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

In collaboration with the Indian National Association for the Study of the Liver (INASL), hepatologists from South Asia and North America/Europe take listeners inside their liver wards to explore how regional context shapes acute liver care. From admission patterns to alcohol use, infections, DILI, nutrition, and access to transplant, the episode highlights key differences and opportunities for shared learning across regions.

This episode is also available on EASL Campus: https://easlcampus.eu/tltm/episode-01

Transcript

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Hello everybody, Welcome to hepatology Ward Rounds. This is East meets West co-hosted by EASL and the Indian National Association for the Study of the Liver. So for this episode of Talk Liver 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 Elliot Tapper, who's the chief of hepatology at University of Michigan, and Doctor Rakhi Mywel, 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 DILI to transplantation, 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, and honestly, this was a really engaging and fun conversation for me personally. I've met Elliot before. He's absolutely lives up to his reputation. Engaging, fought for, exudes wisdom and but this was my first time sitting down properly with Raki, who spoke really insightfully about the real day-to-day challenges she's dealing with on the ground. The kind of 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 also it's quite nice because Elliot and Rakhi have also met each other before and have exchanged ideas in the in the in the conference corridors. But it's such a privilege to kind of bring that kind of shared experience out into the open with this podcast. So I hope you enjoy it. The chat lasts around half an hour long, so let's get into it. Hi, everybody. Welcome, Rakhi. Welcome, Elliot. Thanks for joining us. Great to be with you. Thank you Tom. Let's let's orientate people with where you are in the world. Rakhi, whereabouts are you at the moment? So I, 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: 2:20

45 as of now. OK, and you Elliot, what's going on with you? Well, it's a national holiday, Martin Luther King Junior Day,

and I am taking some time to talk with you at 10: 2:30

20 in the morning. OK. Well we've made we've kind of made phase one and get on you all both together, but you're both super busy clinicians and let's start things off Rakhi with you. If you were, if you were to take me on a tour of the ward or to take me on a ward 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 challenge is almost 50 to 60% of the patients that we're seeing is ALCAP or alcohol-related hepatitis and along with it we're seeing more and more of metabolic associated steatotic liver disease and a combination of both. And on top of that, very often we're seeing drug induced liver injury as the most common etiology that is filling our wards. What about what about you Elliot? What's on the wards at the moment and has it changed over time? What about the last 10 years? Have 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 Rakhi? Maybe the DILI component she picked up on? Yeah. So in the DILI 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 cryptogenic. And in the viral itself what we are seeing is the 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, cytokine, strong secondary HLH, so very varied manifestation of hepatitis A that is which we're seeing 60% of etiologies hepatitis A very interestingly again. Yeah. No, no, no. What was the statistic? Rakhi, Sorry. So I was also talking about the the drug induced liver injury from more often be seeing. Just about the, the hepatitis A we'll come back to DILI, but the A is really interesting. You know, we very, I, I've seen a very only a handful of cases of acute of acute liver failure from A. It's probably because there's just less of it about. Do you think or do you think that the the patient population responds differently to hepatitis A? So it responds very nicely to extracorporeal therapies. That is what we are 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 exorbitant cytokine strong. 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. It's different to what we see Elliot now in the UK and USA. Yeah, without a doubt. It's, 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 massive 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 theme on the wards here in the US. Yeah, really helpful. Really. Can I just also add on hepatitis A, the other very interesting way the hepatitis A we are seeing is the patients who are obese. So not clearly means cirrhotic, but maybe a lesser severe spectrum of MASLD or MASH which has not been diagnosed because we cannot do the even the non invasive surrogates are not very reliable in that setting and they have very severe cardio pulmonary dysfunction. So some form of background chronic liver disease, cardio pulmonary 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 saying. Yeah, really interesting. Go on, Elliot, Go on. Elliot, if I could piggyback on that, because we're definitely seeing that where everybody is arriving with seven severe diagnosis. 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 we're simultaneously battling a 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 saying you're nodding, Rakhi? Are the patients 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 background. So again, to get in the ICU, it becomes very challenging because you have a mixture 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 there's cardiopulmonary and kidney dysfunction. And that is where again where we were discussing the new guidelines for HRS and chronic kidney disease. So all that becomes very interesting in the ICU set of patients yeah. OK, very interesting. And what about the what about the demographics, Rakhi, maybe just even of our population level. I'm assuming your demographics are very different to the USA, Older, younger, more obese, less obese. Just talk me through kind of what patients look like. So for ALCAP, 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 are 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 sixty years or so and they are coming with multiple comorbid diseases. They are the metabolic, pure metabolic mostly that set of patients with lot of comorbid diseases, some also presenting with hepatocellular cancer as the first presentation. Yeah, very interesting. You bring us on to alcohol. Maybe we should talk. Maybe we should talk about alcohol. Let's start with you, Elliot. You mentioned ALCAP right at the top of the show. How are patterns of drinking now? What was drinking like? How are patterns of drinking changing? And then we can kind of contrast that with with Rakhi's experience. Yeah, I think that I grew up and I 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, just bimodal Twin Peaks of alcohol related liver disease happening in the second and third decade and then also in the 5th and 6th. So maybe, maybe ALCAP is the shared thing across the world. It sounds similar. You're getting a similar thing in in India, Rakhi. Yeah, in India, but what we're seeing is the male to female ratio is very different from what we see in the West. So like for our statistics wise also we've seen that the ratio is almost 17 to 20 to 1. So female is not and that's why you see in the literature also we don't have many female patients presenting to us, possibly not because I think so the females are do drinking the male even our phenotype of patients of male drinkers are drinking heavily. So it's like 60% of the alcohol used disorder 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're 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 the people, even the males are denying and they don't they do not disclose that history of alcohol. And with without that history, it's very difficult to make that diagnosis. But but women are drinking in India Rakhi? Yeah, 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 OK. 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 ALCAP in the West Elliot, but maybe not as striking as this. Yeah, I 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 honor awards than ever did before because of a matching of the behaviors around alcohol. And so women are definitely catching up, unfortunately. Very interesting. What people drinking Rakhi, 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 distilled form of anita it is 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 wise are drinking this country liquor and the poor, the lower income strata population is mostly resorting to this form of drinking. Yeah. OK. And then and then the last thing I wanted to to talk about on alcohol is the links with nutrition which we touched on and and poor nutrition is kind of goes hand in hand with the presentations of severe ALCAP. How does undernutrition or poor nutrition play a role? Let's start with India in your ALCAP presentations. Oh, it's a big challenge in our country. And what we're seeing is almost 60 to 80% of our population of ALCAP is actually malnourished. And they're like they're sarcopenic. And because of this possibly and also because we also see a different spectrum of infections. So it it is very difficult in 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 ALCAP 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 have associated very bad prognosis in these patients. But if I was to be, if I was to be provocative to both of you, what's the bigger day-to-day problem, undernutrition and sarcopenia or overnutrition and cardiovascular diabetic complications? We've kind of we've kind of been captured both of those in this conversation. Is one more of a problem than the other? Elliot, 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, and here it particularly across the United States, there is an increase in in obesity and over nutrition and it's and it's there where 1 + 1 = 3 where the alcohol plus the obesity is really setting the stage with a necro inflammatory insult But then by the time someone comes into the hospital for the preceding 3 to 4 months, they are feeling sicker. They're more, they're drinking more heavily, obtaining more calories from there and presenting with micro and macronutrient deficiencies. And so we definitely observe in the wards this sarcopenic obesity. But I think if we had met them six months before that their their body habitus and and their diet would tell us a slightly different story. And then Rakhi, I just wanted to mention one more thing on nutrition. I think we talked about our fair is when, when the Indian population is sick, they stop eating, you told me. Yeah, yeah. So in India there's 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 malnutrition and patients who are already malnourished to start off, they actually become very cachectic. So we see very, very difficult set of patients who have very because also about the what we were talking about the over nutrition. So what we see is when we we have treated these patients a number of means maybe 60% of can also resolve just after like they come out of that episode of alcohol-related hepatitis and what we see is that they 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 abstinent, they recompensate then they get into that metabolic syndrome-related complications for hepatitis C population also be seeing that very often. I don't know about others in the West how often they are seeing. And last question, Rakhi, before we move on. So these severe ALCAPs who when they get ill don't want to eat, do they accept NG tube feeding on the ward? Yeah. So this is also one important thing which we do as a part of our care at 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 fringe means we don't put the routine Ryle's tube. If they disagree, we put a Freka which is much thinner and much easily tolerated. And but usually we it is a difficult time spending with a conscious patient to convince them to get a good nutrition tube and get it entral tube and get the feeding done. That's really interesting. Let's take things on to infections. So in infections are vary between hospital, between water ward between hospital to hospital between regions. So let alone between whole countries. I'm sure the pattern of infection and how it and and the types of infection that are precipitating decompensation, for example, are very different. Elliot, let's let's start with you infections in the cirrhosis patients. What have what have you got? What are you seeing? What's the flavour? 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 or other complications that it's the infections that are driving it. But but which infections, it tends to be the run-of-the-mill ones. So it's going to be UTI's, pneumonias, and prevalent respiratory viruses. And Rakhi. 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 pneumonias, most of them are multi drug resistant infections are communist bug is the Klebsiella followed by E. coli. And we also see a lot of acinetobacter, 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, more and more we are seeing fungal infections in India in the intensive care unit, particularly in again, alcohol ALCAP patients for the ward we see more often spontaneous bacterial peritonitis and if the patient is less thick we see UTI is unary tract infections also very commonly. But yes, thicker the patient more is the incidence of pneumonia. We also see a lot of these spontaneous bacterial empyemas hydrothorax means patients who have their mnemonic effusions and also get these infections in the pleural cavity because it gets very difficult to manage them and you need 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 Elliot we don't see? I haven't seen too much spontaneous bacteria or hydrothorax for a while. I'm also getting a favor from Rakhi 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 antimicrobial resistance. OK. In general, our patients are responding to the standard therapies, but obviously those who had previously been in a hospital or are undergoing haemodialysis, these are people who are at high risk. And and while spontaneous bacterial empyema is is a rare, I definitely recommend that every single person who arrives with ascites 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 winters where you see a lot of viral infections, almost 1/3 of a 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 concomitant. So 60% will also have concomitant bacterial or fungal super infections. But 30% 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 1 very interesting area and what we're seeing like rhinovirus, enterovirus, influenza, all these viruses, not COVID, but these are the viruses that we've seen in our population of serotics. It's very interesting, Rakhi. Do they when they get super sick, do the viral precipitated ACLF for example? Do they behave differently to bacterial precipitated ACLF? Yeah, we see these, these are the ones who actually they just have this cytokinemia, the cytokine release syndrome. So they will have all the cultures are sterile, the procalcitonin 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 cytokine strom and these are these patients actually respond very well to these therapies. Renal replacement therapy is maybe a bit niche, but I'm interested. So renal replacement therapy as a way of tackling cytokine kind storm in these patients. Yeah, that what you're saying? It works quite well and currently I think so of the 28 beds we have in our issue, so I can say 60% of the patients are on CRRT for different indications. OK, OK. I'll just say. Before we get too excited about that, if there's anyone capable of proving that that's effective, it's Doctor Mai Wall and her unit, but 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 crot for people with proof and 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 this 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 grad improvement in the organ dysfunctions and the patients making them eligible for a liver transplant in that setting. I'm talking about CRT. Rakhi, I'm going to, I'm going to move on to something that I think our listeners were really interested to hear about and it's something that came up right at the top, which is DILI. Yeah. So drug induced liver injury, your top three presentations in ICU and on the ward included DILI. Elliot's very much didn't just tell me, Rakhi, what? What are you seeing? What are the culprit agents? Why is it? Why are you seeing it far more than than Elliot? So DILI, again it is a lot of undisclosed data, but we have different presentations of DILI that we're seeing. So one is the patient coming with acute liver failure. So that set of patients, the communist DILI that we encounter is the antitubercular agents. So patients have been given ATT drugs and they are the ones who present. So in that setting for acute on chronic liver failure where the patient has chronic liver disease and presents with acute in salt, we're seeing DILI as the super added cause. So they have some injuries supposing an alcohol-related and they take daily and most of this is complementary and alternative medicines. Cholestatic is another one important presentation where they present with severe pruritus cholestasis, they would have taken anabolic steroids or so that is a different set and again complementary and alternative medicines and herbal medicines are the ones which actually is the dominant cause of Delhi presenting as ACLF. It sounds like a minefield, Elliot, doesn't it? You know, we're, we, we have to think about antibiotics as a, as the kind of the main culprit agents. But Rakhi'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 #1 here in the United States. But rising like a bullet are these drug and herbal related remedies. And I we will have people who are convinced by wellness podcasters to go out and buy expensive remedies is often containing things like turmeric and piperine 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 Rakhi? How do you what do you tell your patients? How do you cut through and and and educate on harm? So we asked them to get the, we get the thing which they have taken. But very unfortunately like you're saying, 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's a lot of research in this area going on to find out what is the exact, the product, the drug or the toxin or the metabolite which is causing this induced liver injury. And during the COVID times, very interestingly, most of the hepatologists had picked up DILI 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 history in our clinical practice because that's we know is the cause. But Rakhi, this 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 to you to to tease through the history and pick up the pieces on the on the ground? But see Ayurveda in India, it has a lot of the people have a lot of faith on Ayurveda. So it is like naturopathy 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 is the patients who are coming up with all these drug induced liver injury due to these and these preparations. That is where it is. Yeah, but I think it's, but I do think it's, 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 corporate agents and of managing them and of educating and, and I agree that we're seeing more and more in the Western and the UK of 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 DILI, anything else on Dilly, No, two other things I wanted to tackle the first. The first is, well, the two things I want to tackle are critical care patients and ICU and then transplant access. Rakhi, tell me, what are the two top indications for transplantation in India as a gateway into this conversation? So very interestingly, we had just analysed the data of patients of ACLF transplanted. So there were around 500 patients who were transplanted. The transplant society is collecting, collating all that data and we had 5000 transplants last year. So annually around 4000 to 5000 liver transplants which happened in our country and very interestingly of all the ACLF, 98% were living donor liver transplants and almost 40% of these patients were ALCAP. So alcohol related hepatitis, 7 to 8% were metabolic liver disease. So there was a majority of these patients were alcohol related hepatitis and ACLF. Let me just quickly before I come to earlier, just just so I'm very clear, there's a the most common indication for transplantation is ACLF, is that what I'm hearing? For us, yeah, no. It's ALCAP. So for us is 500 means I would say around from 5500 patients were transplanted for ACLF and in that almost 40% were ALCAP. But even in the other set of patients, elective transplants, alcohol was the dominant cause. The etiology, yeah and Met-ALD is also catching up. So a lot of patients who have metabolic liver disease and some amount of alcohol or they're concealing for because of insurance, we do not know, but that is another set which we are transplanting. OK, let's cut to Elliot. What's the transplant landscape in the US at the moment? Right now we see battling for #1 alcohol-related liver disease and, and MASH, but that obscures a little bit of a, 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 MASH. 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 the the sort of twin ways that most people are arriving at transplant HCC or, or liver failure. There's a much we haven't talked much about HCC in India. Iraqi. 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 particularly in states of Tamil Nadu, Maharashtra means southern and western states. So North India, it's dominantly living donor liver transplant program. Yeah. I mean, that's a huge difference earlier, isn't it? Do you think we'll be doing more as time comes? What? Why are we? Why are we doing so little living donor transplant? Well, one is that we have a very robust system for deceased donor transplant. 2 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 allographs we're selecting because we're able to clean them up and keep them on the pump fresh for a day case procedure for liver transplantation. It's resulted in a huge increase in the number of people that were saving lives with through transplantation that that pump is a true game changer for us. Is it game changing in India, Iraqi or is it is it? No, we do not. We're not doing that actively, yes, but we are gearing up to it. We're learning from our colleagues in the West. And this is because for us, disease donors are not available. It's not being done. And people proactively, people are not donating their organs. So that is the biggest challenge that is we do not have. Yeah, the liver transplant conferences must be incredibly different in India and in the. States, yeah. And the 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 a liver transplant. So we have a lot of deaths due to patients waiting on the liver transplant dying in their intensive care units because of lack of liver transplants. Fantastic. I think we we've come to the end. I really enjoyed that guys. That was fantastic. And 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, leave the ICU and the techniques and methods and approach pioneered in India or things that we should learn from. Thanks for Elliot. Elliot Rakhi, what about you? For us, I think so this is 1 area which I feel we are struggling is to have a very active transplant program and more and more because we're seeing metabolic liver diseases and associated chronic kidney diseases. You actually need a simultaneous liver kidney transplant because to do both living donor, a life donor liver and kidneys becomes very difficult. And many of these patients we're 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. Rakhi Elliot, it's been a fantastic conversation and look forward to catching up with you again soon. But for now, farewell. Well, that was great. I really, really enjoyed that and I learned a lot. I hope you guys did too. A huge thanks to Elliot and Rakhi 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 Talk Liver To Me.