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Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.

Renal dysfunction is very common among patients with chronic liver disease, and concomitant liver disease can occur among patients with chronic kidney disease. The spectrum of clinical presentation and underlying etiology is wide when concomitant kidney and liver disease occur in the same patient. Management of these patients with dual onslaught is challenging and requires a team approach of hepatologists and nephrologists. No recent guidelines exist on algorithmic approach toward diagnosis and management of these challenging patients. The Indian National Association for Study of Liver (INASL) in association with Indian Society of Nephrology (ISN) endeavored to develop joint guidelines on diagnosis and management of patients who have simultaneous liver and kidney disease. For generating these guidelines, an INASL-ISN Taskforce was constituted, which had members from both the societies. The taskforce first identified contentious issues on various aspects of simultaneous liver and kidney diseases, which were allotted to individual members of the taskforce who reviewed them in detail. A round-table meeting of the Taskforce was held on 20–21 October 2018 at New Delhi to discuss, debate, and finalize the consensus statements. The evidence and recommendations in these guidelines have been graded according to the Grading of Recommendations Assessment Development and Evaluation (GRADE) system with minor modifications. The strength of recommendations (strong and weak) thus reflects the quality (grade) of underlying evidence (I, II, III). We present here the INASL-ISN Joint Position Statements on Management of Patients with Simultaneous Liver and Kidney Disease.

Background Malnutrition is frequently present in patients with cirrhosis. Anthropometric measures such as body mass index (BMI), mid arm muscle circumference (MAMC), triceps skin fold thickness (TST) and subjective global assessment (SGA) have some limitations in assessment of malnutrition. This study aims to determine the prevalence of malnutrition in non-hospitalized cirrhotic and chronic hepatitis patients and to assess handgrip (HG) strength as a tool for identifying malnutrition. Methods Consecutive patients of cirrhosis (n = 352), chronic hepatitis (n = 189) and healthy controls (n = 159) were enrolled. All patients underwent MAMC, TST, HG and SGA assessment. Malnutrition was diagnosed on basis of SGA score. Values of MAMC, TST and HG below the 5th percentile or less than 60% of healthy controls were considered as abnormal. Results According to SGA (taken as standard) 24% patients with chronic hepatitis and 56% of patients with cirrhosis had malnutrition (P = 0.001). In patients with chronic hepatitis prevalence of malnutrition according to MAMC (12%), TST (31%) and HG (18%). In patients with cirrhosis prevalence of malnutrition according to MAMC (27%), TST (60%) and HG (42%). HG exercise strength had the highest area under curve 0.82 (95% confidence interval (CI) 0.78–0.86, P = 0.001) compared to MAMC 0.60 (95% CI 0.55–0.64, P = 0.001) and TST 0.65 (95% CI 0.61–0.69, P = 0.001) for assessing malnutrition. On comparison of HG, TST and MAMC, the sensitivity was 67%, 60% and 31%, respectively, Specificity was 95%, 71% and 89%, respectively, and diagnostic accuracy was 87%, 67% and 71%, respectively. Conclusion HG strength is an excellent tool to assess at bed side the nutrition status in patients with cirrhosis and has the highest diagnostic accuracy compared to other anthropometric tests such as MAMC and TST.

Malignancy masquerading as liver abscess, and presenting with fever, is mainly described in patients with colorectal cancers with liver metastasis. Primary liver tumors such as hepatocellular carcinoma or intrahepatic cholangiocarcinoma presenting as non-resolving liver abscess is extremely uncommon and carries a dismal prognosis. We present a rare case of non-resolving liver abscess as a presenting manifestation of intrahepatic cholangiocarcinoma.

Background In India, both genotype 3 and 1 are predominant genotypes in patients with chronic hepatitis C (CHC). However, there is scanty data on sustained viral response (SVR) rate with conventionally recommended dual therapy with PEG-IFN and ribavirin. Methods In this retrospective study, consecutive patients of CHC of genotypes 1 and 3, attending the single unit of Gastroenterology of our hospital, who received PEG-IFN and ribavirin therapy, were included. Patients who had co-infection with HIV or HBV were excluded. Results A total of 114 patients were included in the study median age 44 (15–72) years, 79% males. Most common presentation was with chronic hepatitis, while 10 (9%) patients had compensated cirrhosis. Nine (8%) patients had associated diabetes, 16 (14%) patients gave history of significant alcohol abuse. The median baseline HCV RNA level was 3.0 × 105 (1.7 × 103–1.8 × 107) IU/mL. The most common genotype was 3 (75%) followed by genotype 1 (25%). 70% patients received PegIFN-α2a (median dose 180 MIU/wk) and 30% patients received PegIFN-α2b (median dose 80 MIU/wk). The median ribavirin dose was 800 (range 800–1200) mg. SVR in genotype 1 was 64% (18/28) while SVR in genotype 3 was 73% (63/86). The factors predicting SVR on univariate analysis were a lower baseline HCV RNA level (less than 3.0 × 105), higher hemoglobin level > 11.8 g/dl, and achievement of rapid virological response (RVR), early virological response (EVR) and end of treatment response (ETR). In multivariate analysis the only baseline factor found independently correlating with SVR was low HCV RNA level ( Conclusion In north India, HCV genotype 3 has a SVR rate of 73%, which is comparable to genotype 1 with SVR rate of 64% when treated with PEG-IFN and ribavirin therapy. A baseline HCV RNA level lower than 3.0 × 105 best predicts SVR in addition to achievement of RVR, EVR or ETR.

Globally, around 150 million people are infected with hepatitis C virus (HCV). India contributes a large proportion of this HCV burden. The prevalence of HCV infection in India is estimated at between 0.5% and 1.5%. It is higher in the northeastern part, tribal populations and Punjab, areas which may represent HCV hotspots, and is lower in western and eastern parts of the country. The predominant modes of HCV transmission in India are blood transfusion and unsafe therapeutic injections. There is a need for large field studies to better understand HCV epidemiology and identify high-prevalence areas, and to identify and spread awareness about the modes of transmission of this infection in an attempt to prevent disease transmission.