RESUMO
BACKGROUND: Liver transplantation (LT) for hepatocellular carcinoma (HCC) has been widely researched and is well established worldwide. The cornerstone of this treatment lies in the various criteria formulated by expert consensus and experience. The variations among the criteria are staggering, and the short- and long-term out comes are controversial. AIM: To study the differences in the current practices of LT for HCC at different centers in India and discuss their clinical implications in the future. METHODS: We conducted a survey of major centers in India that performed LT in December 2022. A total of 23 responses were received. The centers were classified as high- and low-volume, and the current trend of care for patients und ergoing LT for HCC was noted. RESULTS: Of the 23 centers, 35% were high volume center (> 500 Liver transplants) while 52% were high-volume centers that performed more than 50 transplants/year. Approximately 39% of centers had performed > 50 LT for HCC while the percent distribution for HCC in LT patients was 5%-15% in approximately 73% of the patients. Barring a few, most centers were divided equally between University of California, San Francisco (UCSF) and center-specific criteria when choosing patients with HCC for LT, and most (65%) did not have separate transplant criteria for deceased donor LT and living donor LT (LDLT). Most centers (56%) preferred surgical resection over LT for a Child A cirrhosis patient with a resectable 4 cm HCC lesion. Positron-emission tomography-computed tomography (CT) was the modality of choice for metastatic workup in the majority of centers (74%). Downstaging was the preferred option for over 90% of the centers and included transarterial chemoembolization, transarterial radioembolization, stereotactic body radiotherapy and atezolizumab/bevacizumab with varied indications. The alpha-fetoprotein (AFP) cut-off was used by 74% of centers to decide on transplantation as well as to downstage tumors, even if they met the criteria. The criteria for successful downstaging varied, but most centers conformed to the UCSF or their center-specific criteria for LT, along with the AFP cutoff values. The wait time for LT from down staging was at least 4-6 wk in all centers. Contrast-enhanced CT was the preferred imaging modality for post-LT surveillance in 52% of the centers. Approximately 65% of the centers preferred to start everolimus between 1 and 3 months post-LT. CONCLUSION: The current predicted 5-year survival rate of HCC patients in India is less than 15%. The aim of transplantation is to achieve at least a 60% 5-year disease free survival rate, which will provide relief to the prediction of an HCC surge over the next 20 years. The current worldwide criteria (Milan/UCSF) may have a higher 5-year survival (> 70%); however, the majority of patients still do not fit these criteria and are dependent on other suboptimal modes of treatment, with much lower survival rates. To make predictions for 2040, we must prepare to arm ourselves with less stringent selection criteria to widen the pool of patients who may undergo transplantation and have a chance of a better outcome. With more advanced technology and better donor outcomes, LDLT will provide a cutting edge in the fight against liver cancer over the next two decades.
RESUMO
BACKGROUND AND OBJECTIVE: Nonalcoholic fatty liver disease (NAFLD) is conventionally considered to be a disease of obese subjects. Recent data suggests increasing incidence of NAFLD among lean subjects also. The aim of this study was to evaluate the metabolic profile of lean subjects with NAFLD and compare it with obese subjects with NAFLD. We also aimed to compare the same with lean subjects without NAFLD. METHODS: This study included 250 subjects with NAFLD and 500 non-NAFLD controls. Clinical, anthropological and biochemical data were collected. Subjects with body mass index (BMI) >= 25 kg/m2 were taken as obese and subjects with BMI <25 kg/m2 were taken as lean. Study population was divided into four groups i.e. lean subjects with NAFLD (LN), obese subjects with NAFLD (ON), lean subjects without NAFLD (LNN) and obese subjects without NAFLD (ONN). RESULTS: Out of 250 NAFLD subjects, 69 (27.6%) were lean. Out of 69 lean subjects with NAFLD, 54 (78.3%) were having diabetes mellitus. Metabolic profile (including lipid profile, diabetic profile) of lean subjects with NAFLD was significantly abnormal in comparison to lean non-NAFLD subjects. Proportion of subjects with metabolic syndrome was also comparable in both lean and obese NAFLD groups. Despite having comparable BMI, LN groups had significantly higher waist circumference (WC) than LNN. Mean total cholesterol, triglyceride, LDL were significantly higher in obese NAFLD in comparison to lean NAFLD. Mean HDL and VLDL were comparable among both groups. Mean FBS, HbA1c, fasting insulin and HOMA-IR were significantly higher among lean NAFLD group in comparison to obese NAFLD group. Obese NAFLD group had significantly higher levels of SGPT and SGOT as compared to lean NAFLD group. CONCLUSION: Lean NAFLD has significantly higher WC in comparison to non-NAFLD counterparts suggesting possible association with central adiposity. Lean and obese NAFLD share common set of metabolic abnormalities, albeit with varying intensity. Lean NAFLD has more severe insulin resistance in comparison to obese NAFLD. Lean NAFLD subjects appeared to have less severe transaminasemia.
