June 2026

What is Hepatitis B Reactivation? Hepatitis B reactivation (HBVr) is a sudden increase in HBV replication in a patient with chronic or resolved hepatitis B infection, leading to hepatic inflammation and in severe cases, acute liver failure or ACLF. Reactivation can be spontaneous or triggered by immunosuppressive therapy, chemotherapy, or biologics. Dr. Chetan Kalal at Gleneagles Hospital Mumbai specialises in hepatitis B management including reactivation prophylaxis and treatment of severe reactivation with ACLF. Who Is At Risk? HBsAg-positive patients starting chemotherapy, corticosteroids, TNF inhibitors, IL-6 inhibitors, or JAK inhibitors Anti-HBc-positive (HBsAg-negative) patients receiving rituximab or B-cell depleting therapies — high reactivation risk even without active HBV (occult HBV) Organ transplant recipients on long-term immunosuppression HIV-HBV co-infected patients starting antiretroviral therapy Key principle: Screen ALL patients for HBsAg AND anti-HBc before any immunosuppressive therapy. This is mandatory per APASL, EASL, and AASLD guidelines. Symptoms Jaundice, dark urine, pale stools Fatigue, nausea, right upper quadrant discomfort Elevated ALT/AST (often asymptomatic in early reactivation) Severe: ascites, encephalopathy, coagulopathy — signs of ACLF or acute liver failure Prevention: Antiviral Prophylaxis Tenofovir (TAF or TDF) or entecavir started 1–2 weeks before immunosuppression and continued 6–12 months after cessation dramatically reduces reactivation risk. Lamivudine is no longer recommended for prophylaxis due to high resistance rates. Treatment Immediate antiviral therapy (tenofovir or entecavir) is mandatory on confirmed reactivation. Reduce or stop immunosuppression where feasible. Severe reactivation with ACLF or acute liver failure requires ICU care and urgent liver transplant evaluation. FAQs Can I reactivate if HBsAg is negative? Yes — anti-HBc-positive, HBsAg-negative patients (resolved HBV) can reactivate with rituximab or stem cell transplant. Anti-HBc testing is essential before major immunosuppression. Best antiviral for prophylaxis? Tenofovir alafenamide (TAF) or TDF preferred. High barrier to resistance and proven efficacy. Entecavir is an acceptable alternative. Lamivudine not recommended for prolonged prophylaxis. Hepatitis B specialist in Mumbai? Dr. Chetan Kalal at Gleneagles Hospital Mumbai manages complex hepatitis B cases including reactivation. Teleconsultation available for patients in UK, USA, UAE, and internationally. Author: Dr. Chetan Kalal, Hepatologist, Gleneagles Hospital Mumbai. ORCID: 0000-0002-5284-7890. Hepatitis service page.

NAFLD is Now Called MASLD In 2023, a multi-society consensus (EASL, AASLD, APASL) officially renamed Non-Alcoholic Fatty Liver Disease (NAFLD) to MASLD — Metabolic dysfunction-Associated Steatotic Liver Disease. NASH is now called MASH (Metabolic dysfunction-Associated Steatohepatitis). The biology is identical; the new name removes the stigmatising label, emphasises metabolic syndrome as the driver, and creates a cleaner taxonomy. How Common is MASLD in India? MASLD is the most common liver disease in India, with prevalence estimated at 25–38% of the adult population. Rising obesity, type 2 diabetes, and sedentary lifestyles are driving a parallel epidemic. Importantly, lean MASLD — fatty liver in non-obese individuals — is especially prevalent in the Indian subcontinent. When Does Fatty Liver Become Dangerous? Simple steatosis (F0–F1): Usually benign; reversible with lifestyle change MASH with early fibrosis (F1–F2): Elevated risk; close monitoring and lifestyle intervention MASH with advanced fibrosis (F3–F4/cirrhosis): High risk of liver failure, portal hypertension, and hepatocellular carcinoma. Annual FibroScan recommended. Can Fatty Liver Be Reversed? Lifestyle modification (first-line): 7–10% body weight reduction resolves MASH in most patients. Mediterranean diet, avoid sugar-sweetened beverages, 150–300 minutes of moderate exercise per week, complete alcohol abstinence. Pharmacological (2024–2025): Semaglutide (GLP-1 agonist): Significant evidence for weight loss and MASH resolution Resmetirom: FDA-approved March 2024 — first approved drug for MASH with fibrosis (F2–F3) Pioglitazone: Useful in type 2 diabetes with MASH FAQs Does fatty liver cause pain? Most MASLD patients have no symptoms. Some have mild right upper quadrant discomfort or fatigue. Significant pain warrants hepatologist evaluation. Can I drink alcohol with fatty liver? No. Alcohol worsens MASLD at any stage and increases fibrosis risk. Complete abstinence is recommended by all current guidelines. How is MASLD diagnosed? Liver ultrasound is the initial test. FibroScan quantifies fat (CAP score) and fibrosis (liver stiffness). Biopsy remains gold standard for definitive staging when non-invasive tests are inconclusive. Author: Dr. Chetan Kalal, Hepatologist, Gleneagles Hospital Mumbai. MASLD service page. ORCID: 0000-0002-5284-7890.

Why NRI Patients Choose India for Liver Transplant India has become one of the world’s top destinations for liver transplantation — combining internationally trained hepatologists, high-volume centres, and costs that are a fraction of those in the UK, USA, UAE, Canada, or Australia. For NRI patients, Mumbai offers direct international flights, familiar language, family support, and world-class care at centres like Gleneagles Hospital. Dr. Chetan Kalal, the first DM Hepatologist of Maharashtra and liver transplant physician at Gleneagles Hospital Mumbai, coordinates transplant care for patients from the UK, USA, UAE, Gulf (GCC), Canada, Australia, New Zealand, and Africa. Cost Comparison: India vs UK, USA, UAE Country Approximate Cost USA USD 300,000 – 500,000+ UK (private) GBP 150,000 – 250,000 UAE USD 150,000 – 250,000 Canada CAD 200,000 – 350,000 Australia AUD 200,000 – 350,000 India (Mumbai) USD 25,000 – 40,000 Costs vary by centre, donor type, and complexity. Approximate ranges for comparison only. Living Donor vs Deceased Donor LDLT (Living Donor Liver Transplant) is the most common and practical route for international patients. A compatible family member donates approximately 60% of their liver. Both livers regenerate within 6–8 weeks. LDLT avoids the deceased-donor waitlist entirely. How to Arrange a Liver Transplant from Abroad Initial teleconsultation — Send LFT, INR, CBC, creatinine, viral markers, MRI abdomen. Dr. Kalal reviews and advises on transplant indication. Donor evaluation — Blood group, liver volumetry, fitness assessment. Partial workup possible in home country. Travel to Mumbai — Evaluation completed in 5–7 days before listing. Surgery and recovery — ICU 5–7 days; hospital stay 2–3 weeks; return home 4–6 weeks post-transplant. Follow-up — Immunosuppression managed with local physician; teleconsultation with Dr. Kalal. FAQs Can patients from Dubai get a liver transplant in Mumbai? Yes. Mumbai is a 3-hour direct flight from Dubai. Dr. Kalal provides initial teleconsultation before travel. Many Gulf patients choose Mumbai for transplantation. Is the quality comparable to UK or USA? Top Indian centres achieve 1-year survival of 85–90%, comparable to leading Western centres. Surgeons are internationally trained with fellowships from USA, UK, and Germany. What visa is needed? Indian Medical Visa (MED) for the patient and attendant. Gleneagles Hospital provides the required sponsorship letter. Author: Dr. Chetan Kalal, Gleneagles Hospital Mumbai. For international consultation: contact Dr. Kalal. ORCID: 0000-0002-5284-7890.

What is ACLF? Acute-on-Chronic Liver Failure (ACLF) is one of the most severe syndromes in hepatology. The APASL defines it as acute hepatic insult superimposed on chronic liver disease, presenting with jaundice (bilirubin ≥5 mg/dL) and coagulopathy (INR ≥1.5), complicated by ascites and/or encephalopathy within 4 weeks. Dr. Chetan Kalal is a leading ACLF specialist at Gleneagles Hospital Mumbai and has contributed to APASL AARC consensus research. AARC Grading Grade 1 (AARC score 5–7): 28-day mortality approximately 15–20% with optimal medical therapy.Grade 2 (score 8–10): Intermediate mortality; intensive care mandatory.Grade 3 (score 11–15): Mortality exceeds 70% without liver transplantation. Common Precipitants in India Hepatitis B reactivation Alcohol-related liver disease flare Bacterial infections (SBP, pneumonia) Superimposed drug-induced or herbal liver injury Hepatitis E superinfection Treatment Grade 1: Treat the precipitant, nutritional support, lactulose and rifaximin for encephalopathy, prophylactic antibiotics, careful fluid management. Grade 2–3: Immediate tertiary referral. Evaluate for liver transplantation within 7–10 days. Living donor liver transplant (LDLT) is the preferred route in India. FAQs Can ACLF survive without transplant? Grade 1 ACLF can recover with medical management. Grade 2–3 carries high mortality without transplantation. Early AARC scoring and 72-hour reassessment is essential. Best ACLF specialist in Mumbai? Dr. Chetan Kalal at Gleneagles Hospital Mumbai specialises in ACLF management and liver transplant evaluation. Referrals accepted nationally and internationally. Author: Dr. Chetan Kalal, first DM Hepatologist of Maharashtra. ORCID 0000-0002-5284-7890. See also: ACLF service page.

What is ACLF? Acute-on-Chronic Liver Failure (ACLF) is one of the most severe and rapidly fatal syndromes in hepatology. It is defined by the APASL (Asian Pacific Association for the Study of the Liver) as an acute hepatic insult superimposed on a previously diagnosed or undiagnosed chronic liver disease, presenting with jaundice (serum bilirubin ≥5 mg/dL) and coagulopathy (INR ≥1.5), complicated within 4 weeks by clinical ascites and/or encephalopathy in a patient without previous decompensation. Dr. Chetan Kalal is one of India’s foremost experts in ACLF, has co-authored research contributing to the APASL AARC (ACLF Research Consortium) consensus, and manages ACLF cases at Gleneagles Hospital Mumbai. AARC Score and Grading The AARC score (0–15 points) uses six parameters to grade ACLF severity and predict 28-day mortality: Serum bilirubin INR (coagulation) Serum lactate Creatinine Hepatic encephalopathy grade Presence of infection Grade 1 ACLF (AARC score 5–7): 28-day mortality approximately 15–20% with optimal medical therapy. Grade 2 ACLF (AARC score 8–10): Intermediate mortality; intensive care mandatory. Grade 3 ACLF (AARC score 11–15): 28-day mortality exceeds 70% without liver transplantation. Common Precipitants of ACLF in India Hepatitis B reactivation (most common in Asia) Alcohol-related liver disease acute decompensation Bacterial infections — spontaneous bacterial peritonitis (SBP), pneumonia Superimposed drug-induced or herbal-induced liver injury (DILI/HILI) Superimposed hepatitis A or E on chronic liver disease Treatment of ACLF Grade 1: Intensive medical management — treat the precipitant, nutritional support (high-protein diet, BCAA supplementation if encephalopathy), lactulose, rifaximin for encephalopathy, prophylactic antibiotics for infection, and careful fluid management. Grade 2–3: Refer immediately to a tertiary liver centre with ICU and liver transplant capabilities. Evaluate urgently for liver transplantation. The window for transplant is narrow — decisions must be made within 7–10 days of presentation. Liver transplantation is the only definitive treatment for Grade 2–3 ACLF that does not respond to medical therapy. Living donor liver transplant (LDLT) is the preferred route in India given the limited deceased-donor pool. Frequently Asked Questions about ACLF Can ACLF patients survive without a liver transplant? Grade 1 ACLF patients have a meaningful chance of survival with aggressive medical management, particularly if the precipitant is identified and treated early. Grade 2–3 ACLF carries high mortality without transplantation. Early AARC scoring on admission is essential to determine the trajectory and escalate care promptly. How quickly does ACLF progress? ACLF is a rapidly evolving condition. The AARC score should be reassessed at 72 hours and day 7 — an increasing score despite treatment is an indicator to expedite transplant referral. Some patients deteriorate from Grade 1 to Grade 3 within days. Which hospital in Mumbai treats ACLF? Dr. Chetan Kalal at Gleneagles Hospital Mumbai specialises in ACLF management including intensive medical care and liver transplant evaluation for Grade 2–3 ACLF. Referrals from physicians across India and internationally are accepted. Author: Dr. Chetan Kalal — First DM Hepatologist of Maharashtra, AASLD Foundation Award 2016 and 2017. ORCID: 0000-0002-5284-7890. Read more about ACLF treatment at Gleneagles Hospital Mumbai.

Why NRI Patients Choose India for Liver Transplant India has emerged as one of the world’s leading destinations for liver transplantation — combining internationally trained hepatologists, high-volume transplant centres, and costs that are a fraction of those in the UK, USA, UAE, Canada, or Australia. For NRI patients (Non-Resident Indians) living abroad, Mumbai offers a particular advantage: familiar language, family support networks, direct international flights, and world-class medical care at Gleneagles Hospital and other premier centres. Dr. Chetan Kalal, the first DM Hepatologist of Maharashtra and a liver transplant physician at Gleneagles Hospital Mumbai, coordinates liver transplant programmes for patients arriving from the UK, USA, UAE, Gulf (GCC), Canada, Australia, New Zealand, and Africa. Cost Comparison: India vs UK, USA, UAE Country Approximate Liver Transplant Cost United States (USA) USD 300,000 – 500,000+ United Kingdom (NHS — waitlist only; private) GBP 150,000 – 250,000 United Arab Emirates (UAE) USD 150,000 – 250,000 Canada CAD 200,000 – 350,000 Australia AUD 200,000 – 350,000 India (Mumbai — premier centre) USD 25,000 – 40,000 Note: Costs vary by centre, donor type, and patient complexity. These are approximate ranges for comparison only. Living Donor vs Deceased Donor Transplant for International Patients Living Donor Liver Transplant (LDLT) is the preferred and most common route for international patients visiting India. A compatible family member (parent, sibling, child, spouse) donates approximately 60% of their liver, which is transplanted into the recipient. Both livers regenerate to near-full size within 6–8 weeks. LDLT avoids the deceased-donor waitlist entirely. Deceased Donor Liver Transplant (DDLT) is available via the ZTCC Maharashtra waitlist but involves waiting periods that are impractical for international patients visiting specifically for transplantation. DDLT is more suitable for patients who are Mumbai residents. How to Arrange a Liver Transplant in Mumbai from Abroad Initial teleconsultation — Send blood reports (LFT, INR, CBC, creatinine, viral markers), imaging (MRI abdomen or CT triphasic), and any biopsy reports. Dr. Kalal reviews and advises whether transplant is indicated. Donor evaluation — The proposed living donor undergoes blood group, liver volumetry, and fitness assessment. This can be partially done in the home country. Travel to Mumbai — Patient and donor travel together. Most evaluations are completed in 5–7 days before listing. Surgery and recovery — ICU stay typically 5–7 days; hospital stay 2–3 weeks. Most patients return home 4–6 weeks post-transplant. Follow-up — Immunosuppression management can be coordinated with a local physician back home, with teleconsultation follow-up with Dr. Kalal. Frequently Asked Questions Can patients from Dubai get a liver transplant in Mumbai? Yes. Mumbai is a 3-hour direct flight from Dubai. Many patients from the UAE, Saudi Arabia, Kuwait, and other Gulf countries receive liver transplants at Gleneagles Hospital Mumbai. Dr. Chetan Kalal provides initial teleconsultation before the patient travels. What documents are needed for international patients? Passport, medical visa (Indian Medical Visa — MED), sponsor letter from the hospital, all medical records, and proof of relationship with the living donor. Gleneagles Hospital Mumbai has an international patient services team that assists with documentation. Is the quality of liver transplant in India comparable to the UK or USA? India’s top liver transplant centres perform thousands of transplants annually with 1-year survival rates of 85–90%, comparable to leading Western centres. Indian surgeons and hepatologists at premier centres are internationally trained, many holding fellowships from the USA, UK, and Germany. Author: Dr. Chetan Kalal — Hepatologist and Liver Transplant Physician, Gleneagles Hospital Mumbai. ORCID: 0000-0002-5284-7890. For international consultation: Contact Dr. Kalal.

NAFLD is Now Called MASLD — Here is What Changed and Why In 2023, the global hepatology community officially renamed Non-Alcoholic Fatty Liver Disease (NAFLD) to MASLD — Metabolic dysfunction-Associated Steatotic Liver Disease. The rename followed a multi-society consensus (EASL, AASLD, ALEH, APASL) and reflects a more precise understanding of the disease. Key changes in terminology: NAFLD → MASLD (Metabolic dysfunction-Associated Steatotic Liver Disease) NASH → MASH (Metabolic dysfunction-Associated Steatohepatitis) NAFLD cirrhosis → MASH cirrhosis The biology is identical. The new name removes the stigmatising “non-alcoholic” label, emphasises the role of metabolic syndrome (obesity, type 2 diabetes, hypertension, dyslipidaemia), and creates a clearer taxonomy for patients who have both metabolic liver disease and some alcohol use. How Common is MASLD in India? MASLD is the most common liver disease in India, with prevalence estimated at 25–38% of the adult population based on ultrasound-based surveys. The rising rates of obesity, type 2 diabetes, and sedentary lifestyles are driving a parallel epidemic of fatty liver disease. Importantly, MASLD affects non-obese individuals too — so-called “lean MASLD” — which is particularly prevalent in the Indian subcontinent. When Does Fatty Liver Become Dangerous? Most patients with MASLD have simple steatosis (fat accumulation without inflammation) and do not progress to serious liver disease. The danger lies in progression to MASH with fibrosis: Simple steatosis (F0–F1): Usually benign; reversible with lifestyle modification MASH without significant fibrosis (F1–F2): Mildly elevated risk; lifestyle change and close monitoring MASH with advanced fibrosis (F3–F4/cirrhosis): High risk of liver failure, portal hypertension, and hepatocellular carcinoma (HCC). Approximately 10–20% of patients with F3 fibrosis develop cirrhosis over 10 years. Annual FibroScan (transient elastography) is recommended for all MASLD patients to track fibrosis progression without repeated liver biopsies. Can Fatty Liver Be Reversed? Yes — with the right approach: Lifestyle modification (first-line, most evidence): A 7–10% reduction in body weight resolves MASH in most patients and reduces fibrosis by at least one stage in many Mediterranean diet: high in vegetables, legumes, whole grains, olive oil, fish; low in added sugar, refined carbohydrates, and saturated fat Avoid fructose and sugar-sweetened beverages entirely 150–300 minutes of moderate aerobic exercise per week Complete alcohol abstinence Pharmacological options (2024–2025): Semaglutide (GLP-1 agonist): Significant evidence for weight loss and MASH resolution Resmetirom (Rezdiffra): FDA-approved in March 2024 — the first approved drug specifically for MASH with liver fibrosis (F2–F3). Not yet widely available in India. Pioglitazone: Useful in patients with type 2 diabetes and MASH; reduces liver inflammation Vitamin E: Evidence in non-diabetic MASH; limited to specific patient subgroups Frequently Asked Questions Does fatty liver cause pain? Most patients with MASLD/fatty liver have no symptoms. Some experience mild right upper quadrant discomfort or fatigue. Significant pain is unusual in simple steatosis and may indicate complications such as hepatomegaly, MASH with inflammation, or an alternative diagnosis. Any significant abdominal pain warrants evaluation by a hepatologist. Can I drink alcohol if I have fatty liver? No. Alcohol worsens MASLD at any stage. Even moderate alcohol consumption in a patient with metabolic fatty liver increases the risk of progression to MASH and fibrosis. Complete abstinence is strongly recommended by all current guidelines. How is MASLD diagnosed? Liver ultrasound showing increased echogenicity is the standard initial test. FibroScan quantifies liver fat (CAP score) and fibrosis (liver stiffness measurement). Liver biopsy remains the gold standard for definitive diagnosis and fibrosis staging but is reserved for cases where non-invasive tests are inconclusive. Author: Dr. Chetan Kalal — Hepatologist, Gleneagles Hospital Mumbai. MASLD and metabolic liver disease is one of Dr. Kalal’s key clinical areas. Learn more about MASLD management at Gleneagles Hospital Mumbai. ORCID: 0000-0002-5284-7890.