An Introduction to Liver Disease in India

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We thank the AASLD and the editors of Clinical Liver Disease for publishing a special issue focusing on liver disease in India. Although alcoholic and non‐alcoholic liver diseases and viral hepatitis are very common in India as in the rest of the world, there are few conditions that are unique to India and the rest of South Asia. The purpose of this special issue is to focus on these topics and also to highlight the differences of clinical presentation or outcomes of common liver diseases predominantly from an Indian perspective.

The burden of liver disease in India is difficult to assess since the epidemiological data are not robust as in most parts of the world. ¹ The available data, however, show that cirrhosis and its complications as a cause of mortality are increasing in India. Hepatitis B and C, alcoholic liver disease, and non‐alcoholic liver disease are probably the major contributors of cirrhosis and liver cancer‐related mortality. The challenges of managing these conditions in an optimal manner are many, including limitations of resources, hepatologists, and healthcare facilities; the differences in cultural beliefs; the dependence on untested and unproven traditional medicines and herbal supplements; a lack of universal education and the awareness of diseases and their modes of transmission; and increased prevalence of underlying poverty and malnutrition.

There are few infections that are still more prevalent in India than the rest of the world, although the etiology of end‐stage liver disease is slowly shifting to a pattern similar to that seen in Western countries. The common tropical infections that cause liver damage in India include dengue fever, leptospirosis, malaria, and scrub typhus. Additionally, amebic liver abscesses, hydatid cysts, and tuberculosis with hepatic involvement are more commonly seen in India. ² , ³ First‐generation antituberculosis medications and herbal supplements are common causes of drug‐induced liver injury and acute liver failure. ⁴ Attempted suicide attempt with yellow phosphorus is another cause of acute liver failure that is rarely seen outside India. Another unusual hepatobiliary disease seen in rural parts of India is biliary tract obstruction from Ascaris lumbricoides, resulting in cholangitis, choledocholithiasis, and liver abscesses. ²

Hepatitis E is still the most common cause of acute hepatitis and acute liver failure in India, despite the advances India has made in hygiene practices and the sewage treatment. ⁵ Hepatitis E‐induced acute liver failure is associated with a very high mortality in pregnant women, and this is somewhat unique to India. Hepatitis C virus (HCV) is also common in India and mostly due to genotype 3. As in the rest of the world, the World Health Organization’s goal of HCV elimination by 2030 is going to be a huge challenge for India. However, India has made remarkable progress with free medications and a decentralized community‐based treatment model. ⁶ Whether this model will enable India to eliminate HCV remains uncertain at this stage. The vaccination rates for hepatitis B in children are less than 50% in most parts of India, and this along with others challenges such as disease unawareness, the lack of appropriate screening and treatment, the deviations from universal screening of blood borne pathogens by blood banks and the use of improperly sterilized medical instruments are likely to derail attempts of hepatitis B reduction in India unless and until central and state governments enforce the existing regulations and mandate universal HBV vaccination. ⁷

Hepatic venous outflow tract obstruction (HVOTO), known more commonly as Budd‐Chiari syndrome, is a rare disease in India as it is in Western countries, but the risk factors and the patterns of venous obstruction are different in India compared with Western countries. ⁸ There are only limited epidemiological data on hepatocellular carcinoma from India, but anecdotal experience suggests that most patients present with advanced symptomatic stage, as screening protocols are not commonly practiced.

Just as in adults, there is a paradigm shift in the etiology of liver diseases in children with metabolic liver diseases, including obesity‐related fatty liver disease, predominating and “Indian childhood cirrhosis” slowly disappearing. ⁹ Unlike most countries, extrahepatic portal vein obstruction (EHPVO) is the most common cause of portal hypertension in Indian children. Portal cavernous cholangiopathy, rarely reported outside India, is associated with EHPVO. ¹⁰

The challenges to manage patients with advanced liver disease are similar in India as in the rest of world, but the confounding factors are illiteracy, faith in traditional medicine, lack of health care facilities in rural areas, the absence of universal health care and a high prevalence of underlying malnutrition. ¹¹ , ¹² Sarcopenia is very common in Indian patients with advanced cirrhosis, and the presence of sarcopenia is known to increase liver disease‐related mortality. The definitions used in Western countries to diagnose sarcopenia, however, may not be applicable to an Indian population because of a higher prevalence of baseline malnutrition and also because of ethnic differences in body composition. ¹³ Liver transplantation, mostly from liver donors, has evolved in India in the past decade, and the reported transplant outcomes are comparable to those in Western countries. ¹⁴ More prospective and transparent nationwide data may become available soon from the recently instituted Indian Liver Transplant Registry (ILTR). In a country of 1.3 billion people, less than 2000 transplants are done per year, and this is also likely to evolve in the next decade.

In summary, this special issue highlights the challenges and the progress that India has made over past few decades. The major research institutions in India are challenging old dogmas and charting new ideas and pathways for the management of acute and chronic liver diseases.