Mumbai: The COVID-19 pandemic has wreaked havoc globally, giving rise to various other diseases that could have been addressed in the early stages but treatment was delayed due to lockdowns, chances of getting infected in a healthcare setting and restrictions on travel.
Studies show that one in five Indians may be suffering from liver diseases at any point in time. About 10 lakh Indians get diagnosed with liver cirrhosis every year. Liver cirrhosis is the 10th most common cause of death in India. The ongoing pandemic hasn’t made it easier for the healthcare providers as well as patients suffering from liver diseases, to inform specialists.
Liver diseases tend to remain silent for a long period of time. In the early stages of damage, there are no clinical symptoms and therefore the liver disease silently progresses to the stage of liver cirrhosis. Even when the patient has developed cirrhosis there may be no symptoms and the blood reports may be absolutely normal. Patients tend to develop symptoms because of liver disease only when there is advanced cirrhosis also called decompensated cirrhosis, at that stage the patients develop fluid in the tummy called ascites, hepatic encephalopathy called infection of the brain (precoma) and the third is blood – internal bleeding, blood vomiting or blood in stools.
April 19 is celebrated as World Liver Day, the day is observed to spread awareness about liver-related diseases that are on the rise because of lifestyle, alcohol consumption and various foods that harm the liver. The last two years have seen a rise in liver diseases globally. The pandemic has posed unique challenges for healthcare delivery and the care of liver disease patients was no different. Patients with liver cirrhosis cannot wait indefinitely for a liver transplant as there is a high incidence of complications and a significant risk of dying while waiting. Some patients did have time to wait for treatment whereas various patients only had a few weeks. Another complication with liver diseases is that patients suffering from liver diseases can frequently encounter health-related emergencies needing urgent medical care.
Effects of COVID-19 infection on the liver
COVID-19 infection is a respiratory illness but it has affected the liver and worsened the progression of liver diseases amongst patients suffering from liver diseases. Speaking about the impact of COVID-19 infection in relation to its impact on the liver, Dr Manish C Varma, Sr Consultant & Head, Liver Transplant and HPB Surgery, Apollo Hospitals, Hyderabad shared, “The incidence of COVID-19 infections is similar in a patient with and without liver disease. However, as with other comorbid conditions, patients with liver cirrhosis are more likely to have more severe disease, need for hospitalisation and ICU care, and death. COVID-19 infections in addition to causing pneumonia, cause a generalised inflammatory reaction that can affect multiple organs. It can cause abnormalities in liver functions (as seen by blood tests). However, it is highly unlikely to cause liver failure by itself.
The infection has not only had an effect on patients with liver diseases but it has also affected those who had previously had liver transplants. “The biggest impact is the direct effect on post-transplant patients who are immunosuppressed and who are more susceptible to infectious diseases. I have had the misfortune of seeing two of my patients who had successfully undergone a liver transplant many years ago, die of COVID-19 related respiratory illness. But even more tragic is the deaths of people who did not have the virus yet died of COVID-19 effect,” mentioned Prof (Dr) Tom Cherian, Liver Specialist & Liver Surgeon, Wockhardt Group, Maharashtra & South Asian Liver Institute, Hyderabad.
COVID-19 impact on elective liver procedures, paediatric transplants
The treatment of chronic liver disease depends on the stage of cirrhosis which reflects the extent of liver damage. Early stages can be managed with medicines, however, once cirrhosis progresses to more advanced stages, a liver transplant may be the only option. Over the years, liver transplant has become safer and in both adults and children, liver transplantation can be performed with more than 90 per cent success rates and good long-term survival.
Elucidating on the role of the pandemic on paediatric transplants, Dr Somnath Chattopadhyay, Consultant and Head of Department, Hepato-Pancreato-Biliary Surgery and Liver Transplant, Kokilaben Dhirubhai Ambani Hospital, said, “The current COVID -19 pandemic has affected the care of most chronic diseases, especially paediatric liver transplant procedures. With the decrease in organ donation during the pandemic, paediatric patients in need of cadaveric liver grafts were unable to get it in time. So most paediatric liver transplants had to be living-related transplants. Most centres slowed transplant activity during the peak of the pandemic.”
Sharing his views on the challenges that sprung due to the pandemic, Dr Ameet Mandot, Senior consultant, Clinical lead – Adult Hepatology and Liver Transplant Unit, Global Hospital, Mumbai, said, “The COVID 19 pandemic dealt an enormous blow to the healthcare system in India, liver transplants being suspended across many centres. Robust protocols were set in place when it came to paediatric liver transplants. Eg transplantation only of very sick patients, strict adoption of Govt policies regarding testing, treating and isolation of donors and recipients, Telemedicine for follow up awareness of adverse effects of CAMs / herbal supplements etc.
The burden of the pandemic was herculean and the healthcare fraternity felt burnout because of the tremendous workload due to the rising number of infections and the complications that came with it with patients with comorbidities. “The other big challenge was a sudden fall in the number of organ donations which happened with the onset of the pandemic. This resulted in further widening of the already significant gap between the need for liver transplants and the availability of organs. We met this challenge by doing more numbers of living donor liver transplants. We started doing blood group mismatched (ABO incompatible) liver transplants and have so far done many of such operations, in adults and well as children, with good outcomes,” added Dr Varma.
Role of technology, the government in improving liver care
Technology is becoming an integral part of healthcare delivery and advancing and newer technologies are aiding clinicians in the better healthcare delivery that wasn’t possible a few years ago. This has helped improve clinical outcomes as well as time for recovery. “The widespread availability of genetic tests and specialised tests for neonatal screening. Also, the management of paediatric liver diseases has increased in leaps and bounds with an increase in the number of paediatric transplants happening today across the country, commented Dr Akash Shukla, Director, Hepatology, Sir HN Reliance Foundation Hospital, Mumbai.
Healthcare practitioners over the years have started incorporating newer technologies that have helped in developing newer modalities for diagnosis and better treatment for liver diseases. Speaking on newer technologies that hold promise in better treatment for liver diseases, “Some of the technologies that can change the future of liver diseases treatment are screening assays for Wilsons / metabolic liver disease, especially in children, molecular testing for rare diseases eg PFIC ( FIC1/ BSEP/ MDR3), / non-invasive markers for assessing fibrosis, accurate toxicology assays (alcohol, PCM, other drugs). Novel biomarkers could help in early and accurate detection of HCC, Cholangioca. Novel therapies for HBV (NTCP inhibitors, si RNA, combination NUCs), systemic therapy with or without LRT for HCC. Cholangioca, anti-fibrotic, anti-inflammatory therapy for NAFLD etc,” shared Dr Mandot.
Technology has played a very important role in delivering healthcare and medical care. A lot of advances in medical science are driven by or aided by technology. For liver care, technology has helped in diagnosing the liver disease early and accurately. “Many treatment modalities, especially for liver cancer (ie, TACE and TARE), are dependent on technological advances. More recently, robotic surgery has enabled us to carry out surgeries accurately with quicker post-operative. However, the most impactful technological development in recent times has been the introduction of an online consultation platform. Liver disease patients as well as liver transplant patients need ongoing care and regular consultations with their doctors. Online consultations came up as the need of the hour during the pandemic, however, the impact and possibilities are far-reaching. This is going to increase the quality of medical care and provide wider access to quality healthcare to patients across geographic boundaries,” stated Dr Varma.
Dr Chattopadhyay said, technology has played a major role in advancing liver care by increasing awareness about liver diseases. Ultrasound and CT scans can diagnose liver disease with accuracy. Liver transplantation results have improved tremendously owing to improved technology and experience in managing very sick patients.”
The Government of India has initiated various initiatives to improve the healthcare infrastructure of the nation. “Government has played a major role in improving organ awareness, facilitating liver transplants in public sector hospitals, driving scientific organ allocation strategies, and clamping down on organ trade,” observed Dr Chattopadhyay.
Increasing accessibility to better liver care
Access to quality healthcare is of utmost importance for a healthier population. Access to quality liver care is limited by geography, and cost and is not uniform across India. Tertiary care hospitals and specialists have setups in urban areas, mostly tier- I cities. This disparity deprives quality healthcare for those in need in remote and semi-urban regions. The cost of treatment may deter patients.
Online consultation has already revolutionised healthcare delivery, it can also pave the way for better liver care delivery. Patients can consult specialists without physically travelling to distant cities for the consultation. This will reduce costs as well as spare the patient the trauma of travel when not necessary.
Cost is another major barrier to seeking quality healthcare, public-private partnerships, government aid, collaboration with NGOs, crowdfunding, better insurance cover, awareness campaigns can go a long way in reducing the incidence of liver diseases and help the population in working towards a healthier liver for a healthier life.