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Jiao J, Chezar K, Zhang X, Wang D, Cao W, Bindu C, Chen W, Neto AG, Henn P, Riahi I, Wang HL, Papke DJ, Zhao L, Xue Y, Liao X, Zhang X. Postinfantile Giant Cell Hepatitis in Native and Allograft Livers: A Multi-Institutional Clinicopathologic Study of 70 Cases. Mod Pathol 2023; 36:100298. [PMID: 37544363 DOI: 10.1016/j.modpat.2023.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 06/16/2023] [Accepted: 07/28/2023] [Indexed: 08/08/2023]
Abstract
Postinfantile giant cell hepatitis (PIGCH) is a rare hepatitis pattern in adults with variable etiologies and clinical outcomes. We conducted a multi-institutional retrospective study to define the clinicopathologic characteristics of patients with PIGCH. A total of 70 PIGCH cases were identified and reviewed for pathological features, including fibrosis, cholestasis, inflammation, steatosis, necrosis, and apoptosis, as well as the distribution of giant cells and the maximum number of giant cells per high-power field. Demographic and clinical data, including age, sex, laboratory results, etiologies, and follow-up results, were recorded. Among the 70 cases, 40% (28/70) were associated with autoimmune liver diseases, followed by 9 (13%) with unknown etiology, 8 (11%) with viral infection, 5 (7%) with medications, 5 with combined etiologies, and 4 (6%) with malignancies (mostly chronic lymphocytic leukemia). Notably, another 16% were de novo PIGCH in liver allografts, most of which occurred after a rejection event. During follow-up, 26 (37%) patients died of the disease and 44 (63%) were alive. Deceased patients were characterized by older age (mean age, 54.9 vs 45.5 years; P = .02), higher alkaline phosphatase level (mean value, 253.3U/L vs 166.3 U/L; P = .03), higher fibrosis stage (stage 3-4 vs stage 0-2, 57.7% vs 29.6%; P = .03), being more likely to have de novo PIGCH after transplantation (23.1% vs 11.4%; P = .04), and being less likely to have primary autoimmune liver disease etiology (26.9% vs 47.7%; P = .04). These results indicate that PIGCH is a rare pattern of liver injury associated with different etiologies and variable clinical outcomes. Autoimmune liver disease with PIGCH is associated with better survival, whereas de novo PIGCH in allografts is associated with poorer survival. Older age, higher alkaline phosphatase level, and advanced fibrosis are adverse prognostic factors.
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Affiliation(s)
- Jingjing Jiao
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut
| | - Ksenia Chezar
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Xuefeng Zhang
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Donghai Wang
- Department of Pathology, New York University Langone Health, New York, New York
| | - Wenqing Cao
- Department of Pathology, New York University Langone Health, New York, New York
| | - Challa Bindu
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Wei Chen
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Antonio Galvao Neto
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Patrick Henn
- Department of Pathology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Irene Riahi
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - Hanlin L Wang
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
| | - David J Papke
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Lei Zhao
- Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Yue Xue
- Department of Laboratory Medicine and Pathology, Northwestern University, Chicago, Illinois
| | - Xiaoyan Liao
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Xuchen Zhang
- Department of Pathology, Yale University School of Medicine, New Haven, Connecticut.
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Jiao J, Zhang X. Post-infantile Giant Cell Hepatitis: A Literature Review and Meta-analysis. JOURNAL OF CLINICAL AND TRANSLATIONAL PATHOLOGY 2022; 2:100-107. [PMID: 37092012 PMCID: PMC10117396 DOI: 10.14218/jctp.2022.00016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Post-infantile giant cell hepatitis (PIGCH) is a rare disease entity in adults with a multifactorial etiology and widely variable clinical courses and outcomes. The factors associated with the worse outcomes of this disease entity are still unclear. We identified 68 PIGCH patients by searching PubMed and performed meta-analysis. Among the 68 patients, 32% of the cases were associated with autoimmune disorders, followed by 21% associated with viral infections, 10% with medication, and 7% with malignancy. Twenty-four percent of the patients had more than one etiological factor, and 6% had other uncommon etiologies or an etiology that could not be identified. At the time of this report, 17 patients had died of the disease (poor outcome), and 51 patients remained alive with the disease (good outcome). Compared to the patients with a good outcome, the patients with a poor outcome were characterized by older age, lower levels of platelets and albumin, higher level of total bilirubin, and a diffuse distribution pattern of giant cells in the liver. There were no differences in gender distribution, aminotransferase, alkaline phosphatase, gamma-glutamyl transferase, etiological distribution, or other histological features, including interface hepatitis, necrosis, lobular inflammation, portal inflammation, cholestasis, or fibrosis. Further studies would be needed to better understand the disease mechanisms and unmask any additional etiological factors and targeted therapies.
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Affiliation(s)
| | - Xuchen Zhang
- Correspondence to: Xuchen Zhang, Department of Pathology, Yale University School of Medicine, 310 Cedar Street, PO Box 208023, New Haven, CT 06510, United States. Tel: +1 203-785-6010, Fax: +1 203-737-2922,
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Rauf M, Sen S, Levene A, Nisar MK. Giant Cell Hepatitis - A Rare Association with Connective Tissue Disease. Mediterr J Rheumatol 2020; 30:224-227. [PMID: 32467874 PMCID: PMC7241662 DOI: 10.31138/mjr.30.4.224] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 11/09/2019] [Accepted: 11/11/2019] [Indexed: 11/04/2022] Open
Abstract
A 68-year-old gentleman presented to hepatology department with asymptomatic year-long history of stably deranged liver function tests. His peak alkaline phosphatase (ALP), was 828 with alanine transaminase (ALT) of 141. Full liver workup was negative; hence, a liver biopsy was organised, which confirmed giant cell hepatitis (GCH). A computed tomography (CT) scan revealed non-specific interstitial pneumonitis (NSIP) pattern interstitial lung disease supported by lung function tests. Antibody testing showed strongly positive antinuclear antibody (ANA) with anti-polymyositis/scleroderma (anti-PM-SCL) antibody. Clinical picture was in keeping with likely undifferentiated connective tissue disease (UCTD) with polyarthralgia, early morning stiffness, Raynaud's and nailfold infarcts with capillaritis on nail bed examination. Further testing confirmed triple-positive antiphospholipid antibodies twice 12 weeks apart (immunoglobulin M [IgM] anti beta-2 glycoprotein antibodies, lupus anticoagulant and IgM anticardiolipin antibody). He was treated with mycophenolate and hydroxychloroquine with resolution of symptoms. Giant cell hepatitis is uncommon, with only 100 cases reported worldwide. To our knowledge, this is the only report of GCH in the context of UCTD, highlighting the significance of careful evaluation of liver disease overlap and the successful role of mycophenolate mofetil (MMF) in this setting.
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Affiliation(s)
- Maria Rauf
- Histopathology Department, Luton & Dunstable University Hospital, Luton, United Kingdom
| | - Sambit Sen
- Hepatology Department, Luton & Dunstable University Hospital, Luton, United Kingdom
| | - Adam Levene
- Histopathology Department, Luton & Dunstable University Hospital, Luton, United Kingdom
| | - Muhammad K Nisar
- Rheumatology Department, Luton & Dunstable University Hospital, Luton, United Kingdom
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Matta B, Cabello R, Rabinovitz M, Minervini M, Malik S. Post-infantile giant cell hepatitis: A single center’s experience over 25 years. World J Hepatol 2019; 11:752-760. [PMID: 31966907 PMCID: PMC6960295 DOI: 10.4254/wjh.v11.i12.752] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 09/06/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Giant cell hepatitis in the adult population remains very poorly defined with only 100 case reports published in the literature over the last three decades.
AIM To present our center’s experience in an attempt to learn about the predisposing factors, outcomes and efficacy of proposed therapeutic interventions for giant cell hepatitis.
METHODS A retrospective chart review was conducted through the electronic records of the University of Pittsburgh Medical Center. We queried 36726 liver biopsy reports from January 1, 1991 to December 6, 2016. Our search yielded 50 patients who were identified as carrying a definite diagnosis of post-infantile giant cell hepatitis (PIGCH) by pathology. The data collected included demographic information, laboratory data (liver function tests, autoimmune markers) and transplant status. In order to better analyze patient characteristics and outcomes, subjects were separated into a non-transplant (native) liver group and a post-liver transplant (allograft) group.
RESULTS The incidence of PIGCH was approximately 0.14% of all biopsies queried in the 25-year period. The mean age was 48 years with 66% females. Liver function tests were classified as 38.2% cholestatic, 35.3% hepatocellular and 26.5% mixed. Autoimmune hepatitis was found to be the most prevalent predisposing factor leading to PIGCH constituting 32% of cases. Management consisted mainly of immunosuppression, viral targeted therapy, supportive care and in six cases liver transplantations.
CONCLUSION The diagnosis of PIGCH remains clinically challenging and requires a high index of suspicion as well as a thorough history, physical examination, serological workup and liver biopsy. Treatment of the underlying cause can result in clinical stability in a large number of cases.
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Affiliation(s)
- Bassem Matta
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Ricardo Cabello
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, United States
| | - Mordechai Rabinovitz
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Marta Minervini
- Department of Pathology, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Shahid Malik
- Department of Medicine, University of Pittsburgh, Division of Gastroenterology Hepatology and Nutrition, Pittsburgh, PA 15213, United States
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Kethireddy N, Boyle E, Haley M, Reddy A, Forouhar F, Clement J. CLL associated giant cell hepatitis. Leuk Res 2019; 82:43-45. [PMID: 31170661 DOI: 10.1016/j.leukres.2019.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
Affiliation(s)
| | - Evan Boyle
- University of Connecticut, United States
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Rhodes JM, Schuster SJ, Furth EE, Kennard K, Nasta SD, Svoboda J, Porter DL, Mato AR. Management of giant cell hepatitis associated with chronic lymphocytic leukemia - a case series and review of the literature. Cancer Biol Ther 2019; 20:1136-1140. [PMID: 31091174 DOI: 10.1080/15384047.2019.1598763] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Giant cell hepatitis (GCH) is a rare diagnosis in adults that is found in 0.25% of liver biopsies. GCH has been associated with multiple causes including drugs (6-mercaptopurine, methotrexate), toxins, viruses and autoimmune. GCH has been described in few patients with chronic lymphocytic leukemia (CLL). Here we describe three patients diagnosed with GCH thought to be related to underlying CLL and its management. All of our patients were treated with a combination of immunosuppression as well as CLL-directed therapy to address CLL and concomitant liver disease. GCH is a rare manifestation of active CLL and should be ruled out with prompt liver biopsy in patients with CLL with persistent transaminitis without another attributable cause. Prompt treatment of GCH with immunosuppression is required to prevent long-term liver toxicity. If transaminitis does not improve with immunosuppression alone, the addition of CLL directed therapy should be considered in patients who carry this diagnosis to prevent long-term liver toxicity.
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Affiliation(s)
- Joanna M Rhodes
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Stephen J Schuster
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Emma E Furth
- b Department of Pathology , University of Pennsylvania , Philadelphia , PA , USA
| | - Kaitlin Kennard
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Sunita Dwivedy Nasta
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Jakub Svoboda
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - David L Porter
- a Lymphoma Program, Abramson Cancer Center , University of Pennsylvania , Philadelphia , PA , USA
| | - Anthony R Mato
- c CLL Program, Leukemia Service , Memorial Sloan- Kettering Cancer Center , New York , NY , USA
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Kaya M, Akdogan R, Uçmak F, O Ayyildiz M, Karakus A, A Kaplan M. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepatogastroenterol 2018; 8:31-37. [PMID: 29963458 PMCID: PMC6024041 DOI: 10.5005/jp-journals-10018-1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Accepted: 01/24/2018] [Indexed: 11/23/2022] Open
Abstract
Introduction Liver involvement is common in hematological malignancies, but the incidence and pattern of liver injury vary among the different types. The aims of our study were to determine the incidence and clinical course of acute hepatitis and the important factors for its development in patients with leukemia after chemotherapy. Materials and methods All patients with the diagnosis of leukemia who were treated at the Department of Hematology between January 2008 and January 2013 were included in the study. A detailed medical history, clinical and laboratory findings, treatment modalities, complications, and clinical course were recorded retrospectively. Results A total of 124 patients (64 females) with the diagnosis of leukemia were included in the study. The mean age was 45.2 years (16-89 years) and mean follow-up time was 29.7 months (0.25-192 months). A total of 43 (34.6%) patients had acute hepatitis after chemotherapy. Pattern of liver injury was hepatocellular in 31 patients, cholestasis in 2, and mix in 10 patients. Age (p = 0.001), hepatitis B surface antigen (HBsAg, p = 0.007), acute leukemia (p < 0.001), positive blood culture (p = 0.004), the amount of transfused red blood cell (p = 0.001), and amount of transfused platelets (p = 0.002) were significantly different under univariate analysis between the acute hepatitis group and the nonacute hepatitis group. Under multivariate analysis, only acute lymphoblastic leukemia (ALL) was identified as independent predictive factor for development of acute hepatitis after starting chemotherapy. Conclusion Acute and self-limited hepatitis develops in the substantial proportion of patients with leukemia. The most important factor for development of acute hepatitis is the type of leukemia. How to cite this article: Kaya M, Akdogan R, Uçmak F, Ayyildiz MO, Karakus A, Kaplan MA. The Incidence and Predictive Factors in the Development of Acute Hepatitis in Patients with Leukemia. Euroasian J Hepato-Gastroenterol 2018;8(1):31-37.
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Affiliation(s)
- Muhsin Kaya
- Department of Gastroenterology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Recai Akdogan
- Department of Internal Medicine, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Feyzullah Uçmak
- Department of Gastroenterology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Mehmet O Ayyildiz
- Department of Hematology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Abdullah Karakus
- Department of Hematology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Muhammet A Kaplan
- Department of Oncology, Dicle University School of Medicine, Diyarbakir, Turkey
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Aguiar J, A Silva J, García G, Guillén G, C Aguilar J. Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System. Euroasian J Hepatogastroenterol 2018; 8:38-41. [PMID: 29963459 PMCID: PMC6024048 DOI: 10.5005/jp-journals-10018-1255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Accepted: 01/25/2018] [Indexed: 11/23/2022] Open
Abstract
Aim This research focused on the results of the cross-validation program related with the performance of a Cuban novel low-cost real-time quantitative polymerase chain reaction (qPCR) assay for hepatitis B virus (HBV) quantification developed by the Therapeutic Vaccine against Hepatitis B Department, Vaccines Division, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba. Materials and methods Dilution series with the plasmid standard at concentrations of 900,000 to 0.09 copies/reaction (c/r) were made for each PCR instrument. The mean cycles threshold (Ct) values and PCR efficiency were compared among the cyclers. Hepatitis B virus-positive serum samples were used for the calculation of reproducibility of the HBV assay. Biotecon Diagnostics (BCD) also ordered the oligo sequences from a second supplier and compared the PCR performance to those provided from the CIGB. Results All PCR cyclers were able to detect concentrations up to 0.09 c/r. However, below the concentration of 9 c/r, the variation of results increased within and between the cyclers. The PCR efficiency showed satisfying results. The overall coefficient of variation (CV) cycler values were 1.29 and 0.91% for M6 and M19 respectively. No significance was observed between the different primer suppliers. Conclusion The HBV assay was performed with a good concordance between the five real-time instruments from different suppliers. The HBV assay was also performed with a high reproducibility for samples with a high and a low viral load. The HBV assay is robust against different primer suppliers. How to cite this article: Aguiar J, Silva JA, García G, Guillén G, Aguilar JC. Cross-validation Studies of a Novel Low-cost Hepatitis B Virus Quantitative Polymerase Chain Reaction System. Euroasian J Hepato-Gastroenterol 2018;8(1):38-41.
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Affiliation(s)
- Jorge Aguiar
- Department of Therapeutic Vaccine against Hepatitis B, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba
| | - José A Silva
- Department of Oligonucleotide Synthesis, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba
| | - Gerardo García
- Department of Quality Control, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba
| | - Gerardo Guillén
- Department of Therapeutic Vaccine against Hepatitis B, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba
| | - Julio C Aguilar
- Department of Therapeutic Vaccine against Hepatitis B, Center for Genetic Engineering and Biotechnology (CIGB), Havana, Cuba
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The Clinical Spectrum of Hepatic Manifestations in Chronic Lymphocytic Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:863-869. [DOI: 10.1016/j.clml.2017.07.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Accepted: 07/19/2017] [Indexed: 12/18/2022]
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Abstract
While it commonly occurs in the pediatric population, syncytial giant cell hepatitis is rare in adults, which is diagnosed histologically by the presence of multinucleated cells in the liver. The literature has recorded only approximately one hundred cases in adults during the past two decades in whom malignancy is rarely associated with giant cell hepatitis. Our patient is a 66-year-old woman who was diagnosed with chronic lymphocytic leukemia (CLL) and subsequently developed syncytial giant cell hepatitis. This disease is usually linked to virus infection, autoimmune diseases, and drug medications. The association between CLL and giant cell hepatitis is rare, with only three cases reported. In most cases viral particles on electron microscopy are reported and the patients usually have a history of chemotherapy and hypogammaglobulinemia. Unlike such cases, our patient developed giant cell hepatitis in the absence of such confounding variables. The treatment for our patient was a high-dose corticosteroid and rituxan, with improvement in liver enzymes.
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Affiliation(s)
- Neil Gupta
- Yale University School of Medicine, New Haven, Connecticut,, USA
| | - Basile Njei
- Yale University School of Medicine, New Haven, Connecticut,, USA
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Bihari C, Rastogi A, Sarin SK. Postinfantile giant cell hepatitis: an etiological and prognostic perspective. HEPATITIS RESEARCH AND TREATMENT 2013; 2013:601290. [PMID: 23555054 PMCID: PMC3608114 DOI: 10.1155/2013/601290] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 02/05/2013] [Accepted: 02/07/2013] [Indexed: 12/18/2022]
Abstract
Giant cell hepatitis is common manifestation in pediatric liver diseases, but quite uncommon in adults, only about 100 cases reported in the English literature in the last two decades. Data for the present review were identified by a structured PubMed/MEDLINE search from 1963 to December 2012, using keywords postinfantile giant cell hepatitis (PIGCH), adult giant cell hepatitis, and syncytial giant cell hepatitis in adults and liver. We report a case of postinfantile giant cell hepatitis along with the review related to the etiology and respective outcome, as the literature in the last 20 years suggests. This condition is probably due to idiosyncratic or cytopathic response of individual to various hepatocytic stimuli. It is purely a histomorphological diagnosis and does not establish the etiology. Autoimmune liver diseases are most common etiology, in around 40% of cases, but various viruses, drugs, posttransplant condition, and other causes also have been reported. Prognosis depends upon the etiology. In this paper, we emphasized various causative factors of PIGCH and their respective outcome in patients affected by them. We also highlighted the possible pathogenesis and histopathological spectrum of this entity on the basis of description given in various studies and our limited experience of few cases.
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Affiliation(s)
- Chhagan Bihari
- Department of Pathology, Institute of Liver and Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi 110070, India
| | - Archana Rastogi
- Department of Pathology, Institute of Liver and Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi 110070, India
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