Talk Liver To Me - Hepatology Ward Rounds: East Meets West

Hello, everybody. Welcome to Hepatology Ward Rounds. This is East meets West. Co-hosted by easel and the Indian National Association for the Study of Deliver. So for this episode of talk delivered to me, I'll be hosting a global conversation comparing what's really happening on the liver wards on the other side of the world in different healthcare systems and different patient populations. So in this episode, we're joined by Professor Elliott Tapo, the Chief of Hepatology at University of Michigan and Dr. Raqi Maywell, the head of the liver ICU at the Institute of liver and biliary sciences in New Delhi. And the idea is for them to take us inside their day-to-day inpatient hepatology practice from the most common reasons for admission to alcohol to nutrition to infections to daily to transplantation. And it's a practical on-the-ground discussion about what's changing in acute liver care and what challenges are shared and what differs by different regions. And honestly, this was a really engaging and fun conversation for me personally. I've met Elliott before. He's absolutely lives up to his reputation, engaging, thoughtful, exudes wisdom. But this was my first time sitting down properly with Raqi, who spoke really insightfully about the real day-to-day challenges she's dealing with on the ground. The sort of thing that doesn't always make it into guidelines or onto presentation slides, but what kind of defines what inpatient hepatology actually looks like. And I learned a lot. So it's quite nice because Elliott and Raqi have also met each other before and have exchanged ideas in the conference corridors. But it's such a privilege to kind of bring that kind of shared experience out into the open with his podcast. So I hope you enjoy it. The chat lasts around half an hour long. So let's get into it. [Music] Hi everybody. Welcome, Raki. Welcome, Elliott. Thanks for joining us. Ready to be with you. Thank you, too. Let's orientate people with where you are in the world. Raki, whereabouts are you at the moment? So I bring greetings for everyone over here from India. And I'm here at New Delhi. And it's quite late in the night in the evening. So it's like 8.45 as of now. Okay. But, and you, Elliott, what's going on with you? Well, with say, National holiday, Martin Luther King, Jr. Day. And I am taking some time to talk with you at 10.20 in the morning. Okay. Well, we've made, we've kind of made phase one and get on you both together. But you're both super busy clinicians. And let's start things off, Raki, with you. If you were, if you were to take me on a tour of the world or to take me on a ward round, round, round your ICU, what kind of patients would I see? What the top presentations and the type of patients that you're seeing in India at the moment? So our ICU, actually, the challenges are most 50 to 60% of the patients that we're seeing is alkyp or alcohol-related hepatitis. And along with it, we are seeing more and more of metabolic associated stetotic liver disease and a combination of both. And on top of that, very often, we're seeing drug-induced liver injury as the most commonityology that is filling our wards. What about you, Alia? What's on the wards at the moment? And has it changed over time? What about the last 10 years? Are things changed? Yeah, over the last 10 years, we've seen a steady increase whereby now alcohol-related liver disease dominates not only our specific service, but also the hospital at large. And what we're typically seeing is a young person presenting with severe acute alcohol associated hepatitis, but then also those people who are experiencing recurrent decompensation events. Does anything feel particularly different to Rocky, maybe the daily component she picked up? Yeah, so in the daily and particularly, I would like to highlight the etiology for acute liver failure. What we're seeing more and more often is the viral etiology and the cryptogenics. And in the viral itself, what we're seeing is a change in the pattern of the infection with hepatitis A, which was initially not very often seen as presenting as acute liver failure. Hepatitis E was the most common infection. Now more and more, we're seeing hepatitis A. And very interestingly, this hepatitis A is also presenting more often with extra hepatic manifestations. So dominant kidney involvement, lung involvement, with or without cerebral edema. So very sick patients, cytokines, troms, secondary etchial edge. So very varied manifestation of hepatitis A, that is, which we're seeing, 60% of etiologies hepatitis A. Very interestingly, again, yeah. No, no, what was the statistic, Rocky, sorry? So I was also talking about the drug-induced liver injuries from more often, we're seeing just about the hepatitis A. We'll come back to Delhi, but the A is really interesting. Yeah. You know, we very, I've seen a very only handful of cases of of a key of a failure from A. It's probably because there's just less of it about, do you think, or do you think that the patient population responds differently to hepatitis A? So it responds very nicely to extracorporeal therapies, that is what we're seeing, because we have a living donor liver transplant program, but it's not available for most of our patients, considering the volumes, and because these patients are presenting with different means very exuberant cytokines, troms. So most of them are responding very nicely to the extracorporeal therapies that we use in the management, so CRRT, in high dose, along combining it with plasma exchange or adsorption strategies. So very good outcomes, and 80% of these patients are usually coming out of the ICU without a need of liver transplant. This is different to what we see earlier, in the UK and USA. Yeah, without a doubt, it's actually shocking to hear this. In the United States, we are thankfully relatively unaware of acute viral hepatitis these days. It will pop up in clusters, and so, and these will make national news. For example, a homeless encampment in San Diego had a mass of hepatitis A outbreak, which prompted many people to promote vaccination, and thankfully, there was good uptake. Here in Michigan, we had dozens of cases associated with an outbreak affiliated with one restaurant, and we didn't see any deaths, but we did have one transplant, and it was so shocking that all of us remember that event. Acute viral hepatitis rarely results in a dominant seam on the wards here in the US. Yeah, really helpful, really to think. And I just also add on hepatitis A. The other very interesting way the hepatitis A is seeing is the patients who are obese, so not clearly means erotic, but maybe a lesser severe spectrum of maffinity or mesh, which has not been diagnosed, because we cannot do even the non-invasive sorrogates are not very reliable in that setting, and they have very severe cardiopulmonary dysfunction. So some form of background chronic liver disease, cardiopulmonary dysfunction has a dominant manifestations, and again, all this is very unique in which we're seeing more and more with the epidemic of obesity, and along with that hepatitis A. So that is what we are seeing. Yeah, really interesting. Is it going away or going away? Yeah, if I could piggyback on that, because we're definitely seeing that where everybody is arriving with seven severe diagnoses. And there are times when I look around, and I am absolutely shocked at the Olympic level of medicine that is required to support people who are coming into our hospital, gone are the days where someone has one problem focused solely on their liver. And today we're simultaneously battling a severe acute on chronic liver failure and heart failure and pulmonary failure. And of course, everything is complicated by severe chronic kidney disease. Yeah, of course. Yeah, are you seeing, you're nodding Rocky, and the patient's coming through the door more and more complicated year on year? Yeah, we're seeing that. And like what Elliot is saying, this is something which we're also seeing more and more elderly population, and backgrounds, so again, in the ICU, it becomes very challenging because you have a mix of multi organ as a part of both metabolic syndrome. And like he's saying, kidney becomes a very interesting organ to actually understand and manage in these patients. Very often, this cardiopulmonary and kidney dysfunction. And that is where again, where we were discussing the new guidelines for retro arrest and chronic kidney disease. So all that becomes very interesting in the ICU's area of patients here. Okay, very interesting. And what about the what about the demographics, Rocky, maybe just even a population level? I'm assuming your demographics are very different to the USA. Older, younger, more obese, less obese, just taught me through kind of what patients look like. So for Alkha, we're seeing very young people also. So even in the 20 to 30 means third decade patients are coming with alcohol, pure alcohol. But when we're seeing a combination, we're seeing more of alcoholic and metabolic syndrome, in the means 4 to 5 decade. But there is another set of population which is coming beyond 60 years or so. And they are coming with multiple comorbid diseases. They are the metabolic, pure metabolic, mostly that set of patients with a lot of comorbid diseases. And some also presenting with Hepatocelular cancer as the first presentation. Yeah, very interesting. You bring us onto alcohol. Maybe we should talk, maybe we should talk about alcohol. Let's start with you, Elliot, you mentioned Alkaip right at the top of the show. How are patterns of drinking, what's drinking like? How are patterns of drinking changing? And then we can kind of contrast that with Rocky's experience. Yeah, I think that I grew up and I've been around for a while, but not that long. And I grew up with the teaching that alcohol associated cirrhosis is something that slowly develops over decades with people with chronic patterns of overuse. But today, we definitely see that. On the other hand, what we see is severe early presentations of alcohol related cirrhosis and hepatitis because of binge drinking. In the amount of binge drinking that's starting early in college and proceeding through one's early 20s, what we're seeing is that this alcohol is chewing through American livers at a astonishing rate. And we see exactly that. This bi-modal twin peaks of alcohol related liver disease happening in the second and third decade and then also in the fifth and sixth. So maybe Alkaip is the shared thing across the world. It sounds similar. You're getting a similar thing in in India, Rocky. Yeah, in India, but what we're seeing is the male to female ratio is very different from what we see in the West. Yeah. So like for our statistics wise also, we've seen that the ratio is almost 17 to 20s to one. So female is not and that's why you see in the literature also, we don't have many female patients presented to us. Possibly not because I think so, the females are drinking. The male, even our phenotype of patients of male drinkers are drinking heavily. So it's like 60% of the alcohol used to sort of patients are drinking around 60 grams of alcohol every day and also going to binge drinking. But for females, even though we are seeing also that yes, more and more females are going to drinking, but we still not seeing that. And whether there is a denial in revealing that history because there is a social stigma attached to our society and that's how the females are not disclosing. That may be one factor. And the biomarkers that we use to detect is not usually available. And we see that in that people, even the males are denying and they do not disclose that history of alcohol. And without that history, it's very difficult to make that diagnosis. But women are drinking in India, Rakiya. Yeah. It's not that they're not drinking, it's just that they're not. They're drinking, but I'm not very sure whether they're drinking heavily, like the males are drinking. Okay. And we're not seeing that much of alcohol related hepatitis and females in the as of now in the presenting to us. Yeah, I mean, I think we see a little bit more male outcap in the West, Elliot, but maybe not as striking as this. Yeah, I agree. There's definitely a predominance of males, but there's been a shocking change in the trajectory for women whereby they are now making up a higher proportion of patients on our awards than ever did before because of a matching of the behaviors around alcohol. And so women are definitely catching up unfortunate. What people drinking, Rakiya, I think you mentioned to me offline, people are drinking stronger or homebrewed or or. Yeah, so we have this country liquor, which is like a distal form of, and it contains a large amount of alcohol, and it's supposedly more toxic than the, but we don't have, so 30% of our drinkers, basically statistics, why you're drinking this country liquor and the poor, the lower income strata population is mostly resorting to this form of drinking. Yeah, okay. And then the last thing I wanted to talk about on alcohol is the links with nutrition, which we touched on. And poor nutrition is kind of goes hand in hand with the presentations of severe outcap. How does under nutrition or poor nutrition play a role? Let's start with India in your outcap presentations. Oh, it's a big challenge in our country. And what we're seeing is almost 60 to 80% of our population of Al Cap is actually malnourished. And they are like their sarcopenic. And because of this possibly and also because we also see a different spectrum of infections. So it is very difficult and a very small subset of patients which come to us are actually eligible even for corticosteroids. Because that is the actually backbone of management. And they get a lot of these infections possibly because of these risk factors. So malnutrition is a key player. And even in the obese population of Al Cap and with those who have metabolic syndrome, we see more often they have sarcopenic obesity and lack of exercise, more of central obesity and all those factors which are actually very associated way back prognosis in these patients. But if I was to be provocative to both of you, what's the bigger day-to-day problem under nutrition and sarcopenia or over nutrition and cardiovascular diabetic complications? We kind of we've kind of encountered both of those in this conversation. It's one more of run than the other. Elia, what do you reckon? Yeah, I think without a doubt there's probably two phases where nutrition is playing a role. And the first is setting the stage. And here it particularly across the United States, there's an increase in obesity and over nutrition. And it's there where 1+1=3, where the alcohol plus the obesity is really setting the stage with an necronuflamatory insult. But then by the time someone comes into the hospital for the preceding three to four months, they're feeling sicker, they're drinking more heavily, obtaining more calories from there, and presenting with micro and macronutrient deficiencies. And so we definitely observe in the words this sarcopenic obesity, but I think if we had met them six months before that their body habitus and their diet would tell us a slightly different story. And then Rocky, I just wanted to mention one more thing on nutrition that I think we talked about on our fairs, when the Indian population is sick, they stop eating, you told me. Yeah, yeah. So in India, there is also one myth that in liver disease, you have to go on a restrictive diet, you have to curtail everything. So they actually become very malnourished. And that adds to the actually the problems that are associated, so they go into malnourrition. And patients who are already malnourished to start off, they actually become very kectic. So we see very, very difficult side of patients who have very, because also about what we were talking about the over nutrition. So what we see is when we have treated these patients a number of means maybe 60% can also resolve just after like they come out of that episode of alcohol related hepatitis. And what we see is that then they start gaining weight. That is also one problem. So once we have actually managed the nutrition, they go into that metabolic syndrome. I do not know how much are we also picking up these patients because they're different phases in which they go, they get abstinence, they recompensate, then they get into that metabolic syndrome related complications. For hepatitis C population also, we're seeing that very often. I don't know about others in the West, how often they are seen. And last question, before we move on, so these severe out caps, who, when they get ill, don't want to eat, do they accept empty tube feeding on the ward? Yeah, so this is also one important thing which we do as a part of our care with the ICU, but it is very difficult to actually convince them because they will not have appetite and they will be very apprehensive of getting those feeding tubes placed. So what we do in our ICU is we obviously spend time with the patient convincing them and then put a very 16-frange, means we don't put the routine right tube if they disagree, we put a freckle which is much thinner and much easily tolerated. But usually it is a difficult time spending with a conscious patient to convince them to get a good nutrition tube and get it into the tube and get the feeding done. That's really interesting. Let's take things on to infections. So infections are very between hospital, between ward to ward, between hospital to hospital, between regions. So let alone between whole countries, I'm sure the pattern of infection and the types of infection that are precipitating the compensation, for example, are very different. Elliot, let's start with you, infections in the cirrhosis patients. What have you got? What are you seeing? What's the flavor? Yeah, I would say you have to presume at the moment that someone arrives in your hospital with a cirrhosis-related complication that they have an infection. It's that common and it's in particularly amongst those who have progressive disease towards mortality or other complications. It's the infections that are driving it. But which infections it tends to be the run of the mill once. So it's going to be UTI's, pneumonia's and prevalent respiratory viruses. And Rocky? Yeah. So for us, I would say it's a big, big challenge in the intensive care unit to manage these difficult infections. So like the spectrum that we see is quite different based on the like, Elliot is also talking about the severity of the population and where they're coming for. So in the intensive care unit, maybe 80% of our population which we see is pneumonia's. Most of them are multi-drug resistant infections. A communist bug is the Klepsiala, followed by Ecoli. And we also see a lot of acetabactyl pseudomonas and all these. And gram positive infections are less often seen in our setting. In the ICU, we just see 10 to 20%. And more and more, we are seeing fungal infections in India in the intensive care unit, particularly in alcohol patients. For the ward, we see more often spontaneous bacterial paratinitis. And if the patient is less sick, we see UTIs, unit retract infections also very commonly. But yes, sicker, the patient, more is the incidence of pneumonia. We also see a lot of these spontaneous bacterial empymas. Hydrutharase means patients who have stenemonic effusions and also get these infections in the plural cavity. Because it gets very difficult to manage them. And you lead a lot of non-invasive ventilation strategies to manage these patients. And the volume status of these patients is also very difficult to manage. Any comments earlier? We don't see. I haven't seen too much spontaneous bacterial hydrothorax for a while. I'm also getting a favor from Rocky of multi-drug resistant infections, being a bit more of a thing potentially. Yeah, well, you know, so I would say one out of every four patients who arise with an infection has, and in my microbial resistance. Okay. In general, our patients are responding to the standard therapies, but obviously those who have previously been in a hospital or are undergoing hemodialysis, these are people who are at high risk. And while spontaneous bacterial empyma is a rare, I definitely recommend that every single person who arrives with a sightsees or fluid in their chest receive a diagnostic tap to that out. We are also seeing, I would also like to comment on viral sepsis. And we are actually working a lot with a virologist in this area. So particularly in this season. So the winter is where you see a lot of viral infections. Almost one-third of our population who are presenting with an acute influenza-like illness and diffuse pulmonary infiltrates, which we usually think it's bacterial pneumonia, turn out to be infections, purely viral sepsis. And some of them who are coming and presenting late, they more often have concomitants. So 60 percent also have concomitant bacterial or fungal super infections, but 30 percent of these patients are purely viral. And they're different biomarkers and they are different ways to manage because it's all immune dysregulation. So this is one very interesting area. And what we're seeing, like rhino virus, entro virus, influenza, all these viruses, not COVID, but these are the viruses that we're seeing in our population of serotic. It's very interesting, Raki. Do they want to get super sick? Do the viral precipitated ACLF, for example? Do they behave differently to bacterial precipitated ACLF? Yeah, we see these are the ones who actually they just have this cytokinemia, the cytokine released in Rome. So they will have all the cultures of sterile, the pro-calsatonin is not elevated, so they don't respond to your antimicrobials. So how do you manage them? So what we are doing is, again, for patients who have renal dysfunction or concomitant pulmonary ARDS, we use a lot of continuous renal replacement therapy. We use CRRT for different indications for managing these cytokines from, and these are these patients actually respond very well to these therapies. Renal replacement therapy, this might maybe a bit niche, but I'm interested. So renal replacement therapy as a way of tackling cytoskycine storm in these patients. So we're saying it works quite well. And currently I think so of the 28 beds we have in our ICU. So I can say 60% of the patients are on CRRT for different indications. Okay, okay. I'll just say before we get too excited about that, if there's anyone capable of proving that that's effective, it's Dr. Mai Wall and her unit. One of the leading groups for actually doing the randomized trials that prove what is effective. But for the time being, I'm relying on CRRT for people with proven volume overload. I'm just sharing our experience. We've not published this, but this is what we are doing. We are seeing good results. In the sense, see, we cannot achieve a mortality. What we are looking at in the ICU is the endpoints of achieving organ recovery, improvement in ACLF grade, improvement in the organ dysfunctions, and the patients making them eligible for a liver transplant. In that setting, I'm talking about CRRT. Raki, I'm going to move on to something that I think our listeners will be really interested to hear about. There's something that came up right at the top, which is Dilly. So drug and juice liver injury. Your top three presentations are nice to you and on the ward, included Dilly. Elliot's very much didn't. Just tell me, Raki, what are you seeing? What are the culprit agents? Why is it why are you seeing it far more than than Elliot? So Dilly, again, it is a lot of undisclosed data, but we have different presentations of Dilly that we are seeing. So one is the patient coming with acute liver failure. So that set of patients, the common is Dilly that we encounter is the anti tubercular agents. So patients have been given ATT drugs and they are the ones who present so in that setting. For acute and chronic liver failure, where the patient has chronic liver disease and presents with acute insult, we're seeing Dilly as the super added cause. So they have some injuries, supposing an alcohol related, and they take Dilly. And most of this is complimentary and alternative medicines. College static is another one important presentation where they present with severe providers, college tassers, they would have taken anabolic steroids or so that is a different set. And again, complimentary and alternative medicines and herbal medicines are the ones which actually is the dominant cause of Dilly presenting as ACLF. It sounds like a minefield, Elliot, doesn't it? You know, we have to think about antibiotics as the kind of the main culprit agents, but Raki's got a whole cluster of herbal remedies and supplements to kind of contend with on a daily basis. Yeah, and we looked to them for guidance and unfortunately, we're starting to see more of this on our ward. So obviously antibiotics are going to be number one here in the United States, but rising like a bullet are these drug and herbal related remedies. And we will have people for convinced by wellness podcasters to go out and buy expensive remedies often containing things like turmeric and paparine or black pepper, which increases the blood availability of turmeric. And these people will present with severe acute liver injury and they were totally healthy before. They were just trying to optimize their health and ended up meeting a hepatologist instead. Can you help us this Raki? What do you tell your patients? How do you cut through and educate on how? So we ask them to get the we get the thing which they have taken, but very unfortunately, like you say, because we do not get the content. Some people do come and share with us what they have taken, but most often it is just given in the form of something in a wrapper or something. So we just do not know what they have been taking. So there is a lot of research in this area going on to find out what is the exact drug or the toxin or the metabolite which is causing this drug induced liver injury. And during the COVID times, very interestingly, most of the hepatologists had picked up a daily due to a plant which is there in India called as the Giloy. So many people take it as an immune enhancer and they were taking it in such large amounts during that COVID pandemic that people were getting autoimmune related liver failures. And we saw a lot of patients who had presented to us with that injury. And now we've started to recognize and we take it as a routine to take that is free in our clinical practice because that's we know is the cause. But Raki, this is looking in from the outside. This sounds like public health emergency, no? This sound like it needs to come right from the top in terms of patient education. It is that happening or is it left to you to tease through the history and pick up the pieces on the ground? But see, Ayurveda in India has a lot of the people have a lot of faith on Ayurveda. So it is like natural path for the people, general people. But we do not know and that is how the Indian government is actually also planning to do research on this, what is a good Ayurvedic because we do not know what we are seeing in the tertiary care hospitals as the patients who are coming up with all these drug intuers liver injury due to these medicines and these preparations. That is where it is. Yeah, but I think it's by doing it, it probably is one of the main areas we can learn from you. Like Elliot said, you know, you've got a huge amount of experience of teasing out culprit agents and of managing them and of educating. And I agree that we're seeing more and more in the West in the UK of these agents precipitating liver damage. So I think it's important that we can kind of learn from you. I've got two more things that I want to tackle. I think unless there's anything else on Dilly, anything else on Dilly, no. Two other things I wanted to tackle. The first is, well, the two things I want to tackle are critical care patients and ICU and then transplant access. Raki, tell me, what are the two top indications for transplantation in India as a gateway into this conversation? Very interestingly, we had just analyzed the data of patients of ACLF transplanted. So they were around 500 patients who were transplanted. The transplant society is collecting, collecting all that data. And we had 5,000 transplants last year. So I'm really around 4,000 to 5,000 liver transplants, which happened in our country. And very interestingly of all the ACLF's 98% were living donor liver transplants. And almost 40% of these patients were alkyp. So alcohol related hepatitis, 7 to 8% were metabolically with disease. So there was a majority of these patients were alcohol related hepatitis and ACLF. Let me just clearly, before I come to earlier, just on very clear, the most common indication for transplantation is ACLF. Is that what I'm hearing? For us? Yeah. No. He's out. So for us is 500 means I would say around from 5,500 patients were transplanted for ACLF. And in that almost 40% were alkyp. But even in the other set of patients, elective transplants alcohol was the dominant cause. Okay. The etiology. Yeah. And MetALD is also catching up through a lot of patients who have metapolecular liver disease and some amount of alcohol or they are concealing for because of insurance. We do not know. But that is another set which we are transplanting. Okay. Let's cut to earlier. What's the transplant landscape in the US at the moment? You know, right now we see battling for number one alcohol really liver disease and and mesh. But that obscures a little bit of a picture where the sickest patients, those who are presenting with liver failure, ACLF typically have alcohol liver disease and those with HCC people with mesh. So the epidemiology will be mixed. It will show you a rising picture of mesh. There's a little bit of misclassification in there and it's hiding the sort of twin ways that most people are arriving at transplant HCC or liver failure. Is there much we haven't talked much about HCC in India Raki? Are you transplanting much for HCC? Yeah. We are transplanting around 10% or so our transplants are due to HCC and for HCC and for disease donor transplants I wanted to share that it's again for us. It is still preliminary and 80% of the disease donor transplants which are done is done in particular in states of Tamil Nadu, Maharashtra, means southern and western states. So North India is dominantly living donor liver transplant program. Yeah, I mean that's a huge difference, Aliya, isn't it? Do you think we'll be doing more as time comes? Why are we doing so little living donor transplant? Well, one is that we have a very robust system for deceased donor at transplant too. Is that living donor requires a lot of talent and also a risk and then three. What's really changed for us over the last five years or so is the pump and so what we're doing instead of expanding living donor transplantation is expanding which kinds of alligrapes we're selecting because we're able to clean them up and keep them on the pump fresh or a day case procedure for liver transplantation. It's resulted in a huge increase in the number of people that were saving lives through transplantation. That pump is a true game changer for us. Is it game changing in India, Raki? Or is it not? No, we do not, we're not doing that actively. Yes, but we're gearing up to it. We're learning from our colleagues in the Vets and this is because for us, disease donors are not available. It's not being done and proactively people are not donating their organs. So that is the biggest challenge. That's what we do not have. The liver transplant conferences must be incredibly different in India and in the United States. And the problem is the access. So even despite that we're doing such large number of liver transplants, still maybe it's just not even less than 1% of the population needs the liver transplant. So we have a lot of deaths due to patients waiting on the liver transplant dying in our intensive care units because of lack of liver transplants. Fantastic. I think we've come to the end. I really enjoyed that, guys. That was fantastic. I wonder if I could just before we leave everybody, is there any take-home message or anything you've learned from the other region that you kind of will reflect on, Elliot? Well, I think that we need to build bridges around how to reduce the overall burden of drug induced liver injury and then how to learn about keeping people alive with acute liver failure and acute on chronic liver failure so that they can receive that liver transplant or leave the ICU and the techniques and methods and approach pioneered in India or things that we should learn from. Thanks, Elliot. Elliot. Raki, what are you? Well, for us, I think so this is one area which I feel we are struggling is to have a very active transplant program and more and more because we are seeing metabolic liver diseases and associated chronic kidney diseases. You actually need a simultaneous liver kidney transplant because to do both living donor like donor liver and kidney it becomes very difficult and many of these patients we are just losing out because of the access to organ or transplant program. So that is where I think so India needs to work a lot. Raki, Elliot, it's been a fantastic conversation and look forward to catching up with you again soon and but for now, farewell. Well, that was great. I really, really enjoyed that and I learned a lot. I hope you guys did too. Huge thanks to Elliot and Raki once again for such a thoughtful and honest conversation and thank you for listening. If you enjoyed it, please do share the episode. Look for us wherever you get your podcasts and do join us next time on tour livertomy.