Mithun Sharma

Asian Institute of Gastroenterology | AIG · Department of Hepatology

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in India. This review explores the epidemiological trends and the landscape of systemic therapy for HCC in the Indian context, acknowledging the recent shift in etiology from viral hepatitis to lifestyle-associated factors. A comprehensive review of the literature was con...

Human albumin (HA) solution is currently recommended only for patients with spontaneous bacterial peritonitis (SBP) and acute kidney injury (AKI). However, its use in hospitalized patients is quite frequent. The objective was to compare the outcomes of patients receiving HA in recommended (Gr. A) vs. non-recommended (Gr. B) indications. In this pro...

Abstract Introduction: Critically ill cirrhosis (CIC) patients admitted to the intensive care unit (ICU) are usually on broad-spectrum antibiotics due to suspected infection or as a hospital protocol. It is unclear if additional rifaximin has any synergistic effect with broad-spectrum antibiotics in ICU patients with acute overt hepatic encephalopa...

In this report, we present the case of vanishing bile duct syndrome in the setting of classical Hodgkin lymphoma. Vanishing bile duct syndrome was diagnosed retrospectively in this patient with Hodgkin lymphoma, who initially presented with a hepatic abnormality presumed to be drug induced. Vanishing bile duct syndrome is characterized by the disap...

Background/Purpose Genome‐wide association studies have reported the association of common variants with nonalcoholic fatty liver disease in genes, namely, PNPLA3/TM6SF2/MBOAT7/HSD17B13 , across ethnicities. However, the approach does not identify rarer variants with a higher effect size. We therefore sequenced the complete exonic regions of patien...

Background: Patients with cirrhosis are susceptible to infections, especially by multidrug-resistant organisms (MDROs). There are limited data on the incidence of culture-positive infections and the validity of Sepsis 3-criteria in patients with cirrhosis admitted to the intensive care unit (ICU) in India, which we aimed to assess. Methods: In this...

Background Ascites is expected to resolve within 2 to 4 weeks following orthotopic liver transplantation. New-onset ascites after transplant is associated increased morbidity and affects quality of life. The risk of opportunistic infections is high in transplant recipients due to immunosuppressive drugs. Objective The objective was to assess the in...

Cirrhosis transcends various progressive stages from compensation to decompensation driven by the severity of portal hypertension. The downstream effect of increasing portal hypertension severity leads to various pathophysiological pathways, which result in the cardinal complications of cirrhosis, including ascites, variceal hemorrhage, and hepatic...

Background: Liver transplantation (LT) is associated with excellent survival in patients with acute-on-chronic liver failure (ACLF). There is a lack of data assessing the healthcare utilization and outcomes of patients with APASL-defined ACLF undergoing living donor liver transplantation (LDLT). Our aim was to assess pre-LT healthcare utilization...

Liver transplantation (LT) is the definitive therapy for patients with end-stage liver disease, acute liver failure, acute-on-chronic liver failure, hepatocellular carcinoma, and metabolic liver diseases. The acceptance of LT in Asia has been gradually increasing and so is the expertise to perform LT. Preparing a patient with cirrhosis for LT is th...

Background and aims: Kayser-Fleischer (KF) rings are due to copper deposition in Descemet membrane of the cornea in Wilson disease. Pseudo-KF ring (PKF), seen in patients with high bilirubin, is often misinterpreted as KF rings. These are bilirubin deposits in posterior corneal stroma. The aim of the study was to prospectively evaluate the presenc...

Background and study aims Percutaneous liver biopsy is traditionally done on the right lobe of the liver. Endoscopic ultrasound-guided liver biopsy (EUS-LB) can be performed on either the left or right lobe or as a combined bi-lobar biopsy. Earlier studies did not compare the benefit of bi-lobar biopsies to single-lobe biopsy for reaching a tissue...

Background: Atezolizumab-bevacizumab (atezo/bev) combination is a recommended first-line systemic therapy for unresectable hepatocellular carcinoma (uHCC). There are no studies from India reporting the safety and efficacy of this drug in real-world settings where most patients present in an advanced stage. Methods: In this retrospective study fr...

Background: Alcohol is one of the most common causes of liver cirrhosis. Yet, the pattern of alcohol consumption in cirrhosis is rarely studied. This study aims to study the drinking patterns along with the educational, socioeconomic, and mental health in a cohort of patients with and without liver cirrhosis. Methods: This prospective observatio...

Worldwide, an estimated 2 billion individuals consume alcohol, which contributes to short-term or long-term consequences on health and social life. Alcohol is the cause of approximately 1.8 million deaths per year, representing 3.2% of all deaths worldwide. Of the 2 billion individuals who consume alcohol, more than 75 million are diagnosed with al...

Background and Aims Recent studies have reported poor humoral immune response to mRNA vaccines in patients with chronic liver disease (CLD). However, the immunogenicity of ChAdOx1 (vector-based) and BBV152 (inactivated virus) vaccines in patients with CLD and liver transplant recipients (LTRs) is unknown. Therefore, we aimed to assess the immunogen...

Background: Coronavirus disease-2019 (COVID-19) cholangiopathy is a recently known entity. There are very few reports of liver transplantation (LT) for COVID-19-induced cholangiopathy. It is well known that vaccines can prevent severe disease and improve outcomes. However, there are no reports on the impact of COVID-19 vaccines on cholestasis. Ther...

Background Tinospora cordifolia (giloy) is a commonly used herbal supplement mentioned in Indian alternative medicine for its action as an immune booster. During the COVID 19 pandemic many commercial preparations of giloy became popular and gained widespread use among the public to prevent severe COVID 19 infections. Some of these patients develope...

Aim Nonselective beta‐blockers (NSBBs) can reduce the incidence of complications in patients with cirrhosis and prolong survival. The safety and efficacy of NSBBs in real‐world settings in patients with acute‐on‐chronic liver failure (ACLF) identified by the Asian Pacific Association for the Study of Liver criteria are unknown. This study aimed to...

Coronavirus disease-2019 (COVID-19) cholangiopathy is a recently known entity. There are very few reports of liver transplantation for COVID-19 induced cholangiopathy. It is well-known that vaccines can prevent severe disease and improve outcomes. However, there are no reports on the impact of COVID-19 vaccines on cholestasis. Therefore, we aimed t...

Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors. Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infecti...

Background Non-alcoholic fatty liver disease (NAFLD) is now considered to precede the development of diabetes and metabolic syndrome (MetS) overriding the earlier notion of NAFLD being the hepatic manifestation of MetS. Studies identified variants conferring enhanced susceptibility to MetS predominantly in lipid metabolism related genes. A variant...

The COVID-19 pandemic has impacted transplantation worldwide in a major way with infections and post-COVID-19 complications contributing to increased mortality and morbidity. We present a case of a 42-year-old lady who developed rhino-orbital mucormycosis in a postliver transplantation period. The initial presentation of the patient was very subtle...

Terlipressin with albumin, the recommended treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI), is associated with adverse events. Furthermore, the course of AKI in patients with acute-on-chronic liver failure (ACLF) is unknown. We aimed to analyze the safety and efficacy of terlipressin infusion and AKI course in patients with ACLF. W...

Background & aims: Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019 (COVID-19). However, small reports have recently shown an association between Giloy use and the d...

Introduction: This study aimed to evaluate the role of prophylactic norfloxacin in preventing bacterial infections and its effect on transplant-free survival (TFS) in patients with acute-on-chronic liver failure (ACLF) identified by the Asian Pacific Association for the Study of the Liver criteria. Methods: Patients with ACLF included in the stu...

Introduction: Adequate weight loss can lead to reduction in steatosis, inflammation, and fibrosis in patients with obesity and non-alcoholic fatty liver disease (NAFLD). We evaluated the role of endoscopic sleeve gastroplasty (ESG) in patients with obesity and NAFLD. Methods: In this single-center prospective study, consecutive adult patients wi...

Background: Terlipressin with albumin, the recommended treatment for hepatorenal syndrome-acute kidney injury (HRS-AKI), is associated with adverse events. Furthermore, the course of AKI in patients with acute-on-chronic liver failure (ACLF) is unknown. We aimed to analyze the safety and efficacy of terlipressin infusion and AKI course in patients...

Background Steroid therapy is the standard of care for severe alcoholic hepatitis (sAH) at most centres. However, steroids are associated with an increased risk of infections. Therefore, we aimed to compare the outcomes of patients receiving concomitant norfloxacin (NFX) with steroids in patients with sAH. Methods In this double-blind, randomized...

Abstract Background Pre-renal (pre-renal AKI), hepatorenal syndrome (HRS–AKI) and acute tubular necrosis (ATN–AKI) are the various phenotypes of acute kidney injury which are described in decompensated cirrhosis. It has therapeutic and prognostic implications. We aimed to evaluate diagnostic utility of fractional excretion of sodium and urea (FENa...

Background Immunosuppression and comorbidities increase the risk of severe coronavirus disease-2019 (COVID-19) in solid organ transplant (SOT) recipients. The outcomes of COVID-19 in liver transplant (LT) recipients remain unclear. We aimed to analyse the outcomes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in LT recip...

Background Acute kidney injury (AKI) is common in the peri-operative transplant period and is associated with poor outcomes. Few studies reported a reduction in AKI incidence with terlipressin therapy by counteracting the hemodynamic alterations occurring during liver transplantation. However, the effect of terlipressin on post-transplant outcomes...

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Background and Aims Hematopoietic stem cell (HSC) infusion has demonstrated short term improvement in liver functions in chronic liver disease patients. Combination of HSC with mesenchymal stem cells (MSC), which have an immunomodulatory effect may augment the effects and enhance the duration of improvements on liver functions. The aim of the prese...

Background and aims: Currently, there is no pharmacotherapy for non-alcoholic steatohepatitis (NASH), a common liver disorder. In contrast, primary biliary cholangitis (PBC) is a chronic cholestatic liver disease for which ursodeoxycholic acid (UDCA) is the drug of choice. However, 50% of PBC patients may not respond to UDCA. Obeticholic acid (OCA...

COVID‐19 (Coronavirus disease‐2019) has impacted solid organ transplantation (SOT) in many ways. Transplant centers have initiated SOT despite the COVID‐19 pandemic. Although it is suggested to wait for four weeks after COVID‐19, there is no data to support or refute the timing of liver transplant after COVID‐19. Here we describe the course and out...

Cyproterone acetate (CPA), a hydroxyprogesterone derivative, is used to treat advanced prostate cancer and infrequently in females for acne, breast cancer, and hirsutism. Transient mild liver enzymes' elevation is reported in 10% -30% of patients, and acute liver failure (ALF) is uncommon. Here we discuss the first case of CPA-induced ALF from Indi...

Background: alcohol may have additional neurotoxic ill-effects in patients with alcohol related cirrhosis apart from hepatic encephalopathy. We aimed to evaluate minimal hepatic encephalopathy (MHE) with Psychometric Hepatic Encephalopathy (PHES) score and Critical Flicker Frequency (CFF) in alcohol (ALD) and non-alcoholic steatohepatitis related...

Nonalcoholic fatty liver disease (NAFLD) is a global epidemic that is likely to become the most common cause of chronic liver disease in the next decade, worldwide. Though numerous drugs have been evaluated in clinical trials, most of them have returned inconclusive results and shown poorly-tolerated adverse effects. None of the drugs have been app...

Background Acute-on-chronic liver failure (ACLF) is a syndrome of acute portal hypertension with high short-term mortality. ACLF patients have low mean arterial pressure (MAP), systemic vascular resistance, and high cardiac output. This, in turn, leads to an increased incidence of ascites, acute kidney injury (AKI), and hyponatremia. We evaluated t...

We read with interest the study by Wong et al. (1) We congratulate the authors for the commendable work. We would like to share our concerns regarding the study. There were a greater number of patients with hepatorenal syndrome (HRS) in the deceased donor liver transplantation (DDLT) group than living donor liver transplantation (LDLT) group. (1)...

Background Terlipressin with albumin is the recommended standard of care for hepatorenal syndrome. However, there is a paucity of Asian data on the use of terlipressin in acute-on-chronic liver failure (ACLF) patients. We aimed to evaluate the safety and efficacy of terlipressin infusion in ACLF patients with HRS-AKI (acute kidney injury). Methods...

Background: With the increasing prevalence of chronic liver diseases, there is a need for simple and accurate non-invasive modality for diagnosis and staging of liver disease. Fibroscan (Echosens;Paris) is the most popular non-invasive device that uses the technique of transient elastography in assessing the stiffness and steatosis of the liver. Th...

Background: The only proven treatment for non-alcoholic steatohepatitis (NASH) and primary biliary cholangitis are lifestyle changes and ursodeoxycholic acid, respectively. Obeticholic acid (OCA), a farnesoid X receptor agonist, has shown promising results in NASH and PBC. We aimed to analyze the effect of OCA in liver disease. Methods: A comprehen...

Vasoactive drugs form the mainstay of therapy for two of the most important complications of liver disease: hepatorenal syndrome (HRS) and acute variceal bleed (AVB). With cumulative evidence supporting the use in cirrhosis, terlipressin has been recommended for the management of HRS and AVB. However, owing to the safety concerns, terlipressin was...

Background and Aims: Long-term data on cell-based therapies, including hematopoietic stem cell infusion in cirrhosis, are sparse and lacking. Methods: Patients with cirrhosis of non-viral etiology received either standard-of-care (n = 23) or autologous CD34+ cell infusion through the hepatic artery (n = 22). Study patients received granulocyte col...

A significant proportion of patients with non-alcoholic fatty liver disease (NAFLD) in Asian sub-continent are non-overweight and may have different underlying risk factors, lifestyles and metabolic profiles. Seven hundred fifty patients of NAFLD with raised alanine-amino-transferase (ALT) were divided into non-overweight and obese group based on t...

LINKED CONTENT This article is linked to Kulkarni et al and Elhence et al papers. To view these articles, visit https://doi.org/10.1111/apt.15916 and https://doi.org/10.1111/apt.16010

We read with interest the article by Banini et al.1 They have succinctly described the pathophysiology and management of hepatic hydrothorax. We would like to share a few thoughts on the management of hepatic hydrothorax.

Background The incidence of elevated liver chemistries and the presence of the pre‐existing chronic liver disease (CLD) have been variably reported in COVID‐19. Aims To assess the prevalence of CLD, the incidence of elevated liver chemistries and the outcomes of patients with and without underlying CLD/elevated liver chemistries in COVID‐19. Meth...

Background Alcohol is the leading cause of acute-on-chronic liver failure (ACLF). Several severity scores predict the outcome of ACLF. However, there is a lack of simple biomarkers in predicting the outcome of these sick patients. Fatty acid-binding proteins (FABP) are small cytosolic proteins that play a major role in lipid metabolism, energy home...

Background Paracentesis induced circulatory dysfunction (PICD) is seen in up to 70% of patients undergoing large‐volume paracentesis (LVP). We performed comparative effectiveness of available pharmacological interventions for the prevention of PICD in cirrhotic patients undergoing LVP. Methods A comprehensive search of electronic databases from...

Background: 17-beta-hydroxysteroid dehydrogenase 13 (HSD17B13) is identified to be a liver specific lipid droplet associated protein. Over expression of the gene was associated with increased lipogenesis in an animal model. A splice variant (rs72613567:TA) in this gene resulting in a truncated protein was reported to be associated with reduced leve...

Annually, 10% of cirrhotic patients with ascites develop refractory ascites for which large-volume paracentesis (LVP) is a frequently used therapeutic procedure. LVP, although a safe method, is associated with circulatory dysfunction in a significant percentage of patients, which is termed paracentesis-induced circulatory dysfunction (PICD). PICD r...

Background: Non-alcoholic fatty liver disease (NAFLD) is a condition where excess fat accumulates in the liver without alcohol consumption with no approved treatments. Lifestyle changes including dietary modifi- cations are recommended for treatment. Earlier studies identified that the ratio of n-6 to n-3 PUFAs interacted with the rs738409-GG-PNPLA...

Background: Mesenchymal and hematopoetic stem cells(HSC) have been individually used in multiple studies with varied success. Immunomodulatory effect of MSC may augment the effect of HSC. We present this safety study to see the in vivo stability of co culture of HSC and MSC and also the safety of the combination infusion of MSC and HSC in humans. M...

PREDICTORS OF HEPATORENAL SYNDROME: FRACTIONAL EXCRETION OF SODIUM VS FRACTIONAL EXCRETION OF UREA YASHAVANTH H. GOWDA, Rao Pn, Mithun Sharma, Rajesh Gupta, Nitin Jagtap, Mohan K. Ramchandani, GUJJARLAPUDI DEEPIKA, Nageshwar R. Duvvur Background and Aims: Acute kidney injury (AKI) in cirrhosis of liver (CLD) is associated with high short term morta...

Background: Paracentesis induced circulatory dysfunction (PICD) is seen in up to 70% of patients undergoing large volume paracentesis (LVP). Several drugs, like albumin (8g/L of ascites tapped,4g/L), terlipressin, midodrine, noradrenaline, etc have been used to prevent PICD . Till date, albumin is considered as a safe and effective drug for the pre...

INTRODUCTION The paucity of organs for liver transplant coupled with rising cost have paved the way for research in alternative cell based therapies as a bridge to liver transplantation. Our initial published work with 6 months follow up have now been followed up for 3 years and the data is presented below METHODS Cirrhotic patients of non-viral e...

INTRODUCTION Nonalcoholic fatty liver disease (NAFLD) is a common chronic liver disease affecting one-quarter of the world population. NAFLD is also an extra-intestinal manifestation of Crohn's Disease (CD), where it is associated with higher morbidity and mortality. We aimed to (1) characterize risk factors for NAFLD in South Asian CD pts, and (2)...

INTRODUCTION NCPH is the presence of portal hypertension (PH) in the absence of cirrhosis. While Schistosomiasis is the commonest cause in West, myeloproliferative diseases (MPD) characterized by cellular proliferation of one or more hematologic cell lines resulting in extra-medullary hematopoiesis predominantly in the spleen and occasionally in li...

Background and aim: Endoscopic retrograde cholangiopancreatography (ERCP) is treatment modality of choice for management of pancreatobiliary disorders. However, safety of ERCP in the patients with cirrhosis is not adequately studied. This study was aimed to evaluate adverse events in the patients with cirrhosis undergoing ERCP and the predictors o...

Introduction Hepatitis C virus (HCV) displays high genetic diversity, characterized by regional variations in the prevalence of genotype posing challenges to the development of vaccines and definitive treatment. Very few reports exist on the distribution and frequency change of HCV genotypes in India. In the present retrospective study, we aimed to...

Abstract Background and Aim: Nonalcoholic fatty Liver disease (NAFLD) is a spectrum of liver diseases with simple steatosis on one end and Hepatocellular carcinoma on the other. Although obesity is a known risk factor for NAFLD, individuals with normal body mass index also have hepatic fatty infiltration now termed “Lean-NAFLD”. It represents a dis...