Clinical, anthropometric, biochemical and histological character of nonalcoholic fatty liver disease without Insulin Resistance

OBJECTIVES

Nonalcoholic Fatty Liver Disease (NAFLD) is thought to be a hepatic manifestation of Metabolic Syndrome (MS) or Insulin Resistance (IR). The aim of the study was to explore the clinical, anthropometric, metabolic, biochemical and histological profile of NAFLD patients without IR by comparing it with NAFLD with IR.

METHODS

Total 851 patients with sonographic evidence of fatty liver were included. These patients underwent clinical, anthropometric, biochemical and histological evaluation. IR was calculated using the homeostatic model assessment. Liver biopsy done in 285 patients who consented for the procedure and who had MS or raised ALT.

RESULTS

Among 851 NAFLD patients, 561(65.9%) patients were without IR and 290 (34.1%) patients were with IR. The proportion of male sex [230 (41.0%) vs. 89 (30.7%); P = 0.046] were higher but diabetes [19.10% vs. 39.0%; P = 0.000] and MS were [58.80%vs. 78.10%; P = 0.014] significantly lower in non IR group. Body Mass Index (BMI) kg/m2 and Waist Circumference (WC) in cm were also lower in non IR group: [26.6 ± 3.5 vs. 27.9 ± 4.3; P = 0.002] and [93.3 ± 8.4 vs. 95.9 ± 8.4; P = .003]. Lipid profile, ALT, AST and ALP were not differed between the groups. Histopathology reports revealed that lobular inflammation, ballooning and fibrosis were similar in two groups, only steatosis score was higher in IR group [2.0 ± 0.7 vs. 1.8 ± 0.8; P = 0.007].

CONCLUSION

There are significant proportion of NAFLD patients without IR in Bangladesh. NAFLD patients without IR predominantly male, had lower BMI, WC, MS and diabetes. Histologically NAFLD without IR equally severe with ballooning, lobular inflammation and fibrosis except steatosis. Insulin resistance is the principal but not the sole factor for NAFLD in our population.

Healthcare Financing in Bangladesh: Challenges and Recommendations

Bangladesh has achieved remarkable success in improving most of the health indicators over the last couple of decades despite pervasive economic poverty. However, for a sustainable growth health sector should be among the top lists at Government’s policy table. Unfortunately, the recent trend in budget allocation portrayed just the opposite and is concerning as expressed by health experts. Over the last seven fiscal years, budgetary allocation for health dropped from 6.2% to 4.3% of total government expenditure. Due to insufficient public spending, out of pocket payment (OPP) is much higher which is about two-third (64.7%) of total health care spending in Bangladesh. Inadequate and inefficient public healthcare and profiteering tendency of the private healthcare sector are two major factors behind such high private spending. Suffering from a massive shortage of health workforce and with such low public funding it would be very difficult for Bangladesh to fight against upcoming challenges like increasing burden of non communicable diseases (NCDs) and emerging threats due to climate change.Bangladesh Journal of Medical Science Vol.15(4) 2016 p.505-510

IP-10, p53, and Foxp3 Expression in Hepatocytes of Chronic Hepatitis B Patients with Cirrhosis and Hepatocellular Carcinoma

AIM

Elucidating differences in gene expression may be useful in understanding the molecular pathogenesis and for developing specific markers for the outcome of hepatitis B virus (HBV) infection. In the present study, expressions of host gene interferon gamma-inducible protein (IP-10), p53, and Foxp3 were studied in hepatocytes of patients with chronic HBV infection to determine a possible link between selected host gene expression and the outcome of HBV infection.

MATERIALS AND METHODS

The study was conducted in 60 patients with chronic HBV infection and they were divided into four groups: HBV-positive cirrhosis (n = 15), HBV-negative cirrhosis (n = 15), HBV-positive hepatocellular carcinoma (HCC) (n = 15) and HBV-negative HCC (n = 15). Total messenger ribonucleic acid (mRNA) extraction was done followed by complementary deoxyribonucleic acid (cDNA) synthesis, and finally gene expression was performed using real-time polymerase chain reaction (PCR) technique.

RESULTS

IP-10 and p53 gene expressions were lower in HBV-positive cirrhosis, and Foxp3 gene expression was upregulated in HBV-positive cirrhosis in comparison to HBV-negative cirrhosis. The expressions of all the three genes were upregulated among HBV-positive HCC in comparison to HBV-negative HCC. The expression of IP-10, p53, and Foxp3 genes was upregulated in HBV-positive HCC in comparison to HBV-positive cirrhosis.

CONCLUSION

This study indicates that there are variations in the expression of the selected genes among cirrhosis and HCC patients with or without HBV. All the three selected genes were more or less upregulated in HBV-positive HCC patients, but only Foxp3 expression was upregulated in HBV-positive cirrhosis. These three particular genes may have a role in the molecular pathogenesis and clinical outcome of HBV-positive cirrhosis and HCC patients. These aspects need further evaluation by studies with larger numbers of cirrhosis and HCC patients.

HOW TO CITE THIS ARTICLE

Shahera U, Munshi S, Jahan M, Nessa A, Alam S, Tabassum S. IP-10, p53, and Foxp3 Expression in Hepatocytes of Chronic Hepatitis B Patients with Cirrhosis and Hepatocellular Carcinoma. Euroasian J Hepato-Gastroenterol 2016;6(2):149-153.

Pretreatment and on-treatment predictors of viral breakthrough in lamivudine therapy for chronic hepatitis B

PURPOSE

There are remarkable advances in the treatment of chronic hepatitis B (CHB) in the last few years. Unfortunately, prolonged antiviral treatment is associated with increasing risk of drug resistance/viral breakthrough (VBT), which may lead to flare-up and rapid decompensation. We have designed this study to predict the pretreatment and on-treatment factors responsible for development of VBT.

METHODS

This study was conducted during the period of February 2000 to November 2007. We have included 423 patients who received lamivudine (LAM) therapy for at least 1 year and at least 2 follow-ups at 6 months' interval. Follow-up period was 12-78 months. Chi-square test, student's t test, and logistic regression analysis were performed to prove the validity.

RESULTS

Of the 423 study cases, 367 (86.8%) were of male patients and 261 (61.7%) patients were HBeAg positive; the age of the patients was 30.8 +/- 12.9 years. Development of VBT was 4.4, 22.8, 45.3, and 74% at 1, 2, 3, and 4 or more years, respectively. Pretreatment high HBV DNA (P = 0.005) and female sex (P = 0.01) were associated with VBT and pretherapy ALT (P = 0.698), HBeAg status (P = 0.273), and age (P = 0.059) were not associated. Duration of treatment, failure to lose HBeAg at 1 year, and HBV DNA nonresponder at 6 months were significantly (P = 0.001) associated with development of VBT.

CONCLUSION

Persistence of HBeAg at 1 year and HBV DNA nonresponder at 6 months are good predictors of development of VBT.

Non-alcoholic fatty liver disease (NAFLD) among underweight adults

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD), closely linked to obesity, has also been evident in lean and underweight adults. But data pertaining to NAFLD in underweight adults in Bangladesh is very limited. Therefore, we sought to estimate the prevalence and identify the factors associated with NAFLD in underweight adults in Bangladesh.

METHODS

Underweight adults (BMI <18.5 kg/m2) who underwent abdominal imaging from December 2015 to January 2017 were included in this analysis. Multivariable logistic regression was performed to identify the factors associated with NAFLD in underweight adults.

RESULTS

Total 286 (female = 117) participants with a mean age of 28.4 (±13.0) years were included in this analysis. The prevalence of NAFLD in underweight adults was 5.2% (95% CI: 2.6, 7.8). The prevalence was higher in adults ≥30 years (9.2 vs. 3.5 p-value = 0.048), married (9.0 vs. 1.4, p-value = 0.004), sedentary workers (8.7 vs. 1.5, p-value = 0.006, and diabetic individuals (60.0 vs. 5.0, p-value<0.001) compared to their counterparts. Multivariable logistic regression model demonstrated that rural residents had higher odds (aOR: 3.93, 95% CI: 1.07, 14.49, p-value = 0.048) of having NAFLD than urban inhabitants. The odds of NAFLD was 5 times higher (aOR: 5.60, 95% CI: 1.04, 30.29, p-value = 0.046) in patients with positive family history of metabolic traits. Being non-diabetic was protective against NAFLD (aOR: 0.06, 95% CI: 0.01, 0.45, p-value = 0.005) in this selected population.

CONCLUSION

The study results delineate that underweight adults living in rural areas, with a positive family history of metabolic traits and being diabetic are more likely to develop NAFLD in Bangladesh.

High Prevalence of Hepatitis B and C Virus Infections Among Rohingya Refugees in Bangladesh: A Growing Concern for the Refugees and the Host Communities

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Effect of telmisartan and vitamin E on liver histopathology with non-alcoholic steatohepatitis: A randomized, open-label, noninferiority trial

BACKGROUND AND AIM

To compare the effect of telmisartan and vitamin E on liver histopathology of non-alcoholic steatohepatitis (NASH) patients.

METHODS

This noninferiority clinical trial was conducted for 1 year. Fatty liver patients with non-alcoholic fatty liver disease (NAFLD) activity score (NAS) ≥ 5 (in liver biopsy) were selected. All methods were in accordance with the Declaration of Helsinki. Patients who received telmisartan and vitamin E were denoted as Group-T and Group-E, respectively. Forty patients >18 years old were assigned and divided into two groups (20 in each group). Histological improvements were primary outcome measures.

RESULTS

Significant improvement in NAS score was noted in both groups (Group E [GE]: 6 ± 0.8 to 4.36 ± 1.4; P = 0.00 and Group T [GT]: 5.6 ± 0.7to 4.9 ± 1.2; P = 0.03). Fibrosis score improved from 1.6 ± 0.5 to 1.5 ± 0.5 in GE and from 1.7 ± 0.9 to 1.5 ± 0.7 in GT (P = 0.67 and 0.42, respectively). Steatosis improved in GE from 2.07 ± 0.6 to 1.14 ± 0.66 (P = 0.00) and in GT from 1.94 ± 0.57 to 1.56 ± 0.8 (P = 0.05). Lobular inflammation improved from 2.0 ± 0.4 to 1.6 ± 0.5 in GE (P = 0.02) and from 1.9 ± 0.3 to 1.8 ± 0.4 in GT (P = 0.58). Ballooning score in GE decreased from 1.9 ± 0.3 to 1.7 ± 0.5 (P = 0.03), and in GT, it reduced from 1.9 ± 0.1 to 1.5 ± 0.5 (P = 0.19). NAS improvement was similar in GE (1.6 ± 1.2) and GT (0.6 ± 1.1; P = 0.07) when controlled for weight reduction.

CONCLUSION

Telmisartan was similar to vitamin E in improving the histology of NASH patients.

Characteristics of treatment naïve chronic hepatitis B in Bangladesh: younger populations are more affected; HBeAg-negatives are more advanced

BACKGROUND/AIM

Bangladesh is a densely populated country with intermediate endemicity for chronic hepatitis B (CHB). The aim of the present study was to evaluate the biochemical, virological and histological character of CHB patients and to examine the relationship between these indices.

MATERIALS AND METHODS

One thousand and twenty-two patients of CHB fulfilled our inclusion criteria. Inclusion criteria were (1) HBsAg positive for at least 6 months, (2) HBeAg-positive or negative and (3) hepatitis B virus (HBV) DNA positive. Patients with detectable antibodies to human immunodeficiency virus (HIV), hepatitis Delta virus (HDV) or hepatitis C virus (HCV), with previous antiviral treatment, overt cirrhosis and hepatocellular carcinoma, were excluded. Of these, 191 patients were randomly selected for liver biopsy and were evaluated for analysis.

RESULTS

In the 191 patients, male to female ratio was 4.6:1; age distribution was 26.5 +/- 8.5 (mean +/- standard deviation) years. One hundred and seventy-eight (93.2%) patients were under 40 years. Sixty-eight (35.6%) patients were HBeAg-negative, had less DNA load, and were significantly older, more fibrotic and cirrhotic (P < 0.001). Correlation was not found between DNA level and histological activity. Histological activity was not correlated with ALT level in HBeAg-positive patients (P < 0.001).

CONCLUSION

CHB affects the younger population in Bangladesh. HBeAg-positive CHB was associated with more fibrosis and cirrhosis. Serum HBV DNA levels do not correlate with the severity of histological lesions in all patients. Evaluation by liver biopsy remains gold standard for taking decision of treatment.

Pre-existing liver disease is associated with poor outcome in patients with SARS CoV2 infection; The APCOLIS Study (APASL COVID-19 Liver Injury Spectrum Study)

BACKGROUND AND AIMS

COVID-19 is a dominant pulmonary disease, with multisystem involvement, depending upon comorbidities. Its profile in patients with pre-existing chronic liver disease (CLD) is largely unknown. We studied the liver injury patterns of SARS-Cov-2 in CLD patients, with or without cirrhosis.

METHODS

Data was collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19.

RESULTS

Altogether, 228 patients [185 CLD without cirrhosis and 43 with cirrhosis] were enrolled, with comorbidities in nearly 80%. Metabolism associated fatty liver disease (113, 61%) and viral etiology (26, 60%) were common. In CLD without cirrhosis, diabetes [57.7% vs 39.7%, OR = 2.1 (1.1-3.7), p = 0.01] and in cirrhotics, obesity, [64.3% vs. 17.2%, OR = 8.1 (1.9-38.8), p = 0.002] predisposed more to liver injury than those without these. Forty three percent of CLD without cirrhosis presented as acute liver injury and 20% cirrhotics presented with either acute-on-chronic liver failure [5 (11.6%)] or acute decompensation [4 (9%)]. Liver related complications increased (p < 0.05) with stage of liver disease; a Child-Turcotte Pugh score of 9 or more at presentation predicted high mortality [AUROC 0.94, HR = 19.2 (95 CI 2.3-163.3), p < 0.001, sensitivity 85.7% and specificity 94.4%). In decompensated cirrhotics, the liver injury was progressive in 57% patients, with 43% mortality. Rising bilirubin and AST/ALT ratio predicted mortality among cirrhosis patients.

CONCLUSIONS

SARS-Cov-2 infection causes significant liver injury in CLD patients, decompensating one fifth of cirrhosis, and worsening the clinical status of the already decompensated. The CLD patients with diabetes and obesity are more vulnerable and should be closely monitored.

Impact of Diabetes, Drug-Induced Liver Injury, and Sepsis on Outcomes in Metabolic Dysfunction Associated Fatty Liver Disease-Related Acute-on-Chronic Liver Failure

INTRODUCTION

The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute-on-chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied.

METHODS

Patients with MAFLD-ACLF were recruited from the Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were randomly split into derivation (n = 258) and validation (n = 111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered.

RESULTS

The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27% and hypertension in 29%. The dominant precipitants included viral hepatitis (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts.

DISCUSSION

Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

Ultrasonography and computer tomography evaluation of hepatocellular carcinoma with cytohistopathological correlation

The prevalence of hepatocellular carcinoma (HCC) in Bangladesh is 35% among all liver diseases. Sonographic examinations were performed for the evaluation of 38 cases of HCC; then, CT examinations were done of these cases subsequently. Expert opinion was taken in each case for both modalities. Age, sex, clinical features, location of the hepatic lesion, multiplicity, echo-character, CT density, and, contrast enhancement were evaluated in all cases. Histocytopathology reports were collected from the patients and were correlated with the ultrasonography and CT findings. Thirty five cases were detected as HCC on ultrasonography and 36 cases in CT scan. In ultrasonography, most of the lesions (82.9%) were found in right lobe, maximum lesions (45.7%) were hypoechoic and lesion showed mosaic pattern in 68.6% cases, lateral shadowing in 34.3% and posterior acoustic enhancement in 45.7% cases. Significant difference found between mosaic pattern and lateral shadowing (p<0.05). On CT scan, majority of lesions (50%) were hypodense, 91.7% lesions were contrast enhanced. Pattern of enhancement was mostly heterogeneous. Both of the modalitics found sensitive but CT was found more sensitive, specific and accurate than ultrasonography in detecting HCC.

Transition of an acronym from nonalcoholic fatty liver disease to metabolic dysfunction-associated fatty liver disease

Nonalcoholic fatty liver disease (NAFLD) is a global public health concern owing to its substantial contribution to chronic liver diseases. The disease is closely linked to metabolic syndrome (MS), suggesting a common biological pathway and shared disease mechanism for both ailments. Previous studies revealed a close relationship of NAFLD with the components of MS including abdominal obesity, dyslipidemia, hypertension, and hyperglycemia. Hence, a group of experts recently renamed NAFLD as metabolic dysfunction-associated fatty liver disease (MAFLD) in order to encompass a more appropriate pathogenesis of the disease. NAFLD was first named to describe a condition similar to alcoholic hepatitis in absence of significant alcohol consumption. However, knowledge pertaining to the etiopathogenesis of the disease has evolved over the past four decades. Recent evidence endorses NAFLD as a terminology of exclusion and suggests that it may often leads to misdiagnosis or inappropriate management of patients, particularly in clinical practice. On the other hand, the new definition is useful in addressing hepatic steatosis with metabolic dysfunction, which ultimately covers most of the patients with such illness. Therefore, it seems to be helpful in improving clinical diagnosis and managing high-risk patients with fatty liver disease. However, it is imperative to validate the new terminology at the population level to ensure a holistic approach to reduce the global burden of this heterogeneous disease condition.

Biochemical Scoring System for diagnosing Nonalcoholic Steatohepatitis

Noor-E-Alam M, Alam S, Alam AKMK, Al Mahtab M, Rahman S. Biochemical Scoring System for diagnosing Nonalcoholic Steatohepatitis. Euroasian J Hepato-Gastroenterol 2016;6(2):202-204.

Study on ascitic fluid complement 3 level in cirrhotic patients with spontaneous bacterial peritonitis and without spontaneous bacterial peritonitis

BACKGROUND/AIMS

Ascitic fluid Complement 3 (C3) concentration is the most important factor to offer local defense against infection of ascitic fluid. Hepatic synthesis of Complement 3 and its concentration in ascitic fluid is significantly reduced in patients with advanced cirrhosis. The aim of the study was to assess the level of Complement 3 in ascitic fluid in cirrhotic patients with and without spontaneous bacterial peritonitis (SBP) and to identify the group of cirrhotic ascites at risk of developing

METHODOLOGY

A prospective case control study was carried out to compare the level of ascitic fluid Complement 3 concentration in patients with SBP (case-group) and without SBP (control-group). Ascitic fluid Complement 3 level was estimated in 15 patients with SBP (case) and another 15 patients without SBP (control).

RESULTS

In the study, ascitic fluid Complement 3 concentration was 7.3+/-4.3 mg/dL in patients with SBP and 16.4+/-11.3 mg/dL in patients who did not develop SBP.

CONCLUSIONS

Ascitic fluid Complement 3 level is significantly (P=0.009) reduced in cirrhotic patients who develop SBP.

Estimating the cost of illness of non-alcoholic fatty liver disease in Bangladesh

BACKGROUND AND AIM

Non-alcoholic fatty liver disease (NAFLD) is a growing concern, affecting about 45 million of the Bangladeshi population. There is a paucity of research on the economic burden of NAFLD. The study aims to estimate the cost of illness of NAFLD in Bangladesh.

METHODS

In this prospective, cross-sectional study, a total of 250 patients of NAFLD, non-alcoholic steatohepatitis (NASH), and NASH cirrhosis were included from public and private hospitals. Costs of hospitalization, physician fees, investigation costs, expenditures on medical procedures, drugs; and nonmedical costs such as transport expenses and other informal payments (tips) were estimated.

RESULTS

The overall cost per patient per evaluation was (16.90-46 942.00) USD. The cost in public and private hospitals was 384.76 and 1146.93 USD, respectively. The cost per patient of NAFLD was 157.91 (16.90-955.08) USD, and for NASH cirrhosis was 1783.80 (422.48-46 942) USD. The cost of illness increased to USD 281.18 for diabetics and 254.52 USD for hypertensive. If all the NAFLD patients are evaluated once in healthcare settings, the projected cost will be 7.11 billion USD. In NAFLD, cost for investigations, medicines, transportation, and consultation of physicians was 49.08%, 32.41%, 11.11%, and 6.67%, respectively.

CONCLUSIONS

NAFLD is causing a huge economic burden to the healthcare system. The cost of illness is increased with NASH cirrhosis. Overall, this study provides valuable insights into the economic burden of NAFLD in Bangladesh and emphasizes the several ways of intervention to reduce the cost by preventive measures and accessible healthcare for affected individuals.

The Asian Pacific association for the study of the liver clinical practice guidelines for the diagnosis and management of metabolic dysfunction-associated fatty liver disease

Metabolic dysfunction-associated fatty liver disease (MAFLD) affects over one-fourth of the global adult population and is the leading cause of liver disease worldwide. To address this, the Asian Pacific Association for the Study of the Liver (APASL) has created clinical practice guidelines focused on MAFLD. The guidelines cover various aspects of the disease, such as its epidemiology, diagnosis, screening, assessment, and treatment. The guidelines aim to advance clinical practice, knowledge, and research on MAFLD, particularly in special groups. The guidelines are designed to advance clinical practice, to provide evidence-based recommendations to assist healthcare stakeholders in decision-making and to improve patient care and disease awareness. The guidelines take into account the burden of clinical management for the healthcare sector.

Presentation and endoscopic management of biliary ascariasis

Ascaris lumbricoides is a common parasite and the most serious and dramatic presentation is hepatobiliary and pancreatic ascariasis (HPA). Therefore, this study was planned prospectively to elucidate the clinical presentation of HPA and evaluate the efficacy and safety of endoscopic intervention. In this study we documented 77 consecutive patients with HPA from January 2000 to November 2005. All the patients had endoscopically proven HPA. A total of 77 patients were included in the study. The age ranged from 6 to 80 years, with the third decade most commonly (28.6%) affected. Females were 6 times more likely to be affected than males. The commonest presentation was biliary colic (97.4%); other presentations were acute cholangitis (15.6%), obstructive jaundice (9.1%), acute pancreatitis (6.5%), choledocholithiasis (6.5%), acute cholecystitis (6.5%) and liver abscess (2.6%). In this report 51 (66.2%) had living, 10 (13%) had dead and 16 (20.8%) had both living and dead worms. Choledocholithiasis was associated only with dead worms. From one to 23 worms were found in the biliary tree. In 94.8% of cases we had to remove the worm by wide papillotomy followed by basket extraction. We did not experience any major complications during or following the procedures. Three patients had recurrent HPA during the course of follow-up (1 to 12 months). The majority of patients with HPA presented with biliary colic. This should be kept in mind in the management of an acute abdomen, especially in tropical countries. Endoscopic extraction is a safe and effective procedure for the treatment of HPA.

Funds for treatment of hospitalized patients: evidence from Bangladesh

This study was designed to explore sources of funds for health expenditure of patients if they are hospitalized. We have included 379 patients of 3 private and 7 public hospitals to estimate total expenditure. Of them, 229 (60.4%) were from public and 150 (39.6%) from private hospitals. Mean expenditure was Tk 60,613.3 and 8,262.7, and duration of hospital stay was 10.7 and 11.8 days in private and public hospitals respectively. More than half (55%) of the patients from middle class were treated in private hospitals. Of them, 278 (74.0%) were funded by themselves, 48 (12.8%) by loan with interest rate of 100% to 180%, 23 (6.1%) by loan without interest, 17 (4.5%) by losing their fixed asset, and 4 (1.1%) by begging in the street. Most of the patients did bear expenditure by themselves, followed by loan with high interest rate. 'Distress' selling of property was also a source. Middle-class patients could be comfortable with expenditure if they were in public hospitals.

Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.