Hepatocellular Carcinoma Presenting as a Clival Mass

Introduction: Hepatocellular carcinoma (HCC) comprises the majority of primary liver cancer and has a poor prognosis. Clivus metastasis is rare with only a few reported cases in the medical literature. We report a case of a patient who presented with clival mass found to have metastatic HCC. Case Description/Methods: A 63-year-old woman presented for neurosurgical evaluation after she was found to have a skull base mass on computerized tomography (CT) of the head at an outside hospital. She endorsed dysphagia for three months, however denied headaches or visual disturbances. A magnetic resonance imaging (MRI) revealed a 5.4 cm by 2.9 cm by 3.6 cm mass in the clivus, which was deemed as the cause of dysphagia (Figure 1a). The patient subsequently underwent an endoscopic transsphenoidal resection of the clival mass. Histopathology from the tissue revealed a hepatoid carcinoma, concerning for metastatic HCC (Figure 1b and 2c). Immunohistochemical strains were positive for hepatocytic marker arginase-1 (Figure 1d). Laboratory studies revealed alpha fetoprotein (AFP) of 56,344 ng/mL, CA-125 of 376 ng/mL, normal B-HCG and carcinoembryonic antigen (CEA). Thereafter, a triple phase CT of the liver revealed two LI-RADS 5 lesions suggestive of HCC as the primary malignancy. Patient's case was discussed at multidisciplinary tumor board with recommendations for systemic immunotherapy with atezolimumab plus bevacizumab and radiation therapy to the clivus. Discussion(s): The incidence of HCC has almost tripled since the 1980s making it the fastest rising cause of cancer related deaths. Metastasis to the brain comprises 0.26% to 2.2% of cases and the skull base is the most rarely affected anatomical site. Although CNS presentation is rare, we may see more neurological manifestations of metastatic HCC with the persistence of chronic hepatitis infections, the rise of metabolic diseases such as NASH, and an increase in alcohol-related liver disease during the COVID-19 pandemic. Although exceedingly rare, metastasis to the clivus should be considered in the differential diagnosis of skull base masses. Despite detection and treatment, prognosis remains poor and emphasis should be placed on consistent HCC surveillance. This case emphasizes that skull masses must be evaluated diligently as they can be the first sign of underlying liver malignancy. Given the morbidity and mortality associated with HCC, recognition of atypical manifestations of HCC can lead to a prompt diagnosis and initiation of life-saving treatment. (Figure Presented).

Pre-existing chronic liver disease is associated with poor outcome in patients with SARS-CoV2 infection

COVID-19 is characterized by predominant respiratory and gastrointestinal symptoms. Liver enzymes derangement is seen in 15-55% of the patients. Cirrhosis is characterized by immune dysregulation, leading to concerns that these patients may be at increased risk of complications following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Patients with metabolic dysfunction-associated fatty liver (MAFLD) had shown a 4-sixfold increase in severity of COVID-19, and its severity and mortality increased in patients with higher fibrosis scores. Patients with chronic liver disease had shown that cirrhosis is an independent predictor of severity of COVID-19 with increased hospitalization and mortality. An international European registry study included 756 patients with chronic liver disease from 29 countries reports high mortality in patients with cirrhosis (32%). Data of 228 patients collected from 13 Asian countries on patients with CLD, known or newly diagnosed, with confirmed COVID-19 (APCOLIS study) showed that SARSCoV- 2 infection produces acute liver injury in 43% of CLD patients without cirrhosis. Additionally, 20% of compensated cirrhosis patients develop either ACLF or acute decompensation. In decompensated cirrhotics, the liver injury was progressive in 57% of patients, with 43% mortality. Patients with CLD and associated diabetes and obesity had a worse outcome. Liver related complications were seen in nearly half of the decompensated cirrhotics, which were of greater severity and with higher mortality. Increase in Child Turcotte Pugh (CTP) score and model for end-stage liver disease (MELD) score increases the mortality in these patients. In a subsequent study of 532 patients from 17 Asian countries was obtained with 121 cases of cirrhosis. An APCOLIS risk score was developed, which included presence of comorbidity, low platelet count, AKI, HE and respiratory failure predicts poor outcome and an APCOLIS score of 34 gave a sensitivity and specificity of 79.3%, PPV of 54.8% and NPV of 92.4% and predicted higher mortality (54.8% vs 7.6%, OR = 14.3 [95 CI 5.3-41.2], p<0.001) in cirrhosis patients with Covid-19. The APCOLIS score is helpful in triaging and prognostication of cirrhotics with Coivd-19. The impact of COVID-19 on patients with cirrhosis due to non-alcoholic fatty liver disease (NASH-CLD) was separately studied in 177 NASH-CLD patients. Obese patients with diabetes and hypertension had a higher prevalence of symptomatic COVID. Presence of diabetes [HR 2.27], fraility [HR 2.68], leucocyte counts [HR 1.69] and COVID-19 were independent predictors of worsening liver functions in patients with NASH-CLD. Severity of Covid in Cirrhosis could also be assessed by measuring ICAM1 the Intercellular Adhesion Molecule, an indicator of Endothelial Injury Marker. in Cirrhosis with Covid 19 Immunosuppression should be reduced prophylactically in patients with autoimmune liver disease and post-transplantation with no COVID-19. Hydroxychloroquine and remdesivir are found to be safe in limited studies in a patient with cirrhosis and COVID-19. And is safe in cirrhosis patients. However, flare of AIH has been reported in AIH patients. For hepatologists, cirrhosis with COVID-19 is a pertinent issue as the present pandemic cause severe disease in patients with chronic liver disease leading to more hospitalization and decompensation.

Nonalcoholic fatty liver disease and diabetes.

Nonalcoholic fatty liver disease (NAFLD) is the most prevalent chronic liver disease in the world and represents a clinical-histopathologic entity where the steatosis component may vary in degree and may or may not have fibrotic progression. The key concept of NAFLD pathogenesis is excessive triglyceride hepatic accumulation because of an imbalance between free fatty acid influx and efflux. Strong epidemiological, biochemical, and therapeutic evidence supports the premise that the primary pathophysiological derangement in most patients with NAFLD is insulin resistance; thus the association between diabetes and NAFLD is widely recognized in the literature. Since NAFLD is the hepatic manifestation of a metabolic disease, it is also associated with a higher cardio-vascular risk. Conventional B-mode ultrasound is widely adopted as a first-line imaging modality for hepatic steatosis, although magnetic resonance imaging represents the gold standard noninvasive modality for quantifying the amount of fat in these patients. Treatment of NAFLD patients depends on the disease severity, ranging from a more benign condition of nonalcoholic fatty liver to nonalcoholic steatohepatitis. Abstinence from alcohol, a Mediterranean diet, and modification of risk factors are recommended for patients suffering from NAFLD to avoid major cardiovascular events, as per all diabetic patients. In addition, weight loss induced by bariatric surgery seems to also be effective in improving liver features, together with the benefits for diabetes control or resolution, dyslipidemia, and hypertension. Finally, liver transplantation represents the ultimate treatment for severe nonalcoholic fatty liver disease and is growing rapidly as a main indication in Western countries. This review offers a comprehensive multidisciplinary approach to NAFLD, highlighting its connection with diabetes.

63rd Annual Conference of the Indian Society of Gastroenterology, ISGCON 2022

The proceedings contain 380 papers. The topics discussed include: fecal microbiota transplantation with anti-inflammatory diet followed by anti-inflammatory diet alone is effective in inducing and maintaining remission over 1 year in mild to moderate ulcerative colitis - a randomized controlled trial;gut microbial dysbiosis, gut barrier integrity, and severity of chronic pancreatitis: exploring a mechanistic link using an experimental model;acanthosis nigricans-a rare cutaneous association in progressive familial intrahepatic cholestasis type 3;liver mass presenting as acute cardiorespiratory failure;role of serum phosphate levels in acute-on-chronic liver failure patients to predict short-term mortality;association of liver dysfunction in corona virus disease-19 patients;diabetic with emphysematous liver abscess: a case report;non HFE hemochromatosis - the uncommon variant;granulomatous disease with hepatic involvement in a South Indian female;epidemiological profile of acute hepatitis patients hospitalized in a tertiary care center in Western India;and a prospective randomized comparative four arm intervention study of efficacy and safety of saroglitazar and vitamin E in patients with non-alcoholic fatty liver disease/ non-alcoholic steatohepatitis - an interim analysis.

Increased Hepatic ATG7 mRNA and ATG7 Protein Expression in Nonalcoholic Steatohepatitis Associated with Obesity.

The autophagy gene ATG7 has been shown to be essential for the induction of autophagy, a process that used to be suppressed in nonalcoholic fatty liver disease (NAFLD). However, the specific role of ATG7 in NAFLD remains unclear. The aim of this study was to analyze hepatic ATG7 mRNA and ATG7 protein expression regarding obesity-associated NAFLD. Patients included women classified into normal weight (NW, n = 6) and morbid obesity (MO, n = 72). The second group was subclassified into normal liver (NL, n = 11), simple steatosis (SS, n= 29), and nonalcoholic steatohepatitis (NASH, n = 32). mRNA expression was analyzed by RT-qPCR and protein expression was evaluated by Western blotting. Our results showed that NASH patients presented higher ATG7 mRNA and ATG7 protein levels. ATG7 mRNA expression was increased in NASH compared with SS, while ATG7 protein abundance was enhanced in NASH compared with NL. ATG7 mRNA correlated negatively with the expression of some hepatic lipid metabolism-related genes and positively with endocannabinoid receptors, adiponectin hepatic expression, and omentin levels. These results suggest that ATG7-mediated autophagy may play an important role in the pathogenesis of NAFLD, especially in NASH, perhaps playing a possible protective role. However, this is a preliminary study that needs to be further studied.

Acute Cellular Rejection in Liver Transplant Recipients Following Vaccination Against Covid-19

Purpose: The coronavirus disease 2019 (COVID-19) global pandemic has seen the development of effective vaccines in record time. We report a series of five liver transplant (LT) recipients who developed acute cellular rejection (ACR) after receiving COVID-19 vaccinations. Method(s): We performed a single-center, retrospective review of LT recipients who presented with biopsy-proven ACR after receiving a COVID-19 vaccination. Result(s): 603 LT recipients were fully vaccinated against COVID-19 at our center on 10/4/2021. Five (0.77%) patients developed elevated liver enzymes after COVID-19 vaccination without an identifiable cause and had a subsequent liver biopsy consistent with ACR: four (80%) patients were male and the median age was 54 years old. The indication for LT was cirrhosis secondary to non-alcoholic steatohepatitis in three (60%) and alcohol in two (40%) patients. The median time from LT to the first dose of COVID-19 vaccination was 19 months (range 7-26 months). Three (60%) patients had moderate (RAI= 5/9) ACR. All patients were treated with high-dose intravenous methylprednisolone for 3 days and had normalization of liver enzymes. No patients required rescue therapy with anti-thymocyte globulin or developed graft failure. All patients eventually completed their vaccination series. Conclusion(s): LT recipients may be at risk for developing ACR after the COVID-19 vaccination. Further study is required to better understand this relationship while closer monitoring following vaccination may be warranted in this patient population. (Figure Presented).

FATTY LIVER DISEASE IN NHS STAFF AND ROLE OF FIBROSCAN

Introduction It has never been more crucial to ensure the health and wellbeing of our colleagues. This study focuses on the impact of diet, alcohol and activity on the liver and anxiety levels were also reflected upon as a result of the Covid period on NHS staff. A Fibroscan (530, Compact, Echosens) was used as part of a staff 'Love your Liver 'clinic in a NHS general hospital, conducted by Hepatology nurses. Non-alcoholic fatty liver disease (NAFLD) is a rising health problem that can lead to non-alcoholic steatohepatitis (NASH) and cirrhosis with associated liver mortality. In the UK 63% of adults are obese and overweight, 1 in 3 people have earlystage NAFLD. In a previous study we conducted between 2018- 2020, 'NHS Biscuit Culture' 74 staff participated, 60 female and 14 male. Mean age 46.9 (range 25 -70). 59.4% had NAFLD with Controlled Attenuation Parameter (CAP) >248 dB/m with 16.2% also having associated fibrosis with Liver Stiffness Measure (LSM) >7.8 kPa. It was felt the results may act as a 'shock factor' to motivate lifestyle changes. Method 15 patients who were identified as having NAFLD were re-scanned 6 months later and were asked to follow advice on diet and lifestyle. 80% improved the CAP score with a mean reduction of 56.3dB/m. 20% CAP did not improve reported, diet was not changed. During November 2021, we offered a liver clinic to previously scanned staff to re-evaluate but many declined due to weight gain during Covid. Our event incorporated 45 staff, age range 30-71 years (mean age 42.6 years, 39 females, 6 males). Questionnaires were emailed to 45 participants. The questionnaire focused on diet, alcohol, anxiety levels and activity level at work. Results Fibroscan results 47% (n=45) fatty liver, CAP >243 dB/m and 2% (n=45) fibrosis with LSM >7.8 kPa. 9% borderline fatty liver, CAP of 231-237 dB/m and 7% borderline fibrosis LSM 6.2 -6.6 kPa. 18% staff were rescanned that previously had fatty liver in our previous liver events during 2018 to 2020, 50% (n=8) of fibroscan returned within normal range, 37.5% fat content had improved but fatty liver remained, 12.5% of the staff 's results remained the same, fatty liver, no fibrosis. Staff 's weekly diet included candy, sweetened drinks, fast food, fruit and vegetables. Candy 29%, Fast food 27%, sweetened beverages 16%, and 5 or more fruit a day 11%. 20% Staff were already on a diet. Admin staff 41% (n=45), 33% nursing staff, 22% pathology, radiology and dieticians, 2% doctors and 2% management attended the events. 11% currently drinking over 14 units a week (15-25 units), 15% drinking 10-14 units a week. Staff alcohol consumption did increase during the Covid. No alcohol consumption 47% (n=45), 1-5 units 20%, 5-10 units 9%. Mild anxiety 74% (range 0-5), moderate 15% (6-14) and severe 10% (15-21). Pre-existing high level of anxiety 2% of the staff, Covid increased anxiety levels due to increased pressures at work. 10% required further assessment. 56% had limited activity during the day due to job role and 44% regularly mobilised as part of their roles. Conclusion The study tells us that diet and lifestyle has a significant impact on hepatosteatosis. Incidence of NAFLD is considerably higher in staff members (47%) in a district general hospital as compared to the general population (25%). This could be secondary to levels of stress during the COVID pandemic. The study showed a significant reduction in CAP and LSM scores after simple lifestyle advice was given to a group of motivated healthcare workers.

Global burden of nonalcoholic steatohepatitis-related liver cancer, 1990-2019: a systematic analysis for the GBD 2019.

With the pandemic of metabolic diseases, nonalcoholic fatty liver disease (NAFLD) prevalence has dramatically elevated. NAFLD encompasses a spectrum of diseases including simple steatosis and nonalcoholic steatohepatitis (NASH), which can further progress to cirrhosis or liver cancer (LC). However, data are lacking on the burden and trend of NASH-related LC. Here, we analyzed the trends and changes of NASH-related LC burden using Global Burden of Disease (GBD) data (1990-2019). In 2019, the global incidence, prevalence, disability-adjusted life years (DALYs) and deaths of NASH related LC were 36.3 thousand (95% UI 29.5-44.9), 46.8 thousand (38.2-57.6), 796 thousand (657-976) and 34.7 thousand (28.4-43.2), respectively. The absolute numbers and rates of NASH-related LC incidence, mortality, and DALY significantly elevated from 1990 to 2019. With the age increased, the incidences, DALYs and deaths of NASH-related LC significantly elevated. The incidence and mortality rate of NASH-related LC significantly increased from 2010 to 2019 in individuals aged from 20 to 54 and older than 55 years old. We also found that a large disparity of NASH-related LC burden in different socio-demographic index (SDI) locations. The crude number and the age-standardized rate of incidences, DALYs and deaths was highest in the middle SDI locations and high SDI locations showed the largest increase of NASH-related LC burden from 1990 to 2019. Moreover, the proportion of LC incidences, deaths and DALYs attributed to NASH were 4.74%, 5.30% and 4.25%, respectively in 1990 which were increased by 43.5%, 35.3% and 49.4%, respectively in 2019. Conclusion: The global burden of NASH-related LC and the proportion LC burden attributed to NASH are significantly increasing.

Liver enzyme changes following Covid-19 in patients with underlying liver diseases

Objectives: In the recent 2 years,a novel Covid-19 virus played a crucial role in development of severe respiratory and multiple organ failure, including liver.The aim of the study is determine liver injury in patients with underlying liver diseases and evaluate the effect of treatment. Materials and Methods: 137 patients (51% males, 49% females, mean age 34 years ± 6.5 with known liver diseases were admitted to our department for post-COVID control (median time post-infection 34 days ± 1.4). Previously, HBV was diagnoses in 18 (13.5%),mean ALT 31 (52.4-12.6),mean AST 24.8 (52.4-12.6), HCV in 43 (32% mean ALT 57 (195.1-16.9)mean AST 31.3 (61.9-17)), NAFLD/ NASH in 74 ( (54.5%)mean ALT 152.4 (1186 -19.7)mean AST 57.9 (70-19.4)). 22 (32.8%) have received antibiotic prophylaxis only, 25 (37% antiviral treatment (40% favipiravir,60% remdesivir)),9 (13.4%) had both antibiotics and antiviral treatment). Results: Median Elevation of ALT/AST was mostly observed in NASH/NAFLD group with pre-COVID high liver enzymes (median ALT value 42 IU/ml vs 98 IU/ml p<0.005;AST 26 IU/ml vs 84 p<0.005).Mixed treatment with both antibiotics (azithromycin) and Favipirovir was associated with higher elevation of liver enzyme in all groups. NASH/NAFLD patients had the highest elevation of liver enzymes following COVID among chronic liver disease groups. Conclusion: All Post-Covid patients, especially those with NASH/ NAFLD, regardless of the presence or absence of concurrent chronic liver disease, regardless of receiving antibiotics, require monitoring of liver function tests from the beginning of the disease.

Is Fatty Liver Associated with Increased Mortality and Morbidity in Coronavirus Disease 2019 (COVID-19) Pneumonia?

Background: Fatty liver has been shown to be associated with severe COVID-19 disease without any impact on mortality. This is based on heterogenous criteria for defining both fatty liver as well as the severity parameters. This study aimed to study the impact of fatty liver on the mortality and severity of disease in patients with COVID-19 pneumonia. Methods: In a case control study design, patients with COVID-19 pneumonia (COVID-19 computed tomography severity index [CTSI] on high-resolution computed tomography chest of ≥1) with fatty liver (defined as liver to spleen attenuation index ≤5 on noncontrast computed tomography cuts of upper abdomen) were compared with those without fatty liver. The primary outcome measure was in-hospital mortality, and the secondary outcome measures were CTSI score, need for intensive care unit (ICU) care, need for ventilatory support, duration of ICU stay, and duration of hospital stay. Results: Of 446 patients with COVID-19 pneumonia, 289 (64.7%)admitted to Max Hospital, Saket, India, between January 1, 2021, and October 30, 2021, had fatty liver. Fifty-nine of 446 patients died during the index admission. In-hospital mortality was not different between patients with fatty liver (38 [13.24%]) or without fatty liver (21 [13.81%]). COVID-19 CTSI score was found to be significantly higher among patients who had fatty liver (13.40 [5.16] vs 11.81 [5.50]; P = 0.003). There was no difference in the requirement of ICU (94 [32%] vs 62 [39.49%]; P = 0.752), requirement of ventilatory support (27 [9.34%] vs 14 [8.91%]; P = 0.385), duration of ICU stay (8.29 [6.87] vs 7.07 [5.71] days; P = 0.208), and duration of hospital stay (10.10 [7.14] vs 10.69 [8.13] days; P = 0.430) between the groups with fatty liver or no fatty liver. Similarly, no difference was found in primary or secondary outcomes measure between the group with severe fatty liver vs mild/moderate or no fatty liver. High total leucocyte count and Fibrosis-4 (FIB-4) index were independently associated with mortality. Conclusions: Fatty liver may not be associated with increased mortality or clinical morbidity in patients who have COVID-19 pneumonia.

Experience with Remdesivir for Treatment of SARS-CoV-2 in Patients with Liver Cirrhosis

Background. Remdesivir is a nucleotide analogue antiviral that was FDA approved for the treatment of hospitalized patients with coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Remdesivir has been associated with elevations in serum aminotransferase levels but most cases being mild to moderate and reversible upon discontinuation. Although national COVID-19 guidelines and the American Association for the Study of Liver Diseases (AASLD) currently recommend remdesivir for use in hospitalized patients requiring supplemental oxygen, data is limited using remdesivir in patients with chronic liver disease. Here, we describe our experience with remdesivir in patients with liver cirrhosis. Methods. Patients with liver cirrhosis who received remdesivir were identified either prospectively or retrospectively by primary or secondary ICD-10 codes indicating liver disease. Data collected included patient demographics, underlying cause of cirrhosis, co-morbidities, Child-Pugh score, laboratory values (serum aminotransferase levels, serum creatinine) during and following remdesivir, adverse reactions attributed to remdesivir, and mortality (in-hospital, 30-day, and 90-day). Results. A total of 4 patients with underlying liver cirrhosis completed a 5-day course of remdesivir treatment. On admission, Child-Pugh class was A for 1 patient, B for 2 patients, and C for 1 patient. Causes for cirrhosis were nonalcoholic steatohepatitis (NASH), hepatic amyloidosis, and chronic hepatitis B. There were no acute elevations in aminotransferase levels or adverse events attributed to remdesivir therapy. Mortality was high with 50% in-hospital mortality. Of the 2 other patients who survived to discharge, one was discharged to home hospice and the other was readmitted within 30 days and expired during that admission. Conclusion. Since there is limited data available using remdesivir in patients with advanced liver disease, we did not identify any safety concerns related to remdesivir in our cirrhotic patients. Mortality was high illustrating the poor outcomes of patients with advanced liver disease and COVID-19. Patients with cirrhosis should be offered remdesivir if clinically appropriate.

IMPACT OF SARS-COV-2 INFECTION IN WAITING LIST FOR LIVER TRANSPLANTATION

Background and aim: Infections in cirrhotic patients are associated with an increased risk of liver-related complications (LRC) and mortality. Limited data regarding the prevalence of Coronavirus disease (COVID-19) in cirrhotic patients’ awaiting liver transplantation (LT) are available. The aim of this study was to evaluate the prevalence of SARS-CoV2 in a cohort of cirrhotic patients and its impact on LRC rate and on LT.Materials and methods: We retrospectively included 187 waitlist patients for LT from 24-January-2020 (2020-cohort) and 123 patients from 24-January-2019 (2019-cohort). All 2020-cohort patients were screened for COVID-19 symptoms with a survey. COVID-19 infection was defined by a positive PCR assay for SARS-CoV-2 on nasopharyngeal swab or the positivity for specific antibodies or typical lung lesions on CT scan. We also assessed the indirect impact of SARSCoV2 infection on LRC and LT rate, estimated by competitive risk survival analyses in 2020-cohort vs. 2019-cohort (Fine and Gray method).Results: In 2020-cohort, 72.7% (n=136) of patients were male with mean age of 55.5±12, 47.2% (n=85) patients have alcohol and/or NASH related cirrhosis, with a median MELD score of 14.1±7.4. 45.5% (n=71), 38.5% (n=60) and 14.8% (n=23) of patients were A, B and C for Child-Pugh-score, respectively. 172 patients responded to survey and 22% (n= 38) had symptoms. 20/38 patients were tested for SARS-CoV2 and 4 patients were positive. 3/4 patients with COVID-19 disease needed hospitalization and 1 intensive care support. No death was reported and 1 patient was LT. The 2020-cohort and 2019-cohort were comparable for sex (p=0,6), age (p=0.7), comorbidities (p=0.2) and Child-Pugh-score (p=0.2). The cumulative incidence of LRC was not significantly higher in the 2020-cohort vs. 2019-cohort (SHR 0.65, 95% CI 0.36-1.15, p=0.138). The cumulative incidence of LT was significantly lower in the 2020-cohort than in the 2019-cohort (SHR0.21, 95% CI 0.13-0.33, p<0.001). Conclusions: Our study reported a low prevalence rate of SARSCoV2 infection in a cohort of cirrhotic patients waiting for LT. No SARS-CoV2 infection direct or indirect impact on mortality and LRC rate was reported. However, a significant shortage of LT was found in 2020 cohort.

Association of non-alcoholic fatty liver disease and COVID-19: A literature review of current evidence.

The coronavirus disease 2019 (COVID-19) pandemic has swept through nations, crippled economies and caused millions of deaths worldwide. Many people diagnosed with COVID-19 infections are often found to develop liver injury, which, in a small portion of patients, progresses to severe liver disease. Liver injury in the form of elevated transaminases, hyperbilirubinemia and alterations in serum albumin has been observed to be higher in patients with severe forms of the disease. Those who already have insult to the liver from chronic disease, such as nonalcoholic fatty liver disease (NAFLD) may be at the greatest disadvantage. The severity of COVID-19 also seems to be driven by the presence of NAFLD and other co-morbidities. About 25% of the global population has NAFLD. With such a widespread prevalence of NAFLD, understanding the disease progression of COVID-19 and the occurrence of liver injury in this vulnerable population assumes great significance. In this review, we present an overview of COVID-19 infection in patients with NAFLD.

"SARS-CoV-2 Infection in Liver Transplant Recipients - Immunosuppression is the Silver Lining?"

BACKGROUND: COVID-19 is associated with higher mortality among patients who have comorbidities. However, evidences related to COVID-19 among post liver transplant recipients are scarce and evolving. METHODS: Adult Indian patients who had undergone liver transplantation at our centre since 2006 and were under regular follow-up, were contacted either telephonically or on email. Data were recorded related to symptoms and diagnosis of COVID-19, need for hospitalization, and need for ICU stay and mortality. RESULTS: Eighty one (3.71%) of the 2182 adult Liver transplant (LT) recipients on regular follow-up reported SARS-CoV-2 infection between 1st April 2020 and 31st May 2021. Mean age was 51.3(±9.8) years, and 74(91.4%) were males. Thirty five (43.2%) patients had one or more comorbidities. Twenty one (25.9%) patients were transplanted less than 1 year ago. Forty four (54.3% ) patients had mild disease only while 23(28.4%) patients had severe COVID-19 disease. Of the 81 patients 14 patients died and overall mortality was 17.3. CONCLUSION: Uncomplicated liver transplant recipients without comorbidities who acquire SARS-CoV-2 do not have poor outcome.

Exercising in the COVID-19 era: implications in non-alcoholic fatty liver disease (NAFLD).

COVID-19 is a major public health pandemic. Risk factors for severe infection and poorer outcomes include cardiovascular disease, obesity, type 2 diabetes mellitus and non-alcoholic fatty liver disease (NAFLD). Lifestyle interventions, including diet and physical activity modifications, are the current recommended treatment for NAFLD. In this communication, the authors discuss the crossover link between NAFLD and severe COVID-19 infection and the impact of essential public health measures to suppress the spread of COVID-19 on exercise and physical activity participation in patients with NAFLD. The future of exercise prescription and the potential use of digital technology in addressing NAFLD healthcare needs in the COVID-19 era are also explored.