Akash Roy

Background: Cirrhosis often remains silent until decompensation, after which survival deteriorates sharply. Contemporary, transition-aware estimates are limited, especially in Asian-predominant cohorts. We analyzed trajectories from compensated advanced chronic liver disease (cACLD) through sequential decompensations to death. Method: In this multicenter study, we analyzed retrospective data from an adult cohort with liver stiffness ≥15 kPa from vibration-controlled transient elastography across 19 institutions internationally. Decompensation included ascites, hepatic encephalopathy, spontaneous bacterial peritonitis, or variceal bleeding. Multistate models were constructed to characterize patient trajectories across 4 main clinically meaningful states: baseline cACLD, first decompensation, a subsequent second decompensation, and death. Etiology-specific subgroup analyses were conducted, and the effects of univariable predictors on transitions were also examined. Results: Among 1777 patients, 265 (14.9%) developed a first decompensation over a median follow-up of 4.25 years. In the main multistate analysis cohort, from baseline cACLD, first decompensation occurred in 215 patients at 3.10 per 100 person-years, while death occurred at a rate of 1.01 per 100 person-years. The rate of a second decompensation was higher following the first decompensation, at 42.73 per 100 person-years. Patients with alcohol-associated liver disease had the highest rate of progression from baseline to first decompensation, whereas patients with hepatitis B etiology had the lowest progression rate into a second decompensation following a first decompensating event. Conclusion: Most patients with cACLD remain compensated over 10 years of follow-up, but once decompensation occurs, trajectories accelerate, and survival worsens. Transition-aware, etiology-stratified estimates enable individualized prognostication and earlier risk-guided intervention, including timely transplant referral.

Background Acute-on-chronic liver failure (ACLF) is a rapidly progressive syndrome marked by high short-term mortality. While diabetes mellitus (DM) is known to worsen liver-related outcomes, its specific impact on alcohol-related ACLF (ALD-ACLF) remains underexplored. This study aimed to assess the prognostic impact of DM on 90-day outcomes in ALD-ACLF using data from the APASL ACLF Research Consortium (AARC) database. Methods This observational study involved data from 5612 ACLF patients with documented 90-day outcomes. We identified 2096 patients with ALD-ACLF precipitated by alcoholic hepatitis. Patients with non-ALD etiologies, mixed etiologies, or non-alcoholic precipitants were excluded. Diabetic and non-diabetic patients were compared using 1:2 propensity score matching based on key baseline covariates. Survival outcomes were assessed using Kaplan–Meier analysis and multivariable Cox regression. Results After matching, 109 diabetic patients were compared with 218 well-matched non-diabetic controls. Diabetic patients had significantly lower overall survival (32 vs. 57%) and transplant-free survival (31 vs. 50%) compared to non-diabetics (log-rank p < 0.001). On multivariable Cox regression, DM was independently associated with increased 90-day mortality (HR 1.739, 95% CI 1.262–2.395, p < 0.001), along with elevated serum lactate (HR 1.187 per mmol/L, p < 0.001) and creatinine (HR 1.267 per mg/dL, p < 0.001). Conclusion Diabetes mellitus is a significant independent predictor of mortality in patients with ALD-ACLF. These findings highlight the need for early identification and integrated management of diabetes in ACLF care pathways to improve clinical outcomes.

Background: Medically unexplained symptoms (MUS) are common in clinical practice, often leading to repeated investigations, escalating healthcare costs, and patient distress. Despite their high prevalence, MUS are frequently mismanaged due to delayed psychiatric involvement, resulting in fragmented care and poor outcomes. Objective: To highlight the diagnostic and therapeutic relevance of psychiatric evaluation in patients with persistent physical symptoms lacking an organic basis. Methods: This retrospective case series describes six individuals (aged 22–55) who presented with chronic, unexplained physical symptoms across various specialities in a tertiary care hospital. All underwent extensive investigations with no definitive organic diagnosis. Upon referral to psychiatry, they were assessed using ICD-10 criteria and relevant symptom severity scales. Diagnoses included somatisation disorder ( n = 4), somatoform pain disorder ( n = 1), and factitious disorder (Münchausen syndrome) ( n = 1). Interventions included SSRIs/SNRIs, psychoeducation, cognitive-behavioural therapy (CBT), and supportive psychotherapy. Follow-up ranged from 1 to 3 months. Results: Five of six patients showed significant clinical improvement within 3 months of psychiatric intervention. Unnecessary investigations ceased, functional recovery improved, and health service use decreased. The Münchausen case demonstrated partial engagement but reduced hospital-seeking behaviour. Conclusion: Early psychiatric evaluation is pivotal in the management of MUS. Consultation-liaison psychiatry plays a crucial role in bridging the mind-body gap, reducing healthcare burden, and improving outcomes through integrated care.

Objectives: This work aims to describe technical feasibility and clinical outcomes of endoscopic‐ultrasound‐guided gastrojejunostomy (EUS‐GJ) as a first line treatment option for malignant gastric outlet obstruction (mGOO).Methods: This is a large multicenter study where patients undergoing EUS‐GJ across seven tertiary care centers from India were analyzed. The primary outcomes were technical success defined as correct stent placement without any leak, and clinical success defined as improvement in gastric outlet obstruction symptom score (GOOSS) on follow‐up. Secondary outcomes were (a) adverse events rates, (b) symptoms recurrence, (c) death on follow‐up, and (d) resumption of chemotherapy.Results: A total of 71 patients underwent EUS‐GJ with technical success of 94.3%. After successful stent placement, all patients tolerated oral liquid diet on day 1, whereas 89.5% and 95.5% tolerated oral solid diet on day 2 and day 7, respectively. Overall, 9/71(12.6%) patients had major adverse events, which included maldeployment in 6/71(8.4%). Mean duration of follow‐up was 76.13 ± 58.09 days. On follow‐up, reintervention was required in two (3%) patients. Around two‐thirds of patients gained weight and could resume their chemotherapy post‐EUS‐GJ. Kaplan–Meier survival analysis showed that post EUS‐GJ, mean overall survival (symptom recurrence or death) of 144.39 ± 11.53 days (95% CI 121.7–167.0).Conclusion: EUS‐GJ is an excellent modality for the palliation of mGOO, providing high clinical success with extremely low rates of reintervention and acceptable safety profile. It should be considered as a primary modality for managing these patients, and enteral stent should be reserved for patients where EUS‐GJ is not possible.

Metabolic diseases have exponentially increased in recent years, which has led to an increased prevalence of metabolic dysfunction–associated steatotic liver disease and concomitant kidney diseases. Ascites are a common presentation of cirrhosis, and renal impairment in cirrhosis is well described. However, patients with end-stage renal disease (ESRD) may also present with ascites even in the absence of cirrhosis. The literature on the management of patients with ESRD with ascites with or without concomitant cirrhosis is limited. Massive ascites in this population are often refractory to medical therapy and are associated with dismal prognosis. Pathophysiologically, increased hepatic vein hydrostatic pressure, fluid retention, increased peritoneal membrane permeability, and impaired peritoneal lymphatic drainage are proposed mechanisms for ascites in ESRD without cirrhosis. Identifying underlying cirrhosis and portal hypertension (PH) has therapeutic implications in such patients. However, diagnostic tools such as serum ascites albumin gradient and noninvasive tests to identify cirrhosis have limited utility in ESRD. Hemodialysis and continuous ambulatory peritoneal dialysis are effective but can be associated with hemodynamic compromise and peritonitis, especially in those with PH. TIPS for ascites has a limited role in the presence of ESRD due to the increased risk of HE. Kidney transplant is the treatment of choice in ESRD with ascites without PH. Simultaneous liver–kidney transplant remains the definitive treatment in the presence of PH, but is less commonly feasible, and kidney transplant alone in the presence of PH can be associated with the risk of decompensations. This review discusses the approach and management of ascites in chronic kidney disease and ESRD specifically.