recently had an Iraqi gentleman, 65 years old who was detected to have a small 5 cm liver cancer one year ago. He could not get appropriate treatment at that time when it was in a curable stage. The cancer grew over a period of one year and the patient presented to us with liver failure. He had jaundice, accumulation of fluid in his belly, swelling of legs, mental confusion which are all signs of liver failure. The cancer had increased in size to 10 cm, had invaded the blood vessels and spread to the lung. He was brought to our center in Bangalore in a desperate state. He had three sons, all of them willing to donate a portion of their liver for liver transplantation. Unfortunately this was not a correct indication for transplantation. The patient could be offered only supportive care and passed away in three weeks.
9. How can liver diseases lead to cancer?
80% of liver cancers occur in livers, which have already developed cirrhosis. Cirrhosis is an advanced stage of liver disease in which the liver becomes scarred due to long standing ongoing damage due any factor such as chronic hepatitis B or C, alcohol use, non-alcoholic fatty liver disease. Cirrhosis is the most important risk factor for liver cancer. Certain causes of liver disease such as hepatitis B and C carry a higher risk of developing liver cancer. Ongoing liver damage over several years leads to repeated cycles of liver cell death and regeneration. Occasionally some of these regenerating liver cells become cancerous. Hepatitis B and C viruses specifically cause genetic changes in the liver cells causing them to turn cancerous. The best way to prevent liver cancer is early diagnosis and treatment of a chronic liver disease so that cirrhosis does not develop. Hepatitis B and C can be treated with effective antiviral drugs and the risk of liver cancer can be significantly reduced. Once a patient develops liver cirrhosis, it is important to do periodic ultrasound scans once in 6 months. This allows detection of cancers at an early stage when they are small and may not cause any symptoms. Small cancers are curable.
10. Your advice on how to avoid liver diseases.
Over 90% of liver diseases are preventable. Fatty liver disease can be controlled by following a healthy lifestyle keeping weight under control, regular exercise, eating a low fat and carbohydrate diet and making sure that other metabolic diseases such as diabetes, if present are well controlled. Hepatitis A and E are viruses that are transmitted through contaminated food, water and drinks. Food hygiene and sanitation in restaurants and eateries is important to prevent these infections. Hepatitis A and B are effectively prevented by a vaccine and these are recommended for all children as well as adults who are at risk of developing these infections. Screening for hepatitis B and C is important to detect these infections and all individuals especially in areas where there is high prevalence of infection should get screened at least once in their lifetime.
11. Is liver transplantation included in all health and medical insurance policies around the world, in the Mena, in the UAE? If not, do you recommend that health insurers consider this? Why?
Insurance coverage for liver transplantation is variable and depends from policy to policy. Most policies do not affect self-inflicted liver disease such as alcohol related diseases. There is also variability between policies in the diagnosis and treatment of Hepatitis B &C, which can contribute to people’s reluctance to get tested and treated. It is WHOs goal to eradicate hepatitis B and C by 2030, which in my opinion will need a combined effort from health care providers and payers to effectively treat these diseases with medications. Insurances would of course pay if liver disease is related to other causes such as non-alcoholic fatty liver and patient needs a liver transplant. At this moment, organ transplant in the UAE is limited, and some patients patients have to go abroad for this procedure. If the insurance policy covers treatment only within the UAE, then the transplant procedure would not get covered.
12. Your opinion on liver organ donation.
It is essential that organ donation be promoted at all levels right from government policies down to public education. There is an immense need for liver transplantation in the Middle East and Asia. Even in Europe and the West, where deceased donor organ transplantation occurs widely, there continues to be a shortage for organs. In Asia, deceased donor organ donations rates are very low and more than 90% of liver transplants being performed are living donor organ transplants. In the Middle East, except for few centers in Saudi Arabia and Egypt, deceased donor organ donation occurs rarely. It is important to have concerted efforts from all the countries in MENA region to establish liver transplant programs and promote deceased organ donation in order to reach and cure more patients.
13. How can we be sure that the liver organ transplantation will be safe for both the donor and the beneficiary?
Appropriate selection of donors for living donor liver transplants is very important. Liver donation by living donors is a major surgery and should not be taken lightly. A donor should have compatible blood group, be absolutely healthy, should not be overweight and should not suffer
from any major illnesses. Most liver transplant centers have well established protocols for detailed evaluation of living donors to ascertain that the surgery will be safe for them. Donors undergo a battery of blood tests, CT scan, liver biopsy, cardiac testing and various multi-specialty assessments to ensure their fitness. The donors should have an adequate volume of liver in order to safely donate a part of their liver to the patient. Healthy individuals can donate upto 65 to 70 % of their liver. The remnant liver regenerates in a few months.