ILBS Annual Book Report 2017

2017 MILESTONES 99983 OPD Patients 27495 Day Care Admissions 156563 Day Care Procedures 13712 Fibroscan 8156 Emergency Care 1219 Major HPB Surgeries यकृ तामृत 88 Liver Transplants 38 Renal Transplants 157 Number of Publications 27th University Ranking (MHRD-NIRF) A NAAC Accreditation Grade Annual Report 2017 Institute of Liver & Biliary Sciences A Deemed-to-be-University





CONTENTS Chairman’s message Directors message The quintessential growth From the editors’ desk Hepatology..............................................................................................03 Eight years ago, on the auspicious day of Makarsankranti, Pediatric Hepatology............................................................................41 when the sun entered the sphere of Capricorn, marking the Hepatopancreatobiliary & Liver Transplant Surgery.................53 beginning of uttarayan, there was a beginning of a liver centric revolution, shaping up of an idea into reality, transformation of a Anesthesia and Critical Care..............................................................66 Nephrology landscape into the magnificent centre for liver care, personification ...............................................................................................78 of the hope of thousands of patients deserving world class care and Renal Transplant and Urology...........................................................84 Oncology hospital services. On this day the seeds of Institute of liver and biliary ................................................................................................90 sciences were sown, and through these eight years with the efforts of expert Radiology and Interventional Radiology.......................................98 hands, knowledgeable, experienced minds, toiling on the soil of dedication for patient care, clinical acumen, evidence based approach, perseverance Laboratory Medicine...........................................................................110 for research and commitment for academic excellence, we have now Pathology.......................................................................................111 grown into a ‘kalpavriksha’, bearing fruits of healthy smile on our patients’ face, Microbiology ...............................................................................117 widening branches through national and international collaborations, adorning Clinical Virology...........................................................................129 leaves synthesizing skill and knowledge and oxygenating our patients’ lives and still Biochemistry................................................................................138 deepening roots to keep ourselves grounded. Hematology and Clinical Pathology....................................146 Our editorial team is privileged to amass the achievements of 2017 in the 8th annual report “Yakritamrit”. The report starts with “Yakrit Samhita” describing the Clinical and Cellular Transplant Immunology..................152 mission, vision and values of ILBS. The report describes the effort put in by each staff Genetics.........................................................................................156 member in the various departments for patient care, hospital services, diagnostics, National Liver Disease Biobank.............................................160 infrastructure development, academics research etc and this is what the cover design Transfusion Medicine.........................................................................166 depicts. Compiling the achievements and work of Team-ILBS work in limited space was challenging and omissions if any were not done inadvertently. Cardiology.............................................................................................172 The editorial team is indebted to our director Prof. S.K.Sarin, for his constant support and Molecular and Cellular Medicine...................................................174 nurturing the vision of the Institute to scaling heights. The editorial team thank Dr Anil Clinical Research..................................................................................200 Agarwal, Mr Dinesh Taneja, Mr. Kulvinder Singh, Mr. Raj Chaudhri, Ms. Meena Bajaj, Mr. Academics..............................................................................................209 Sunil Kaushik, Mr Gaurav Agarwal, Mr Manish, Mr Dhiraj, Mr Shailendra, Ms. Bijoya, Ms. College of Nursing..............................................................................232 Savera and Ms. Sudrishti, for helping at various stages of the report preparation. We Publications...........................................................................................240 acknowledge the work of Three Zero Inc Team (Ms Rukhsar, Mr Luqman, Mr. Chandan Hospital Services.................................................................................253 and Mr Tarun Kumar Diwaker) and SDG Technoprints for timely printing. Finally, we appreciate the team spirit of all the ILBS departments for their support in ILBS organization................................................................................282 compilation of “Yakritamrit”. Administration.....................................................................................294 Human Resource.................................................................................297 Dr Gayatri Ramakrishna Finance and Accounts........................................................................299 Dr Pratibha Kale Purchase.................................................................................................303 Dr Vikrant Sood Dr Shantanu Dubey Information Technology...................................................................306 Fire and Security..................................................................................309 Photo Gallery........................................................................................312 Published On Behalf Of The Director, ILBS, New Delhi

Content Chairman’s message Directors Foreword The Quintessential Growth Hepatology........................................................................................................................................................................................... 02 Pediatric Hepatology........................................................................................................................................................................... 32 Hepatopancreatobiliary and Liver Transplant Surgery..................................................................................................................... 42 Anaesthesia and Critical Care............................................................................................................................................................ 52 Nephrology........................................................................................................................................................................................... 62 Renal Transplant and Urology............................................................................................................................................................. 66 Oncology.............................................................................................................................................................................................. 70 Radiology and Interventional Radiology........................................................................................................................................... 78 Laboratory Medicine........................................................................................................................................................................... 86 Pathology......................................................................................................................................................................................... 87 Microbiology.................................................................................................................................................................................... 92 Clinical Virology............................................................................................................................................................................ 101 Biochemistry.................................................................................................................................................................................. 109 Hematology and Clinical Pathology........................................................................................................................................... 114 Clinical and Cellular Transplant Immunology............................................................................................................................ 118 Genetics......................................................................................................................................................................................... 121 National Liver Disease Biobank................................................................................................................................................... 123 Transfusion Medicine......................................................................................................................................................................... 128 Cardiology.......................................................................................................................................................................................... 134 Molecular and Cellular Medicine.................................................................................................................................................... 136 Clinical Research............................................................................................................................................................................... 156 Academics......................................................................................................................................................................................... 163 ILBS a Deemed-to-be-University................................................................................................................................................. 164 College of Nursing........................................................................................................................................................................ 181 Publications................................................................................................................................................................................... 187 Hospital Services................................................................................................................................................................................ 197 ILBS organization................................................................................................................................................................................ 223 Administration............................................................................................................................................................................... 232 Human Resource........................................................................................................................................................................... 234 Finance and Accounts................................................................................................................................................................. 236 Purchase........................................................................................................................................................................................ 240 Information Technology............................................................................................................................................................... 243 Fire and Security........................................................................................................................................................................... 247 Photo Gallery...................................................................................................................................................................................... 251











A QUINTESSENCE GROWTH IN LIVER CARE Vision, Mission and Values of Team ILBS Our Vision Institute of Liver and Biliary Sciences (ILBS) envisions to be the centre of excellence providing the best quality care to every patient for liver and billiary diseases by integrating top standard clinical practice, competency-based training and imparting best education through cutting edge research. Our Mission  To deliver superior value based patient care in diagnosis and treatment by evidence based clinical practice.  To provide benchmark standards at par with international level on niche area of liver diseases, organ transplantation, biliary diseases and allied disciplines.  Practicing ‘Leadership with Care’ by pursuing best practices, adopting state of the art diagnostics , quality control and assurance.  Creating standard in health care culture by reinforcing ethics and values.  To provide capacity building by imparting specialized education, training skill development in niche areas of Liver and Biliary disease.  Amalgamating the skills and structure of academic medical universities, clinical and research acumen of the research institutes and managerial skills of the corporate world and theray establishing as a torchbearer in health care practice and education.  To provide patient care at the top by allowing transparency in management processes, facilitating patient satisfaction, ensuring dignity and rights of the patients.  Enabling employees , students and associates to achieve and unleash their full potential for being brand ambassadors and future leaders.  To make realize the government bodies that liver care should be a part of routine primary care and should not be a matter of neglect. Our Values ILBS has always been values-driven. Our values underpins the way we integrate values of clinical practice, education, research and skill development. Our core values focus on:  Integrity and ethical values for proper conduct.  Focussed thinking which is just not simply adopting one single method, but a holistic approach employing various methods for liver based therapies.  Excellence in both clinical and research areas of liver disease.  Team work for enabling best patient care and collaborative imitative for capacity development.  To be the Torchbearers and Pioneers to take on new challenges and developing solutions in both patient care and academic pursuit.

Amulya Liver In the quest of keeping the liver healthy and young, we continuously strive towards treating and preventing liver disease, and improving the liver heath for quality of life to our patients through patient care, health care delivery , educational programmes and research activities. The patient care focused towards primarily the liver disease and all the allied disciplines of Nephrology, Cardiology, Critical care, Anaesthesia, Pulmonology, Neurology, Radiology, Pathology, Microbiology and Virology are focused around liver. Thus , we have Liver-centric programmes and support systems specializing in liver disease. The Pediatric Hepatology is the only dedicated pediatric liver unit in the country providing niche based care to young children suffering from rare genetic liver diseases. ILBS has pioneered drug based approaches for liver care and has state of the art liver dialysis unit and affordable liver transplant programmes for people with serious liver disease and often treating cases that others turn away. Our Milestones A dream and vision for monothematic liver care services came to reality in 2009 when the Institute of Liver and Biliary Sciences (ILBS) was started as an autonomous research and teaching Institute under government of National Capital Territory of Delhi. ILBS has since then found the distinction of deemed-to-be-University with an “ A “ grade NAAC accredited ranking as the only Liver University in world. In a short span of eight years, ILBS has emerged as a young pioneering Institution with four pillars of patient care, teaching, training and research. Patient Care, Volumes and Outcomes ILBS maintain nations largest team of highly trained liver specialists and surgeons, with extensive sub-specialty expertise across dozens of related services, including an exclusive programme offered for young children with rare liver diseases. ILBS has become a national referral centre for treating the most serious liver diseases and has the best success rate in patient outcome at par with the International standard. ILBS is the only public undertaking running a successful liver transplant programme in a Government setup. ILBS has achieved a milestone in liver transplantation as it has liver transplant and 150 kidney transplants with high success rate and outcomes compared to international standards. A World-Class Care Team  ILBS with a total strength of more than 500 staff and has about 70 specialized faculty highest in number in any National setting dedicated for liver care. A large number of specialized nursing staff and technical expertise offer customized care for every inpatient and outpatient.  Our team members have extensive training in Adult Hepatology, pediatric Hepatology, Organ retrieval and Transplant, Anesthesia and Specialized critical care in organ transplant, Clinical Nutrition and Supportive Lab medicine comprised of liver niche based approaches in microbiology, pathology, virology, immunology, hematology and transfusion medicine in treating challenging cases of liver disease.

 Our experts have developed one of the nation’s premier programs for liver treatment of patients who do not undergo liver transplant due to donor non availability, a ray of hope is offered to them through the use of growth factors; GCSF+erythropietin a protocol developed at ILBS for the first time. ILBS also reported the first clinical benefit of fecal microbial transplantation (FMT) in patients with severe alcoholic hepatitis with beneficial effects. Our doctors and nurses are also pioneers in life-saving fetal cardiac interventions. Quality and safety We are committed to delivering exceptional care ad extending quality and safety initiatives too.  Our hepatology cases has increased as we are now a well established premier National referral centre as we provide specialized drug based therapies, extracorporeal liver support system and transplant services to end stage liver disease.  The transplant cases are actually increasing over the years as we have a successful surgical outcome and recovery. Additionally compared to corporate sector we offer affordable healthcare in organ transplant services.  The large volume of liver based referral has attracted many clinical trials which offers free of cost medicines providing a ray of hope to those individuals while they await transplant. Academic Excellence and National Recognition ILBS is unique in nurturing a vibrant academic hub for liver-centric teaching and training programmes. The Institute attracts best of the national talent. The uniquely conceptualized “Liver University” provides focused liver centric training to budding aspiring doctors, nurses and scholars in the field of clinical management of liver patients and for research related to liver diseases. This is very well evident from the fact that each year the number of ambitious students applying for various academic courses at ILBS is gradually increasing. On the basis of teaching and research based academic strength, recently ILBS was ranked 27th amongst the Indian universities in the MHRF-NIRF ranking framework. In recently conducted NAAC inspection by UGC, ILBS was a warded an “A” Grade. Being a Liver Centric Academic-Hub, ILBS attracts some of the brightest candidates for higher degree superspeciality programmes The students passing out from ILBS have received placements in some of the countries topmost Institution and these students are carrying forward the vision and legacy of the ILBS: to serve with dedication. In addition, in the last few years ILBS has nurtured a vibrant research culture in a clinical setting to bridge the gap between the bench and the bedside. For modern biological research, the scientists at ILBS make use of the state of the art cutting edge technologies such as Next Generation Sequencing, proteomics and molecular biology tools. The academic research output from ILBS have been published in the most prestigious international journals of high impact. In view of the academic excellence, ILBS was recognized by Ministry of Science and Technology and was awarded two prestigious grants: (a) a national HCV-Biobank funded by the Dept of Biotechnology, (b) DST-FIST laboratory for confocal imaging by the Dept of Science and Technology. (c) DST supported

laboratory for research in alternative cellular therapies, The Institute has also filed patent for drug delivery using hepatocyte specific nanoparticles. International Recognition The contributions made by ILBS in hepatitis research received international recognition by World health organization (WHO). Since the last three years ILBS is the worlds first health organization collaborating centre on Liver diseases and second on viral hepatitis. The forefront work done in the field of liver failure and alcoholic hepatitis by clinician and scientist was recognized internationally and a joint ILBS-INSERM Metabolomics laboratory was established to carry out dedicated research in the areas of Next Generation Science. ILBS has also signed a number of MOUs with leading universities and Institutes worldwide. Yakritamrit The great Indian physician and surgeon, Charaka and Susruta, recognized the liver as Yakrit, which means the organ that controls the body. The present eight annual report, Yakritamrit, meaning nectar that bestows immortality to liver, describes the efforts made by Team-ILBS for improving the liver-care. This forms the central dogma of the Institute i.e having a focused healthcare approach in treatment and cure of liver and biliary diseases. The faculties, residents, nurses and technical staff work closely to improve liver-care services, enhance the academic experience, and strive towards insightful research for alleviating patients sufferings. The five pillars that support ILBS organization are the operations, administration, finance, HR and IT. A close cooperation and synergy between all the departments makes the ILBS-Team unstoppable and marching towards to achieve higher goals of disease-free liver and allied organs. Yakritamrit, unfolds with the milestones achieved by ILBS in its journey of eight years and making its presence felt as a trend setter in Liver-Care.









Yakrit Samhita

Hepatology 2

Hepatology Hepatology Our mission is to establish ‘Hepatology’ as a comprehensive discipline of medicine which can provide distinctly advanced and protocol based patient care, training and clinical and translational research for patients of liver diseases. We also appreciate that a Hepatologist has to know other disciplines of medicine including metabolic medicine, nephrology, cardiology and intensive care. The Hepatology department at ILBS provides emergency, elective and tele-medicine based management to patients with liver, biliary and pancreatic diseases by a highly specialized and dedicated team of faculty, residents and supportive staff. With a rigorous academic program and constant monitoring and mentoring, the department is able to provide protocol and evidenced based care to an increasing number of difficult-to-diagnose and treat patients. The department has initiated efforts to promote the study of Hepatobiliary Sciences as a super-specialty and initiated advanced training in the field of Hepatology and Transplant Hepatology. Adult Hepatology Services Diagnosis and treatment of non-alcoholic fatty liver disease (NAFLD), alcoholic liver disease, viral hepatitis (Hepatitis B, C, E, A and D), auto-immune hepatitis, drug hepatitis, and all causes of jaundice and liver failure are attended to. Gall stones and bile duct stones, pancreatic diseases, liver, gall bladder and GI cancers add to the specialized care. The following advanced care services are routinely covered through the hepatology department. ƒ Liver Intensive Care The institute has established one of the best liver intensive and critical care services with specialized rapid response teams. The LICU teams include specialists from Hepatology (Dr. 3

Rakhi Maiwal, Dr. Rajan) and the Critical Care team (Dr. Lalita Gauri Mitra, Dr. Prasant and Dr. Vandana) round the clock. We provide care guided by a protocol-based treatment and rapid response by a multidisciplinary team ably supported by the nephrology, cardiology, pulmonology teams.  Acute GI Bleeds Patients with acute GI bleed are seen immediately in the emergency room and appropriate treatment is given immediately (Door to needle time <30 mins) including emergency endoscopy (door to scope time about 3 hours) throughout the year (24x7) which has resulted in keeping mortality to around 14% in patients with UGI bleed. Patients who fail the combination of endotherapy and vasoactive agents are taken up for portal pressure (HVPG) measurement and if suitable, considered for emergency TIPS procedure. There is a dedicated team available round the clock for all these procedures. New intervention of placing self-expanding metal stent, the Danis Ella Stent has greatly improved control of refractory variceal bleeding and patient survival. Probably the highest number of such stents are placed in the country, at the ILBS.  Hepatic coma Hepatic encephalopathy is the occurrence of confusion, altered level of consciousness, and coma as a result of liver failure. It may ultimately lead to death. A substantial increase in the patients admitted with hepatic coma occurred in the past one year. These patients are managed based on standard protocols and with our state of the art hepatic coma ICU functioning. New ammonia targeted approaches were introduced in with improved outcomes. The area is led by Prof. B C Sharma and Dr. Vikram Bhatia.  Acute Liver failure Acute liver failure is the appearance of hepatic encephalopathy rapidly after jaundice, and indicates that the liver has sustained severe damage. Common causes include Hepatitis E, Hepatitis A, and drugs. ILBS has been involved in the treatment of ALF patients with a rapid response team working round the clock and with the availability of urgent liver transplantation the outlook of this disease has improved substantially. Specialized monitoring with Optic Nerve Sheath Diameter (ONSD) measurement and Transcranial Doppler improved our diagnostic capabilities. Apart from this, we do high-volume plasma-exchange which removes a wide array of inflamatory toxins and cytokines in these patients and therefore facilitates recovery of the failing liver by providing an environment conducive for liver regeneration. High-volume plasma exchange in patients with acute liver failure is covered as a bridging therapy to spontaneous regeneration or liver transplantation. We routinely do plasma exchange for liver failure and have done this therapy in more than 100 patients in our intensive care unit, which is again probably the highest in the country. An early continuous renal replacement therapy (CRRT) in patients with acute liver failure is routinely done at our center. We have also successfully ordered a combination of these therapies in few patients with improved outcomes. 4

 Acute on Chronic Liver failure (ACLF) Liver failure can develop either acutely in the absence of any pre-existing liver disease [i.e. acute liver failure or ALF] or as acute on chronic liver failure (ACLF) which denotes a sudden deterioration of known or unknown chronic liver disease patient, which can be life threatening and requires intensive ICU care. This entity was first defined in India and ILBS has henceforth carried Abbreviations: AGB: Acute GI Bleed; HE: Hepatic intensive research in this disease and encephalopathy; ALF: Acute liver failure; ACLF: Acute on developed effective treatments for Chronic liver failure. this deadly condition. ILBS serves as the nodal center for the Asian Pacic Association for the Study of the Liver ACLF Research Consortium (AARC) coordinated by Dr. Ashok Chowdhary. At ILBS, there has been an ever-increasing referral of patients for management of these emergencies as shown in the figures above.  Liver dialysis Articial liver support systems can be non-cell based or cell- based systems. Several non-cell based extracorporeal liver support systems like hemodialysis, hemofiltration, plasma exchange, charcoal perfusion have been used in the past with a goal to remove the putative toxins and inflammatory cytokines to allow additional time for the liver to recover or as a bridge to liver transplantation However, in all these protein bound toxins are removed to only a minor extent. Single pass albumin dialysis (SPAD), molecular absorbent and recirculation system (MARS) and recently, Prometheus (FPSA–fractional plasma separation and adsorption) which remove both water soluble and protein bound toxins have emerged as liver support therapies in patients with acute and acute on chronic liver failure. The Prometheus system which combines the FPSA method with high-flux hemo-dialysis (of the blood) in an extracorporeal detoxification system. These newer developing therapies have demonstrated benifits in biochemical parameters, systemic hemodynamics, hepatic encephalopathy and also renal functions but are expensive and enough data is available on safety of these devices. They can be used as a bridge for spontaneous recovery or transplantation in patients with ALF. In patients with acute on chronic liver failure (ACLF) with hepatorenal syndrome or hepatic encephalopathy (without contraindications for transplantation)in order to improve their chances to be listed and transplanted. We at ILBS have the Prometheus system, the first of it’s kind in India. We at ILBS are also trying to develop our “bioartificial liver” with extracorporeal bioreactors containing 5

hepatocytes which can provide additional synthetic and biotransformatory liver functions, which may be more effective than completely artificial systems like Prometheus which provide excretory capacity alone. ƒ Acute Kidney Injury (AKI) It is a frequent and ominous complication in critically ill cirrhotics. AKI in these patients is usually a result of systemic inflammation and bacterial infection. In the remaining patients, diuretic use, large volume paracentesis, variceal bleed, use of nephrotoxic medications or structural kidney damage are other potential causes. Apart from routine management of AKI which includes discontinuation of nephrotoxic drugs, vasodilators, non-steroidal anti- inflammatory drugs and diuretics, antibiotics, volume expansion with intravenous albumin and additional use of terlipressin and noradrenaline is considered for non-responsive AKI or hepatorenal syndrome. Since the response to vasoconstrictors is seen in only one third, renal replacement therapy is frequently required. Our liver intensive care is equipped with 24x7 dialysis services. We provide intermittent hemodialysis, slow low exchange dialysis (SLED) as well as continuous renal replacement therapy (CRRT). Continuous RRT is better tolerated than routine hemodialysis in liver patients because of improved cardiovascular stability and less effect on intracranial pressure. With the able support of the nephrology team, more than 2,000 SLED procedures and more than 300 CRRTs have been done till date in patients with liver failure with AKI. We have also effectively combined hemodialysis with hemoperfusion as a technique to remove different toxins (bile acids, ammonia, cytokines) that accumulate in patients with liver failure and for endotoxin removal in patients with septic shock. ƒ End of Life Care In patients with cirrhosis end of life is an important aspect of ICU care wherein the patients either are in a persistent state of coma, have requirement of indefinite life support with no curative possibilities which may lead to economic ruin in face of medical futility and no benifit. After a consensus opinion within the ICU team care providers the decision for end of life is discussed with the family. As a part of this, care is focused on palliating a terminally ill patient’s pain and other symptoms and attending to their and their family’s emotional and spiritual needs. ƒ Viral Hepatitis (A,B,C,E) and Hepatocellular Carcinoma Services Hepatitis B and C are common causes of chronic liver disease in India and nearly 45 and 12 million people are estimated to be infected with these viruses in India respectively. They are also the common cause of cirrhosis and liver cancer. The area is led by Dr. Manoj Kumar and Dr. Ankur Jindal. ILBS sees one of the largest referrals for hepatitis B,C and Liver cancer as shown in figure. ƒ Alcoholic liver disease At ILBS, alcoholic liver disease is the most common diagnosis requiring admission. ALD constitutes more than 40% of our in-patients and 2/3rds of our patients with acute-on- 6

chronic liver failure. We have protocol based treatments available for alcoholic hepatitis patients led by Dr. Shasthry. We have recently shown survival benefits in patients not responding to the standard of care with growth factors and those not eligible for standard of care with use of new protocols using fecal microbiota transplantation (FMT) from a healthy donor. We further are trying to standardize protocols, which could in future become the standard of care in the management of severe alcoholic hepatitis patients. Liver stiffness and fat measurement: Early diagnosis and intervention can lead to a substantial reduction in morbidity and mortality from all conditions that lead to cirrhosis. Liver stiffness is important for evaluating the stage of liver fibrosis. The transient elastograpy (FibroScan ) ® technique measures the liver stiffness. This is used to quantify hepatic fibrosis in a totally non-invasive and painless manner, with no contra-indications for the patients. FibroScan allows accurate assessment of liver fibrosis resulting from all chronic pathologies that cause damage to the liver, including metabolic syndrome and non-alcoholic fatty liver disease, chronic viral hepatitis and excess alcohol intake. In the early stages of liver disease tests and conventional ultrasound have a poor predictive value in assessing fibrosis. Liver stiffness measurement is the ideal diagnostic tool to accurately identify liver fibrosis and fat quantification and is being increasingly used at ILBS. ƒ Endoscopy Services The department of hepatology provides most comprehensive endoscopic services- both diagnostic and therapeutic. Our spacious endoscopy unit has seven fully equipped 7

rooms- two for gastroscopy, one for colonoscopy, one each for endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), cholangioscopy, Intraductal ultrasound, one balloon enteroscopy room, and one room for extra-corporeal shock wave lithotripsy (ESWL). Experienced endoscopists, nurses and anesthesiologists receive all patients in a spacious day care reception area, where they are assessed pre- procedure. All elective endoscopic procedures at ILBS are carried out with tailored sedation provided by consultant anesthesiologists. Patients undergoing prolonged procedures, and high-risk patients are administered general anesthesia with elective endotracheal intubation and ventilation. After the procedures, patients are monitored in a segregated post-procedure observation area with full monitoring facilities and privacy. The services are evidently supervised by the resident medical officer, Dr. Poonam. We have a round–the-clock gastrointestinal bleeding service and a round the clock, GI Bleed unit with consultant endoscopists on 24-hour call. The highlights of the gastrointestinal bleeding service include a fully equipped ambulance with on-site resuscitation facilities, to triage at admission, and all endoscopic therapeutic procedures. These include variceal banding and injection, glue injection, thermal coagulation, argon plasma coagulation (APC), and hemostatic metallic stent implantation, Dennis Ela stent placement. We take pride in having the shortest ‘door to endoscopy’ time, which is unrivaled by any other hospital. Our interventional radiology services work in tandem, and provide salvage angioembolization , TIPS and BRTO services for difficult to control or inaccessible bleeding sources. ILBS has one of the largest experiences in emergency TIPS stent placement. All patients with gastrointestinal bleeding are managed in an intensive care setting. We provide comprehensive pancreato-biliary endoscopy services. These include Extra- corporeal shock wave lithotripsy (ESWL) to fragment pancreatic and bile duct stones, therapeutic ERCP, and diagnostic and therapeutic endoscopic ultrasound (EUS) procedures. We have the experience of one of the highest EUS procedures done in the country. All our EUS procedures are done under anesthesia, providing unsurpassed patient comfort and safety. We are the one of the center to have dedicated on-site cytopathology services, with EUS sampling adequacy rates exceeding 97%. We are routinely doing intra-gastric balloon (IGB) placements for management of patients with morbid obesity with perceivable results. Thirty-four IGB placements were done in 2017 alone. We have the second generation cholangioscopy system and intra-ductal ultrasound systems for difficult biliary pathologies. We also have the holmium laser based system for cholangioscopic treatment of difficult bile duct stones. We are also introducing magnification and image-enhanced endoscopy, contrast- enhanced EUS, EUS-elastography, miniprobe sonography, and in-vivo histology by using probe-based laser confocal system. We are setting up a state-of-the art data archiving and management system, for audit and research purposes. Our endoscopy informatics system is integrated with the hospital PACS system. The goal of endoscopy services at ILBS is amalgamation of cutting edge technology with a humane touch. We strive to make endoscopy a pleasant experience for all patients, with attention to small details including 8

lockers for personal belongings, clean clothes and towels, clean toilet facilities, and post- procedure discussion of the findings. Our smiling and pleasant staff is trained to put patient apprehensions at ease. Hemospray, Danis-Ella stent Intra Ductal UltraSonography Magnification (Zoom) Endoscopy for better placement in managing UGI (IDUS) appreciation of vascular and surface patterns bleed There is ever increasing load of endoscopic procedures through the years as shown in figures below. Abbreviations: EVL: Endoscopic variceal ligation; APC: Argon plasma laser coagulation; HP: Heater probe; Glue: Glue injection; ERCP: Endoscopic retrograde chlolangiopancreatography, Others include Extra-corporeal shock wave lithotrypsy, Polypectomy and Achalasia Dilatation Hepatic 9

ƒ Hemodynamic Laboratory The hepatic hemodynamic laboratory is the backbone of Hepatology services. Under the supervision of Dr. Ankur Jindal, it provides detailed insight into the liver pressure which determines the outcome of patients with liver disease. Measurement of the hepatic venous pressure gradient (HVPG) is currently the best available method to evaluate the presence and severity of portal hypertension. Other unique features of this laboratory are accurate measurement of Pulmonary pressures, which is helpful in accurate diagnosis of porto-pulmonary hypertension and measurement of cardiac output; and simultaneous liver biopsy sampling even in patients with ascites and liver disease enabling accurate diagnosis and severity of liver disease. The management of patients of liver disease is based on reduction in complications (such as variceal bleed, development of ascites and renal failure) and an opportunity to regenerate the liver. All this is done in a protocol and outcome based manner at the ILBS. Normal HVPG is <5 mm Hg and an HVPG >10 mm Hg (termed ‘clinically significant portal hypertension’ or CSPH) predicts the development of various complications of cirrhosis. Importantly, HVPG above 12 mmHg is the threshold level for variceal rupture and a reduction of HVPG to <12 mmHg or by 20% of baseline considerably reduces the risk of bleeding, mortality and other complications of cirrhosis, such as spontaneous bacterial peritonitis and hepatic encephalopathy. We are currently running protocols on HVPG response based approaches on primary prophylaxis of variceal bleed in cirrhotics and HVPG based approach for managing acute variceal bleed. Sequential HVPG measurements are helpful to optimize drug therapy or switch to another form of therapy. Hepatic vein pressure grdaient measurement thought the transjugular route Number of procedures for Transjugular liver biopsy (TJLB) and Hepatic vein pressure gradient (HVPG) 10

The main advantages of the hepatic vein catheterization technique are its simplicity, reproducibility, and safety. Since its result has important implications, the appropriate and correct measurement of HVPG is an important issue both in research and clinical practice. Because of its relatively invasive nature and domain skills, this facility is available in very few centers in the world. We at ILBS regularly perform this procedure taking due precautions that all the steps are performed with precision and patient safety. ƒ Quantitative Liver Function Tests At ILBS we have been able to standardize and establish two tests of quantitative live functions, Indo-cyanin green (ICG)and13C-Methacetin Breath Test (MBT). ƒ Clinical Nutrition The department of Clinical Nutrition was established in ILBS, in 2012. The department is committed to providing nutrition management to the patients, along with nutrition education and research in collaboration with all the other departments at ILBS. Services for a detailed assessment of the nutritional status including the body composition analysis using a bioelectrical impedance analysis system are provided by the department. Specialized enteral nutrition formulations are routinely used for the patients. The department of clinical nutrition runs a dedicated liver nutrition clinic wherein along with the other referred cases, more than 250 obese cirrhotics are under follow-up. All these patients undergo a thorough nutritional work-up and nutritional management. In addition to this the department takes a lead in the routine nutritional management of patients in the ICU in consultation with the treating hepatoloist. This includes assessment of nutritional risk, initiation and management of eneteral and parenteral nutrition, assessment of nutritional adequacy and transition feeding. In the year 2017 more than 1000 body composition analysis using a bioelectrical impedance analysis system were provided by the department. Very soon the department would be covering the assessment of nutritional requirements through indirect calorimeter to the OPD as well as ICU patients. Several nutrition related research projects are underway for the fulfillment of the degree of PGCC, PhD, DM and M.Ch students. Under the leadership of Prof. Y K Joshi and Dr. Jaya Benjamin, the department plans to expand its services in the coming years by providing academic leadership in clinical nutrition through a well established nutrition support team, nutrition laboratory, advanced research along with education and training in the field of clinical nutrition. ƒ Liver regeneration and stem cell therapy Only about 2-5% of patients, with advanced cirrhosis are able to get liver transplant. Lack of a donor, very advanced stage, financial and social issues are the major limitations. There is therefore an urgent need to provide alternative methods of maintaining and improving liver functions. In this regard, emerging science of regenerative medicine is considered an effective alternative therapeutic approach that can effectively manage the necro- inflammatory death of hepatocytes, potentiates immunomodulation and thus promote native liver regeneration and repair. 11

In cirrhosis as well as in ACLF, the supportive signals for liver to regenerate get severely compromised and liver microenvironment becomes impermissible for regenerating cells, resulting in reduced liver mass and function. Potential of stem cells to differentiates into multiple cell lineages raises the exciting possibility that these cells can be used in repair and liver regeneration, when resident stem cells are not sufficient for the regeneration • MSC therapy • MSC therapy • BM Stem cell therapy of a failing liver During liver • Hepatocyte/HPC therapy • Immune mediated massive • Compromised native liver • Bio-artificial support • Macrophage therapy death of hepatocytes regeneration, bone marrow- • Accumulation of necrosed regeneration • PC therapy derived hematopoietic stem cellular debris cells (HSC) may mobilize ACLF to the liver and, together with hepatocytes and • Macrophage therapy • Compromised liver capacity to • Immune dysfunction systematic • MSC therapy • GCSF resolve Fibro-inflammotory response intrahepatic stem cells, • MSC therapy • Inflammation SEPSIS • GMCSF • BM Stem cell therapy • Immune cell therapy contribute to the proliferation • GCSF • Bio-artificial liver support of liver cells. Mechanistically, the approaches attempting Therapies for liver repair and regeneration to augment bone marrow stem cell can be divided into two main categories: enhancement of the endogenous stem cell response and augmentation of cell-based therapies by transplantation. The field of liver regeneration is led by Dr. Lovkesh, Dr. Anupam and Dr. Chhagan Bihari at ILBS. The trio under the guidance of Prof. Shiv Sarin has done many seminal works in the area of regenerative medicine. Growth factor administration was shown to be a simple and novel method of mobilizing BMSCs. We at ILBS, have successfully used growth factors like granulocyte colony stimulating factor (G-CSF) and erythropoietin to mobilize stem cells to the periphery in patients with advanced cirrhosis and ACLF and shown survival benefit in a subgroup of these patients. It was shown that there is a senescence of bone marrow in patients with advanced cirrhosis. 12

Patients with early decompensated cirrhosis (MELD<16) and those with a healthy cellular baseline BM respond better to growth factor therapy. Based on these concepts, growth factor administration after proper selection of patients is now a part of routine treatment of CLD patients at ILBS, particularly in those not having any option of transplant. Several laboratory and clinical studies showed that various cells, including mature hepatocytes in adult liver (adult HCs), fetal liver cells (FLCs), hepatic stem/progenitor cells (HSPCs), mesenchymal stromal cells (MSCs), are the potential sources of cell based therapies for liver failure, including acute on chronic liver failure as well as acute liver failure. Thus, our future endeavor in this field of regenerative hepatology includes novel interventional approaches, including transplant of bone marrow cells and/ or exosome infusion from allogeneic healthy bone marrow in the management of cirrhosis. Also we are studying the role of MSC transplant in management of ACLF patients. Utilization of macrophage therapy and/or CSF1 is also in our pipeline projects. Recently, in collaboration with IIT Kanpur, we have worked on a bio- articial Liver (BAL) device to meet the metabolic demands of body. We have also worked on an emerging new approach of using decellularized liver for this purpose. We aim for a future in which no patient with liver disease dies due to failure to get liver transplant. With this aim and with a strive to become a centre of Excellence for Hepatic Regenerative Therapies, ILBS has received grant from Department of Science and Technology (DST) for a project entitled “Development of non-transplant therapeutic strategies for advanced liver diseases”; phase 1 of which is ongoing. ƒ Transplant Hepatology Liver disease either acute or chronic when failed to improve with medical management, liver transplant is the therapy. Acute liver failure or acute on chronic Persistent fibro- Dysfunction and Compromised Native exhaustion of inflammatory liver repair, liver failure require emergent Liver failure in CLD and Liver Failure translational chllanges response to injury Immune cells regeneration transplant whereas end stage liver disease needs a prompt and /Decomepnsation Cirhosis timing decision for the same. Acute on Chronic liver failure Our transplant team led by Prof. Project: 1 and 2 Project: 3 and 4 Shiv K Sarin and monitored by Dr. •Restoration of immune •Novel Therpeutic Approaches dysfunction for treatment of liver failue Ashok Choudhury. The students Novel approaches and potential clinical outcomes •Amelioration of fibro- regeneration of liver and potentiating native liver Repair and regeneration get unique opportunity to be inflammatory response •Extra-corporal biological liver exposed to this highly specialized •Supplementing native support systes as a bridge to transplant liver regeneration care during their posting Novel transplant free Hepatic regenerative Therapies that includes pre-transplant Non-Transplant Therapeutic Strategies for Advanced Liver Diseases 13

evaluation of donor and recipient, pre-transplant optimization and post transplant follow up. The students also presented the clinical challenges in Liver Clinics of Indian Society Gastroenterology [Dr. Vinod, 2016; Dr. Shakti and Dr. Juned, 2017]. ILBS is the only public sector hospital in government setting to have a successful transplant programme with 101, 93 and 87 liver transplant per year in 2015, 2016 and 2017 respectively. This is possible due to able led by Transplant Surgery team by Prof. Viniyendra Pamecha and Dr. Senthil Kumar. Cadaver transplant, as well as maintenance of transplant waiting list in strict accordance of the NOTTO Guideline is a great achievement where nearly 250 patients were routinely followed by Transplant hepatology team and record maintained by Transplant Coordination department led by Mrs. Vibhuti-a passionate and dedicated person. The post transplant care is covered by surgical and medical resident doctors, nursing staff; 24x7 phone support (transplant SR on call mobile no-+91 7835055601), whatsapp support (mobile no-+91 9650951049), email ([email protected]) and a dedicated post-transplant ward supervised by Dr. Ashok Choudhury. Post transplant complications are uncommon; and if they occur, they are managed well. These include progressive multifocal leukoencephalopathy (PML), late onset antibody mediated rejection (AMR) in ABO compatible transplant, Graft Versus Host Disease (GVHD), post-transplant lymphoproliferative disease (PTLD), post LT malignancies. An algorithmic approach to post-LT Biliary complications is undertaken by ERCP or PTBD. International (7) and national (15) fellows had been trained on transplant hepatology till date. Training of manpower (Fellowship on transplant hepatology, transplant critical care and transplant immunology, transplant nursing and co-ordination), academic excellence, translational research (noninvasive methods for early detection of graft rejection, cell based therapy for steroid resistant rejection and immunoscan, etc.) and strategies to increase organ donation awareness, organ retrieval and promotion of cadaver transplant are in pipeline for the future. ƒ Protocol based treatment For patients with acute on chronic liver failure (ACLF), portal hypertension and variceal bleeding, hepatitis B and C and non-alcoholic steatohepatitis (Fatty liver disease), the department has been able to standardize the treatment protocols. ƒ Patient support services For patients with hepatitis B and C, and portal hypertension, highly skilled and trained nurses are available to monitor the patient treatment and outcomes. 14

Training and CME Regular training programs are conducted for BLS and ACLS certication. Resident doctors, casualty medical officers, nurses and technicians have regular access to high quality clinical CMEs at the institute. Services Rendered Services 2016 2017 Emergency care services 7650 8132 OPD services 53054 58987 ICU admissions 1180 1252 HDU admissions 1435 1567 Ward admissions 3667 4304 Upper GI Endoscopy diagnostic 8098 8313 Colonoscopy diagnostic 1760 1812 ERCP 784 893 EUS diagnostic 550 574 EUS therapeutic 254 232 ESWL 27 23 Capsule Endoscopy 34 21 Enteroscopy 81 54 Fibroscan 12457 13712 HVPG 1990 1772 TJLB 560 573 Cholangioscopy 7 11 Regeneration and stem cell therapy 69 65 Gastric Balloon 18 30 Nutrition counseling 3646 4850 Body Composition Analysis 1113 914 New Services and Facilities Fecal (Stool) Microbiota Transplantation (FMT) Unit The human microbiota consists of trillions of microorganisms found in the human body, with the majority of organisms colonizing the gut from mouth to colon. A large number of diverse microbial species reside in the distal gastrointestinal tract, and gut microbiota dysbiosis (imbalances in the composition and function of these intestinal microbes) and excessive release of gut microbial products into the portal circulation has been implicated to have pivotal role in the development and progression of many of the liver diseases and their complications, mos 15

importantly -non-alcoholic steatohepatitis, alcoholic liver disease, alcoholic hepatitis, hepatic encephalopathy, sepsis in liver diseases etc. Globally, many efforts are currently concentrated on exploring potential possibility of exploiting the gut microbiome in the management of liver diseases. An improved understanding will fuel the conception and realization of novel therapeutic and preventive strategies. The gut microbiome (interaction between different microbes and their genes) contains 100 times as many genes as the whole human genome and hence is an important and less explored area in medicine. Fecal (stool) microbiota transplantation (FMT) involves acquiring healthy microbes from a related donor and then instilling these into the GI tract of the diseased individual. At ILBS, FMT is being used as a novel method in the treatment of severe alcoholic hepatitis, which otherwise is lethal nearly half, with limiting targetted therapeutic options other than liver transplantation. Earlier, we at ILBS have utilized FMT for the treatment of steroid ineligible responsive alcoholic hepatitis wherein the response has been encouraging with an improved survival. Lately we have initiated a trial where we intend to compare the effectiveness of FMT in comparison to steroids (which is the only approved option with its own side effects and limitations) in patients of severe alcoholic hepatitis. Up till now, more than 50 patients have been enrolled in the trial. Due to increased demand of day care services like large volume paracenteses, pleural fluid paracentesis (in hepatic hydrothorax) albumin infusions etc, we have opened a new albumin day care in Phase-2, first floor since June 2017. This ward has 15 operational beds of which 5 are dedicated for USG guided ascites tapping. The ward covers facilities to the needy patients in three shifts, with prior appointment. Dedicated telephone extension has been allocated to take appointments to avail the day care facilities- [Albumin Day Care Phone No. 011-46300000-Extn: 22152] The ward is catering over 500-600 patients a month since its inception. 3 shifts are being run where about 15-20 patients per shift undergo paracentesis and receive albumin infusion. The service is supervised by Dr. Shasthry and Dr. Ali. Educational Activities  Institute of Liver and Biliary Sciences - Center for Research on Inflammation, INSERM, Paris (ILBS-CRI) Symposium March 29-30th, 2017.  Workshop on Liver Diseases and Diabetes, Indo-French Perspectives, April 26th 2017. 16

 World Hepatitis Day - 2017: 28 July, 2017.  Hepatitis Awareness Day: 4 Dec, 2017.  Midterm INSCN Meeting 2017 of the Indian Society of Clinical Nutrition “Nutrition, Obesity and Metabolic Diseases-Current Perspectives and Challenges”, 29th November, 2017. Courses Offered Course Candidates admitted Candidates passed DM Hepatology: Admitted Dr.Vinay Kumar, Dr.Rakesh Kumar, Dr.Vinod Arora, Dr. Rajan V, in 2016: Dr. Satyam, Dr. Sushrut Dr. Sumeet Kaint, Dr. Vikash Prakash PhD Clinical Nutrition and Ms. Harshita Tripathi (Ph.D) Ms. Harshita Tripathi (PGCC) PGCC Clinical Nutrition APASL School Hepatology: Total number of trainees- 5 Dr. Kamala Trained in 2017 Retnam Mayilvaganan, Ms. Khangemban Bijya Devi, Ms. Thangjam Surjalata Devi, Dr. Nitin Yadav, Dr. Debi Prasad Department’s Achievements Department Research activities: Department is actively involved in clinical as well as basic research in varied areas such as Portal hypertension, Viral hepatitis, Alcoholic liver diseases,Non alcoholic fatty liver disease, Acute Liver Failure, Acute on Chronic Liver Failure, Kidney injury in Liver diseases, Liver regeneration , Liver transplant. Department of hepatology has given important contributions to developing guidelines for treatment of various hepatological diseases like APASL guidelines for hepatitis B, hepatitis C, liver brosis, hepatocellular carcinoma, variceal bleed, non-cirrhotic portal hypertension, International ascites club guidelines for AKI in cirrhotics. Department is also involved in developing novel therapies for liver diseases like regeneration therapies of liver using growth factors, fecal microbiota therapy for severe alcoholic hepatitis, newer biomarkers for liver cancer, AKI etc. Resident’s Achievements Dr. Sumeet Kainth Had a presidential plenary at AASLD on the topic “efficacy and Safety of carvedilol In patients of acute-on-chronic Liver failure With Small Or No esophageal varices – A placebo control open label randomised trial (NCT02583698)” and was awarded young investigator travel award at AASLD 2017. Dr. Vikash Prakash Had an oral presentation at AASLD 2017 on the topic “Early introduction of a combination of low dose terlipressin and noradrenaline as vasopressors is superior to high dose noradrenaline alone in patients of cirrhosis with septic shock (NCT02468063)” and was awarded international travel award at AASLD 2017. 17

Dr. V. Rajan Had an oral presentation at AASLD 2017 on the topic “ Early addition of prokinetics reverses gut paralysis and improves survival in critically ill cirrhotics- An open label placebo controlled RCT (Feed Intolerance and Treatment-FIT protocol)”. Dr. Anand Kulkarni Had an oral presentation at AASLD 2017 on ω3 polyunsaturated fatty acids(PUFA) lipid emulsions are safe and eective to reduce endotoxemia and sepsis in patients with Acute on Chronic Liver Failure -A randomised controlled trial.(NCT 02691533). He was adjudged the best abstract presentation by a fellow at the AASLD and awarded international travel award at AASLD 2017. Ms. Harshita Tripathi Won the 2nd Prize in free paper presentation at ISGCON 2017, December 14th-17th, 2017 Bhuvaneshwar, Odisha. “Modified NUTRIC Score Guided Aggressive Nutrition Therapy Significantly Decreased 28 Day Mortality in Critically ill patients in Liver Intensive Care Unit”. Visiting Faculty Institution Date of Visit Dr. Moreshwar S Desai Baylor College of Medicine, Houston. TX. 26-01-2017 Prof. Akira Asao Kyushu University Hospital, Fukuoka, Japan 13-02-2017 Prof. Tamir Miloh Baylor College of Medicine, Houston, Texas, USA 03-03-2017 Dr. Scott L. Nyberg Mayo Clinic, USA 09-03-2017 School of Medicine and Health Sciences George Prof. Rakesh Kumar 19-03-2017 to 22-03-2017 Washington University, Washington DC, USA Prof. Gyongyi Szabo University of Massachusetts Medical School, USA 10-03-2017 Directeur Center for Research on Inflammation, UMR Prof. Renato Monteiro 29-03-2017 to 30-03-2017 1149, Paris, France National (French) Institute of Health (Inserm), Paris, Prof. Richard Moreau 29-03-2017 to 30-03-2017 France Institut National de la Santé et de la Recherche Prof. S. Lotersztajn 29-03-2017 to 30-03-2017 Médicale (INSERM), Paris, France Institut National de la Santé et de la Recherche Prof. B Van Beers 29-03-2017 to 30-03-2017 Médicale (INSERM), Paris, France Centre de Recherche sur l’Inflammation(CRI) in Paris, Prof. Maude Le Gall 29-03-2017 to 30-03-2017 France Dr. Marc Bulterys Global Hepatitis Program, WHO HQ, Geneva 13-04-2017 Dr. Yvan Hutin Global Hepatitis Program, WHO HQ, Geneva 13-04-2017 Dr. Thierry Damerval Deputy CEO, INSERM, Paris, France 26-04-2017 Dr. Richard Moreau INSERM, Paris, France 26-04-2017 Dr. Christophe Junot CEA, Paris, France 26-04-2017 Dr. Joël Doré INRA, Paris, France 26-04-2017 18

Visiting Faculty Institution Date of Visit Dr. Sophie Lotersztajn Research Center on Inflammation, INSERM, Paris, France 26-04-2017 Prof. Valérie Paradis Research Center on Inflammation, INSERM, Paris, France 26-04-2017 Prof. Didier Samuel INSERM,Paris, France 26-04-2017 Head of Infection and Immunoiology Prof. Mike Turner 27-04-2017 Wellcome Trust, UK Prof. Richard Moreau INSERM, Paris, France 04-07-2017 to 08-072017 Prof. Christian Brechot President, Institute Pasteur, Paris, France 09-07-2017 to10-072017 Prof. Margaret Hellard Burnet Institute, Australia 19-07-2017 Dr. Pratap C. Reddy Founder Chairman, Apollo Group of Hospitals, 07-08-2017 Johns Hopkins Bloomberg School of Public Health, Prof. Shruti Mehta 02-11-2017 Baltimore,USA Dr. Sunil Suhas Solomon Johns Hopkins School of Medicine, Baltimore, USA 02-11-2017 Faculty, ASU Center for Evolution, Medicine, and Public Prof. Kenneth H. Buetow 09-11-2017 Health Arizona State University, US Department of Gastrointestinal Medical Oncology, the Prof. Manal Hasan University of Texas MD Anderson Cancer Center, Houston, 09-11-2017 Texas. Prof. Christian Brechot President, Institute Pasteru, Paris, France 28-11-2017, 29-11-2017 Senior Lecturer and Consultant Clinical Nutritionist, , Dr. Ranil Jayawardena 29-11-2017 University Colombo, Sri Lanka Clinical Nutrition Specialist Lecturer- Medical Faculty Dr. Luciana B Sutanto 29-11-2017 Diponegoro University Semarang, Indonesia International Dean Eurasia and South Asia Professor of Prof. William Cushley Molecular Immunology 07-12-2017 University of Glasgow, Scotland, UK Johns Hopkins University School of Medicine Johns Dr. Susrutha Kotwal MD Hopkins Bayview Medical Center Division of Hospital 13-12-2017 Medicine Baltimore, MD Prof. Richard Moreau INSERM, Paris, France 15-12-2017-17-12-2017 18-12-2017-20-12-2017 Dr. Puneet Puri Virginia Commonwealth University, USA 22-12-2017-23-12-2017 19

Staff Faculty Designations Prof. B C Sharma Professor and Head Prof. Shiv Kumar Sarin Senior Professor Prof. Y K Joshi Senior Professor Dr. Vikram Bhatia Additional Professor Dr. Manoj Kumar Sharma Additional Professor Dr. Rakhi Maiwall Associate Professor Dr. Shasthry SM Associate Professor Dr. Ankur Jindal Associate Professor Dr. Ashok Choudhury Associate Professor Dr. Jaya Benjamin Assistant Professor Dr. Lovkesh Anand Assistant Professor Dr. V Rajan Assistant Professor Dr. Vinod Arora Assistant Professor Senior Residents Dr. Junaid Ahmed, Dr. Shakti Choudhary, Dr. Anand, Dr. Abhinav Verma, Dr. Manjul Mishra, Dr. Karan Kumar, Dr. Harsh Tevitha, Dr. Apoorva Pandey, Dr. Vinay Kumar, Dr. Sushrut, Dr. Rakesh Kumar, Dr. Satyam, Dr. Seema, Dr. Varsha Shasthry, Ms. Puja Bhatia, Ms. Harshita Tripathi Technical Staff Mr. Krishan Kumar Gahlout, Mr. Ravinder Kumar, Mr. Rajesh Kumar Rai, Mr. Shashendra Kumar, Mr. Jitender Nursing Staff Ms.Jamuna Rani, Ms.Maloti Pegu, Ms.Amy Chui Chui, Ms.Ritu Anamika, Mr.Vipin Mohan, Ms.Rajani Gulliya, Mr.Sunder Lal, Ms.Deepa Mathew Academic and Research Achievements of Faculty Dr. Dr. Barjesh Chander Sharma Dr. Barjesh is a Professor and has taken over as the Head of the Hepatology Department in 2017. He joined the institute as Professor of Hepatology in 2016. He has more than 20 years of clinical and teaching experience. Prior to joining ILBS he served as Professor Gastroentrology at G.B.Pant hospital. His main interest and work has remained in the field of Hepatology, specially hepatic encephalopathy. He is recipient of many prestigious awards such as Olympus J Mitra Award , ISG – SR Naik Memorial Award 2006 etc. He is the assistant editor of Hepatology International and serves as editorial member of many gastroenterology journals such as World Journal of Gastroenterology, J Gastroenterol Hepatol and Journal of Clinical and Experimental Hepatology.  Total Number of publications 216  Total Number of publications in 2017 4 20

 Conferences attended  APASL Annual Conference, Tokyo, Japan.  China international Hepatology Symposium Beijing, China.  APASL STC on Recent Advances in Presentation and Management of Cirrhotic  Complications. Busan, Korea.  APASL STC on Hepatitis C Virus, Kaohsiung, Taiwan.  AASLD, Liver Meeting, Boston USA.  APASL STC on Hepatitis B Virus, Beijing, China. Dr. Shiv Kumar Sarin Dr. S.K.Sarin, MD, DM, D.Sc. (Hony.), FNA, FNASc is a Senior Professor of Hepatology and an Adjunct Faculty, Molecular Medicine at JNU. He is also the Director, WHO Collaborating Centre on Viral Hepatitis and Liver Diseases. He is the founding Co-Chief Editor of Hepatology International. His main areas of current research include Acute-on-chronic liver failure, liver regeneration and portal hypertension. Prof. Sarin has been bestowed with Padma Bhushan (third highest civilian award of the country) by the Govt of India. He is a member of all the three science academies of the country. He has been a recipient of Shanti Swarup Bhatnagar award, the highest Award in Science in India, The World Academy of Medical Sciences International Prize, EASL International Recognition Award and ‘Most Distinguished Physician from India” from the American Association of Physicians of India. Key Leadership Roles (National): (i) Chairperson Institutional Ethics Review Board Jawaharlal Nehru University, New Delhi, (ii) Standing Selection Committees and Standing Academic Committee, All India Institute of Medical Sciences, Patna. (iii) Scientific Advisory Committee of Centre for Stem Cell Research (CSCR), Christian Medical College, Vellore, (iv) Standing Academic Committee, Postgraduate, Institute of Medical Education and Research, Chandigarh. Key Leadership Roles (International): (i) Chairman-Steering Committee of the Asian Pacic Association for the Study of the Liver (APASL), Secretary General-Asian Pacic Digestive Week Federation (APDWF),Member (ii) International Health Regulations (2005 (IHR (2005)) Roster of Experts, as an expert in Hepatitis (ABCDE) of World Health Organization, (iii) Global Guidelines Committee, Hepatology Interest Group, Training Centers of the World Gastroenterology Organization WGO. Visiting Faculty- Mayo Clinic , Rochester, Minnesota, USA.  Total Number of publications 482  Total Number of publications in 2017 44  Total Number of projects 4 21

Awards International First Ralph Kohn Memorial Lecture at the Institute of Hepatology, London, UK October 10, 2017 . Awarded The Henry L. Bockus Medal -2017 by World Gastroenterology Organization at World Congress of Gastroenterology at ACG 2017, Orlando, USA,October 16, 2017. This is given once in 4 years. National Dr. U. K. Sheth Oration, at Seth GS Medical College and KEM Hospital, Jan 2017. Dr. CM Habibullah Memorial Oration at 13th Annual Conference of -STEM 2017, Bangalore Feb., 2017. Prof. N. Rajan Memorial Oration 2017 at 10th Annual ASGK conference at Kottayam Kerala on March 12, 2017. Dr. Muralidhar S Rao oration at ISG-KCON -2017 Karnataka Gulbarga on November 12, 2017. Dr. DV Datta Memorial Oration at Indian National Association for the Study of the Liver (INASL) at ISGCON-2017 at Bhubaneswar on December 16, 2017. Representative/ Expert in the following Committee/Bodies (National)  Adjunct Faculty School of Molecular Medicine, Jawaharlal Nehru University (JNU), New Delhi.  Chairman, Institutional Ethics Review Board Jawaharlal Nehru University, New Delhi.  Member, Planning Board of the Babasaheb Bhimrao Ambedkar University, Lucknow. (1-4-2014-31-3-2017).  Member, Institute Body, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow.  Member of the Governing Board of International Institute of Health Management Research (IIHMR). Representative/ Expert in the following Committee/Bodies (International)  Director, WHO Collaborating Centre on Viral Hepatitis and Liver Diseases.  Secretary General, Asian Pacific Digestive Week Federation (APDWF) 2016–2018 Singapore. Health Services to the Community  Trustee in the NGO to support the underprivileged children “Udayan care”.  Trustee “Liver Care Trust” for the public education and care of patients with liver diseases. Prestigious Fellowships  Fellow of American Association for Study of the Liver Disease (FAASLD).  Fellow of American Gastroenterology Association (FAGA).  Fellow The World Academy of Medical Sciences. 22

Lectures delivered and papers presented Several lectures delivered at international and national conferences. Projects DST Project- Development Of Non-Transplant Therapeutic Strategies For Advanced Liver Diseases: Phase-1 (from July 2017). Dr. Y.K. Joshi Dr. Y.K. Joshi joined ILBS in 2012 as a Senior Professor of Clinical Nutrition. Prof. Joshi did his MD (General Medicine) from Friendship University, Moscow, USSR, and Ph.D. from the Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi. He has had an illustrious career as a clinician with special interest in nutrition from 1975 to 2011 at AIIMS, he superannuated as a Professor from the Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi.  Total Number of publications 150  Total Number of publications in 2017 3 Dr. Vikram Bhatia Dr. Vikram Bhatia did his graduation and post-graduation (M.D. in Internal Medicine) from Maulana Azad Medical College (MAMC). He completed his sub-specialty training in Gastroenterology (D.M.) from the All India Institute of Medical Sciences (AIIMS), New Delhi, in December 2002. He subsequently continued to work in the Gastroenterology Department of AIIMS, before joining the Institute of Liver and Biliary Sciences (ILBS), New Delhi as a faculty member in June 2008. Dr. Vikram Bhatia has been active in academics, including teaching of fellows, conducting training workshops, and doing research. He has over 128 publications to his credit, including 10 book chapters. His current H-index rating at the Google Scholar is 25. Dr. Bhatia has been the recipient of several awards, notable being: SGEI annual oration for 2017, Outstanding Young Gastroenterologist Award by World Endoscopy Organization (WEO) in 2014, Alkem Om Prakash Memorial Award by the Indian Society of Gastroenterology (ISG) in 2010, European Society of Gastrointestinal Endoscopy (ESGE) International fellowship award in 2007, Young Investigator Award at the Asian Pacific Digestive Week (APDW) in 2006, Fellowship of the Japan Cancer Society in 2005, and the Japanese Society of Gastroenterology (JSGE) overseas fellowship award in 2004. Dr. Bhatia has trained extensively in centers of excellence in different parts of the world, including the Aichi cancer Center Hospital (ACCH), Nagoya, Japan, under Dr. Kenji Yamao, in the years 2005, 2009, and 2013, at the Gentofte Hospital, Denmark under Dr. Peter Vilmann, in 2007, and at the Osaka University Hospital, Japan in 2004. 23

His areas of interest are Endoscopic Ultrasound (EUS), and gastrointestinal and pancreato- biliary cancers.  Total Number of publications 128  Total Number of publications in 2017 12 Dr. Manoj Kumar Sharma Dr. Manoj Kumar Sharma, Additional Professor in Department of Hepatology, has obtained his DM in Gastroenterology from G B Pant Hospital, New Delhi in 2005. After that he worked as Assistant professor in Gastroenterology at G B Pant Hospital till 2008; after which he is at ILBS. He is also the organizing secretary of the upcoming APASL annual meet -2018.  Total Number of publications 113  Total Number of publications in 2017 13  Total Number of Projects 2 Dr. Rakhi Maiwall Dr. Rakhi Maiwall has completed her MBBS in 2003 with 3 gold medals and finished her MD Internal Medicine from Lucknow University in 2007 with gold medal. She has done her DM in Gastroenterology from Christian Medical College, Vellore in 2011. She is presently working for ILBS-ECHO project of telemedicine for training general physicians in rural and semi-urban areas of India in the management chronic liver related disorders particularly Hepatitis C and B virus related and leading the department of telemedicine at ILBS. She is having special interest in critical care medicine and renal disease in patients with ACLF and chronic liver disease, iron and liver, liver regeneration and artificial liver support therapies. Attended Certificate Course by EDIC, ESCIM New Delhi Attended Symposium on Liver Transplant by International Liver Transplant Society (ILTS) at Boston Did 6 weeks training in “Inflammatory and Stress Responses in Chronic Liver Disease” located at the Center of Research on Inflammation (CRI, Paris, France Collaborating investigator of the ACLF Research Consortium (AARC).  Total Number of publications 48  Total Number of publications in 2017 13  Total Number of Projects 4 Lectures Delivered  Human Albumin Structure Functions and Therapeutic Role in Cirrhosis–International Ascites Club-APASL, Shanghai 2017  “Immunomodulation in Liver Failure”-APASL, Shanghai 2017 24

 Management of AKI- beyond HRS- INASL, New Delhi 2017  Management of Hyponatremia- Special Interest Group-Ascites, INASL,New Delhi 2017  Plasmapheresis in Liver disorders-Expanding Indications, CMC Vellore 2017  Plasma-Exchange in Liver Failure-Can it change prognosis? Critically ill liver patient at Frontiers in Liver disease, Aster Integrated Liver Care, Kochi Kerala  Chronic Hepatitis B-Therapeutic Options and Challenges, Kanpur 2  Chairperson/Panelist in various National Meetings Papers presented Oral papers  Acute Kidney Injury In Critically Ill Cirrhotics With Severe Sepsis And Septic Shock Has Major Influence On Organ Failures And Outcomes- A Single Center Prospective Study, APASL, Shanghai 2017.  Incidence, Predictors and Outcomes of Transition of Acute Kidney Injury to Chronic Kidney Disease in patients with Cirrhosis-ISGCON Plenary.  Degree of Hepatic and Systemic Hemodynamic Alterations Predicts Development of AKI and Mortality in Patients with Cirrhosis, AASLD, Washington 2017.  Neutrophil-Gelatinase-Associated Lipocalin and Cystatin C predict AKI Progression and Transition to Chronic kidney disease in Critically Ill Cirrhotics, AASLD, Washington 2017. Posters  Assessment of Presence and Dynamic evolution of Organ Failures during Early Intensive Management by MERCIC model can guide inappropriate ‘Futile Care’ in the first week in Critically Ill Cirrhotics, ESCIM, Vienna.  Organ Failures Associated with Acute Kidney Injury in Critically Ill cirrhotics have a major influence on disease progression and outcomes- a prospective ICU based study, ESCIM, Vienna  Dynamic AARC-AKI score determines Extrarenal Organ Failures and Bacterial Infection in patients with Acute on Chronic Liver Failure , AASLD, Washington, 2017. Clinical Trials Conducted  Early Versus Late SLED in critically ill cirrhotics-A prospective randomized controlled trial  On-Demand versus Protocol-guided RRT in Cirrhotics with Stage 3 AKI-A prospective randomized controlled trial.  Early Versus Late CRRT in critically ill cirrhotics-A prospective randomized controlled trial  High Volume Plasma Exchange versus Standard Medical Treatment in patients with Acute Liver Failure-A Randomized Controlled Trial.  Epidemiology And Clinical Impact Of Bacterial Infections In Hospitalized Patients With Liver Cirrhosis:A Multicenter Observational Prospective Survey Among The Members Of 25

The International Club Of Ascites.  High versus Low Target MAP in critically ill cirrhotics with septic shock. Awards  Oral Paper presentation in AASLD, Boston.  Plenary paper award in ISGCON, New Delhi. Dr. Shasthry S M Dr. Shasthry obtained MD General Medicine in 2009 from Jawahar Lal Nehru Medical College, Ajmer, Rajasthan and later completed DM in Hepatology from Institue of Liver and Biliary Sciences, New Delhi in July 2014. Presently he is working as Assistant Professor, Department of Hepatology and has special interest in the areas of alcohol related disorders, Systems biology in HPB diseases, endoscopic procedures in the area osf hepato-pancreato-biliary diseases.  Total Number of publications 11  Total Number of publications in 2017 4  Total Number of Projects 1  One month advanced endoscopy fellowship from Kyushu university hospital, Fukuoka, Japan. Dr. Ankur Jindal Dr. Ankur Jindal has completed his MBBS in 2008 with 1 gold medal and 3 certificates of honours and finished his MD Internal Medicine from PGIMER, Chandigarh in 2011. Completed DM in Hepatology ILBS in 2014. He has the capability and skills of performing both upper and lower GI diagnostic and advanced therapeutic ERCPs. He also has expertise in hepatic hemodynamics including Hepatic Venous Pressure Gradient measurement and transjugular liver biopsies. He is presently working as Associate Prof. of Hepatology and Liver transplantation at ILBS. He had undergone observership for 2 weeks at Virginia common wealth university Richmond, VA, USA under Prof. Arun Sanyal and his team on liver transplant, basic and clinical research methodology. His areas of interest are Viral Hepatitis, Portal hypertension, and Hepatorenal syndrome. He has publications in leading journals including New England Journal of Medicine, GUT, Endoscopy, Clinical Gastroenterology and Hepatology and Liver International.  Total Number of publications 22  Total Number of publications in 2017 10 26

Invited Lectures  Delivered a lecture on “Management of Hepatitis B” in All India Congress Of Obstetrics and Gynaecology (AICOG), Delhi chapter on August.  Delivered a lecture on “ Management of AKI in acute variceal bleed” in 1st National conference on Critical Care Hepatology at New Delhi on January, 2017.  Live demonstration of “Technique of HVPG measurement” in 1st National conference on Critical Care Hepatology at New Delhi on January, 2017.  Delivered a lecture on “Approach to a patient with Jaundice” in Medicine update 2017 at MAMC, New Delhi in March 2017.  Invited as external expert in Global hospital, Mumbai for symposium on “ Liver failure and transplantation” in March 2017.  Delivered a lecture on “ HIV-HBV co-infection” at Indo-US symposium on HIV and opportunistic infections at PGIMER, Chandigarh in December, 2017. Conference presentations 1. Presented a “Difficult to manage HCV infection” case scenario in 3rd Singapore hepatitis Conference, SHC Singapore 2017. 2. Jindal A, Kumar M, Sarin SK. Higher efficacy of sequential therapy with tenofovir and pegylated interferon-alpha 2b versus tenofovir monotherapy in HBsAg positive chronic hepatitis B. ISGCON Young investigator session. Dr. Ashok Choudhury Dr. Ashok Choudhury has completed his MBBS in 2004 with 3 gold medals, 3 honours and the best graduate of the outgoing batch and finished his MD Internal Medicine. He completed his Doctorate of Medicine (DM) in Hepatology at Institute of Liver and biliary Sciences (ILBS), New Delhi. Presently working as Associate Professor in the Department of Hepatology and Liver Transplant. Actively involved in the patient care both inpatient and outpatient as a consultant. He had undergone observership at Kings College Hospital London in liver transplant as well as at Virginia Common Wealth University, Virginia USA. For his outstanding work he received the prestigious Best fellow research award by American Association of Liver Disease (AASLD) in 2014 at Boston, young investigator by European Association for Study of Liver (EASL) in 2014 at London, in 2016 at Barcelona, Spain and by International Liver Transplant Society (ILTS) in 2016 at Seoul Korea and by APASL in 2017 at Shanghai, China and covered in Europe by webMD magazine. Currently he co-ordinates the APASL ACLF Research Consortium (AARC) multinational registry for Asia Pacific. He is involved in a lead role as a transplant hepatologist that includes- pre-transplant evaluation, perioperative care and post transplant follow up including endoscopic procedure for biliary complications.  Total Number of publications 38  Total Number of publications in 2017 11 27

 Total Number of Projects 4 ƒ International Conferences  International Faculty to EASL, 2017, Amsterdam, delivered a talk on liver regeneration therapies in ACLF.  International Faculty to APASL, 2017, Shanghai China and coordinated the APASL- ACLF Research Consortium meeting. ƒ National Conferences  SGCON 2017 December delivered a talk on-liver regeneration and its impact and chairing a session in ACLF.  GISICON 2017-October delivering a talk on- Gut microbiota and cirrhosis-sepsis.  ISCM-Delhi on Septic shock-Target beyond MAP.  Kerala Gastrointestinal surgery society, Kochi 2017 delivering a talk on Liver transplant in ACLF and impact of SIRS and Sepsis.  CCILBS-Delivered talks on HPS and POPH during liver transplant waiting and on Septic shock in cirrhosis. Conference presentations 1. Plenary paper at Indian Society of Gastroenterology, Dec 2017, Bhubaneswar, India. 2. Plenary paper at European Society for Study of Liver , April 2017, Amsterdam. 3. Plenary paper at Asia Pacific Association for Study of Liver, Feb 2017, Shanghai China. Award Young Investigator Award 2017, Asia Pacific Association for Study of Liver, Shanghai, China. Dr. Jaya Benjamin Dr. Jaya Benjamin did her B.Sc. in Clinical Nutrition and Dietetics and M.Sc. (Gold Medalist) in Foods and Nutrition from the Mahrishi Dayanand Saraswati University, Ajmer, Rajasthan. After completing her Ph.D. from the department of Gastroenterology and Human Nutrition at the All India Institute of Medical Sciences, New Delhi, she continued to work at AIIMS as a Senior Research Officer. She joined the department of Clinical Nutrition, ILBS in 2013. She has keen interest in nutrition related clinical research, has attended many workshops and presented papers and won awards at numerous national and international conferences. She is the reviewer of reputed national and international journals and also the Principal Investigator of Indian Council of Medical Research (ICMR) funded extramural project  Total Number of publications 14  Total Number of publications in 2017 3  Total Number of sanctioned extramural projects 1 28

Invited Lectures in 2017 1. Nutritional Management of a Cirrhotic on RRT at First National Conference on Critical Care and Infections in Liver Disease, 24-26 January 2017 at Institute of Liver and Biliary Sciences, New Delhi. 2. Nutritional Management in Chronic Liver Disease- ILBS-ECHO (Extension for Community Healthcare Outcomes) Program on 17.1.17 at Institute of Liver and Biliary Sciences, New Delhi. 3. Assessment and Nutritional approaches to Sarcopenia in cirrhosis at ILBS-CRI Symposium (Centre for Research in Inflammation) France on 29-30th March, 2017 at ILBS New Delhi. 4. Panel discussion on Role of Probiotics in Liver Transplantation at Symposium on Probiotics in Practice organized by IDA, Delhi Chapter, 11th November, 2017. 5. Nutritional Optimization Prior to Liver Transplantation at 50th National Conference of the Indian Dietetic Association, 18-20th December, 2017, Science City, Kolkata. Dr. Lovkesh Anand Dr. Lovkesh Anand completed his MBBS from Calcutta University with a gold medal and was awarded cash prize for securing second highest marks in the University. He finished his MD Internal Medicine from PGIMS Rohtak followed by DM in Hepatology from Institute of Liver and Biliary Sciences, New Delhi in 2015. He joined as an Assistant Professor in the Department of Hepatology in October 2015. He is actively involved in outdoor and indoor patient care; advanced endoscopy including upper GI endoscopy (diagnostic and therapeutic), colonoscopy, enteroscopy, side viewing, ERCP; and hepatic hemodynamic studies. He is currently playing the lead role (under guidance of Prof. Sarin) in regenerative medicine and clinical stem cell therapy ongoing in liver disease at ILBS. He did his observorship at Virginia Common Wealth University, Virginia, USA and MRM centre for regenerative medicine, University of Edinburgh, UK. His research interest includes liver regeneration, transplant hepatology, autoimmune liver diseases and nutrition in patients with ACLF as well as chronic liver disease.  Total Number of publications 11  Total Number of publications in 2017 4  Total Number of Projects 2 Invited Presentation  Critical care and infections in liver disease 2017: Invited talk on “Nutrition in ALF”.  Indian Medical Association - College of General Practitioners; Kanpur: Invited talk on “Nutrition in liver disease”. Presentations  Oral and poster presentation in AASLD, 2017 at Washington DC, USA.  Presidential poster at ISGCON 2017 at Bhubaneshwar, India. 29

Dr. V Rajan Dr. V Rajan completed his MBBS from Barkatullah University, Bhopal, MP and finished his MD Medicine from SSMC, Rewa, MP in 2010. He did his DM in Hepatology from Institute of Liver and Biliary Sciences, New Delhi in 2017 and has joined as an Assistant Professor in the Department of Hepatology. He did a short-term observership at Stanford Medical center, Stanford University, USA under Prof. W. Ray Kim. He has gained experience in transplant hepatology, critical care medicine and endoscopic procedures. His area of interest includes, Portal hypertension, ACLF and Viral Hepatitis.  Number of International and National presentations 4 Dr. Vinod Arora Dr. Vinod Arora completed his MBBS from UCMS and GTB Hospital, University of Delhi, Delhi and MD Medicine from LHMC and SSKH, University of Delhi, in 2013. He did his DM in Hepatology from Institute of Liver and Biliary Sciences, New Delhi in 2017 and has joined as an Assistant Professor in the Department of Hepatology. He did a short-term observership at Hospital Clinic, Barcelona, Spain. He has gained experience in transplant hepatology, critical care medicine and endoscopic procedures. His area of interest includes, Portal hypertension, ACLF and Viral Hepatitis.  Number of International and National presentations 4 30

31

PEDIATRIC HEPATOLOGY 32