INTRODUCTION:Scrub typhus is a re-emerging, neglected tropical disease in India, often presenting with nonspecific symptoms. While classical features are well-documented, atypical and severe manifestations are underreported and frequently misdiagnosed. OBJECTIVES:Our objective was to describe uncommon clinical manifestations of scrub typhus in hospitalized patients at two tertiary care hospitals in Northern India. METHODS:This prospective cross-sectional study included 22 adult patients (no controls) with serologically confirmed scrub typhus (IgM ELISA positive) presenting between January 2024 and June 2025. Only cases with atypical manifestations were included. Demographic, clinical, laboratory, and imaging data were analysed descriptively. RESULTS:The study of 22 hospitalized scrub typhus cases with atypical presentations revealed the presence of multi-organ involvement with marked hepatic and renal impairment. In severe cases, mean values of urea (97.7 vs. 10.2 mg/dL, p = 0.001), creatinine (2.14 vs. 0.84 mg/dL, p = 0.004), ALT (218.7 vs. 11.5 IU/L, p = 0.011), AST (208.5 vs. 37.2 IU/L, p = 0.008), and ALP (427.6 vs. 95.6 IU/L, p = 0.001) were markedly elevated. ROC analysis of urea (AUC = 0.902), creatinine (AUC = 0.888), and ALP (AUC = 0.875) confirmed them as strong predictors of severe disease. CONCLUSION:The correlation heatmap and boxplots highlighted strong associations between ALT and AST (r = 0.98) as well as urea and creatinine (r = 0.83), along with distinguishing outliers indicating associated hepatic injury, renal impairment, and thrombocytopenia.

INTRODUCTION:Cirrhotic cardiomyopathy (CCM) is a prevalent yet underrecognized complication of chronic liver disease (CLD), characterized by diastolic dysfunction and subclinical myocardial impairment. While N-terminal pro-B-type natriuretic peptide (NT-proBNP) is commonly elevated in cirrhosis due to myocardial wall stress, its diagnostic utility is confounded by hyperdynamic circulation and impaired renal clearance. Galectin-3, a biomarker of myocardial fibrosis and inflammation, has emerged as a potentially superior marker. This study aimed to compare the diagnostic performance of Galectin-3 and NT-proBNP for identifying cardiac dysfunction in patients with CLD. MATERIALS AND METHODS:A present cross-sectional study included 280 adults with CLD who underwent comprehensive echocardiography and biomarker testing. Patients were categorized as cases or controls based on systolic or diastolic dysfunction. Diagnostic accuracy was assessed using receiver operating characteristic curves, sensitivity, specificity, predictive values, and multivariable logistic regression. Associations between biomarkers and echocardiographic parameters were evaluated using Spearman correlations. RESULTS:Galectin-3 levels were significantly higher in cases than controls (27.5 ± 9.9 vs. 14.1 ± 3.9 ng/mL, P < 0.001), whereas NT-proBNP showed greater variability and weaker discrimination. Galectin-3 (≥18.5 ng/mL) achieved an area under the curve (AUC) of 0.97, sensitivity 91.8%, specificity 88.4%, and accuracy 90.4%, outperforming NT-proBNP (>300 pg/mL; accuracy 79.8%). In multivariable models, Galectin-3, right ventricular systolic pressure (RVSP), and E/A ratio remained independent predictors (AUC 0.99). Galectin-3 showed strong correlations with ejection fraction (ρ = -0.88) and left atrial diameter (ρ = 0.43), whereas NT-proBNP correlated only weakly with RVSP. CONCLUSIONS:Galectin-3 demonstrates superior diagnostic accuracy and stronger associations with echocardiographic dysfunction compared with NT-proBNP. Incorporating Galectin-3 into diagnostic pathways may enhance early detection and risk stratification of CCM in patients with CLD.

BACKGROUND AND AIM:Serum homocysteine is frequently elevated in chronic liver disease, but its prognostic relevance and etiology-specific associations in cirrhosis remain uncertain. This study aimed to compare fasting serum homocysteine levels in alcoholic and viral cirrhosis and to evaluate their association with disease severity. MATERIALS AND METHODS:This cross-sectional observational study included 60 adult cirrhosis patients (30 alcoholic and 30 viral hepatitis B or C-related) enrolled at a tertiary care center. Cirrhosis was diagnosed clinically, radiologically, and by transient elastography. Fasting serum homocysteine, Vitamin B12, and folate levels were measured. Disease severity was assessed using Child-Turcotte-Pugh (CTP) and MELD-Na scores. Correlation analysis, receiver operating characteristic (ROC) analysis, multivariable regression, interaction models, and etiology-stratified analyses were performed. RESULTS:Median serum homocysteine levels were comparable between alcoholic and viral cirrhosis (13.76 vs. 12.85 μmol/L; P = 0.095). Overall, homocysteine showed no significant correlation with CTP score (ρ=0.131; P = 0.319) or MELD-Na score (ρ=0.212; P = 0.103). In viral cirrhosis, homocysteine correlated positively with CTP score (ρ=0.399; P = 0.029) and independently predicted CTP class C (adjusted OR = 1.163; 95% CI 1.005-1.346; P = 0.043). No independent association was observed in alcoholic cirrhosis. Discriminatory performance of homocysteine for severe cirrhosis was limited (area under the curve = 0.542 for CTP C and 0.615 for MELD-Na ≥20). CONCLUSIONS:Serum homocysteine is not a universal marker of cirrhosis severity but may have etiology-dependent relevance, with stronger associations observed in viral cirrhosis.

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Hepatitis A virus (HAV) is the commonest cause for pediatric acute liver failure (PALF) in India. The objective of the study was to identify the predictors of mortality and to evaluate the utility of Peds-HAV model in a cohort of non-LT HAV-PALF. The study included HAV-related PALF from two non-transplant centers. The predictors of outcome were identified by univariate analysis followed by Cox regression analysis. The prognostic accuracy of Peds-HAV model, King’s College Hospital (KCH) criteria and pediatric end-stage liver disease score (PELD) were evaluated. As many as 140 children with PALF were included, of whom 96 (68.6

Background: Commonly used prognostic scores for acute on-chronic liver failure (ACLF) have complex calculations. We tried to compare the simple counting of numbers and types of organ dysfunction to these scores, to predict mortality in ACLF patients. Methods: In this prospective cohort study, ACLF patients diagnosed on the basis of Asia Pacific Association for Study of the Liver (APASL) definition were included. Severity scores were calculated. Prognostic factors for outcome were analysed. A new score, the Number of Organ Dysfunctions in Acute-on-Chronic Liver Failure (NOD-ACLF) score was developed. Results: Among 80 ACLF patients, 74 (92.5%) were male, and 6 were female (7.5%). The mean age was 41.0 +/- 10.7 (18 - 70) years. Pro fi le of acute insult was; alcohol 48 (60%), sepsis 30 (37.5%), variceal bleeding 22 (27.5%), viral 8 (10%), and drug-induced 3 (3.8%). Pro fi les of chronic insults were alcohol 61 (76.3%), viral 20 (25%), autoimmune 3 (3.8%), and non-alcoholic steatohepatitis 2 (2.5%). Thirty-eight (47.5%) were discharged, and 42 (52.5%) expired. The mean number of organ dysfunction (NOD-ACLF score) was ->4.5, simple organ failure count (SOFC) score was >2.5, APASL ACLF Research Consortium score was >11.5, Model for End-Stage Liver Disease-Lactate (MELD-LA) score was >21.5, and presence of cardiovascular and respiratory dysfunctions were significantly associated with mortality. NOD-ACLF and SOFC scores had the highest area under the receiver operating characteristic to predict mortality among all these. Conclusion: The NOD-ACLF score is easy to calculate bedside and is a good predictor of mortality in ACLF patients performing similar or better to other scores.

INTRODUCTION:Cyanoacrylate glue injection has become standard of care for acutely bleeding as well as for primary and secondary prophylaxis of high risk gastric varices. There is limited data on safe and effective amount of glue injected. Our study was aimed to fulfill the gap. MATERIALS:It was retrospective analysis of endoscopy laboratory chart, videos and corresponding case sheets of all consecutive endoscopies January to September 2022. Number, type and size of gastric varices, amount of glue injected and outcomes (technical success, intra procedural and post-procedural complications) were noted. RESULT:Among 337 upper gastrointestinal endoscopies performed during the study period, 12 patients had gastric varices. 3 had GOV1F1, 2 had GOV1F2, 8 had GOV2F2, 1 had GOV2F3 and one had isolated gastric varices, IGV2F1. 4 patients had history of upper GI bleed. 3 had one, 4 had two and 3 had three varices. 3 patients had &lt;0.5 cm and 8 had &gt;0.5 cm size varices. Cyanoacrylate glue was injected in 4 patients. Technical success was achieved in all (100%) patients. The amount of Cyanoacrylate glue injected was decided by the size and number of varices and varied between 1-4 ml depending on the above factors. Two patients had intra-procedural, self subsiding bleeding, one patient had severe abdominal pain needing intramuscular analgesic. None had fatal complication. CONCLUSION:Size and numbers of gastric varices are deciding factors for amount of glue injected during endotherapy. References Kumar A, Singh S, Madan K, et al. Undiluted N-butyl cyanoacrylate is safe and effective for gastric variceal bleeding. Gastrointest Endosc 2010;72(4):721-727. Saraswat VA, Verma A. Gluing gastric varices in 2012: lessons learnt over 25 years. J Clin Exp Hepatol 2012;2(1):55-69.

Garg et al.[1] argue in a review article in January 2021 issue of that journal that severe coronavirus disease 2019 (COVID-19) is a distinct entity. In this evolving pandemic, the authors underscore a few important points about the manifestations of severe acute respiratory syndrome- coronavirus-2 (SARS-CoV-2) and weigh up various treatment options. Table 1 of the article enumerates comorbidities associated with severe COVID-19. This table correctly includes several medical conditions which increase the risk of developing severe disease. In this respect, US Centers for Disease Control and Prevention runs a webpage where it provides live information – called living document – to share which we are amassing on a daily basis.[2] This list includes pregnant women in the high-risk group, among several others. The health-protection agency releases guidelines regarding pregnancy, breastfeeding, and caring for newborn.[3] Here, the American public agency points out that pregnant people are at increased risk for severe illness from COVID-19 and death, compared to non-pregnant people. Additionally, pregnant people with COVID-19 might be at increased risk for other adverse outcomes, such as preterm birth (delivering the baby earlier than 37 weeks). Elisabeth Mahase informs in British Medical Journal that pregnant women with SARS-CoV-2 are more likely to need intensive care on the basis of a study.[4] Hence, we propose that this point should be included in this list. On the basis of these findings, Rasmussen et al.[5] explore an option of delaying pregnancy during this public health crisis while examining public health recommendations for COVID-19 and beyond. Under the heading ‘Medical Treatment’, the authors discuss various treatment options available to such patients and point out their outcomes. Under Remdesivir, the authors state that it’s considered beneficial in the treatment of COVID-19. Here, we emphasize ACTT-1 trial conducted by Beigel et al.[6] and its Final Report. The report states that Remdesivir is beneficial in only that subgroup of moderately ill patients which require oxygen support. If the disease is not severe enough to have this requirement, curves of Kaplan–Meier estimates in Figure 2 don’t get separated, resulting in no overall benefit. Conversely, if the disease is so much severe that they need high-flow oxygen/non-invasive ventilation/mechanical ventilation or extra corporeal membrane oxygenation (ECMO), again there is no benefit of this repurposed antiviral drug. An accompanying editorial explains this intriguing behaviour of the drug. It clarifies that in the initial stage, viral replication is the predominant pathology and antiviral drugs act effectively in these patients, whereas later on due to cytokine storm, inflammatory system goes haywire and then anti-inflammatory drugs have value. Therefore, it’s important to assess the stage a patient is having in his disease process, which may determine choice of drugs at that specific point of time. Figure 3 of the trial explores time to recovery according to subgroup. An interesting finding there is that the drug works better for ‘other’ race – other than White, Black and Asian ones. That finding deserves further scrutiny and results should be analysed accordingly. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. We accessed all the webpages at the time of submission of this Letter.

HepatologyVolume 76, Issue 2 p. E29-E29 CORRESPONDENCE Letter to the editor: Nanoparticle therapeutic vaccine for hepatitis B: An unfulfilled dream Ajay Kumar Patwa, Corresponding Author Ajay Kumar Patwa drajaymd12345@gmail.com orcid.org/0000-0002-3274-7462 Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, India Correspondence Ajay Kumar Patwa, Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, India. Email: drajaymd12345@gmail.comSearch for more papers by this authorSumit Rungta, Sumit Rungta Department of Medical Gastroenterology, King George’s Medical University, Lucknow, IndiaSearch for more papers by this authorVivek Kumar, Vivek Kumar Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, IndiaSearch for more papers by this author Ajay Kumar Patwa, Corresponding Author Ajay Kumar Patwa drajaymd12345@gmail.com orcid.org/0000-0002-3274-7462 Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, India Correspondence Ajay Kumar Patwa, Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, India. Email: drajaymd12345@gmail.comSearch for more papers by this authorSumit Rungta, Sumit Rungta Department of Medical Gastroenterology, King George’s Medical University, Lucknow, IndiaSearch for more papers by this authorVivek Kumar, Vivek Kumar Gastroenterology Unit, Department of Medicine, King George’s Medical University, Lucknow, IndiaSearch for more papers by this author First published: 28 February 2022 https://doi.org/10.1002/hep.32421Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume76, Issue2August 2022Pages E29-E29 RelatedInformation

Tinospora cordifolia (Giloy) is an herbal supplement commonly used in the Indian alternative medicine system Ayurveda. This herb has been promoted to the public in India as an immune booster to prevent novel coronavirus disease 2019. However, small reports have recently shown an association between Giloy use and the development of herb‐induced liver injury (HILI) with autoimmune features in some patients. This large retrospective Indian multicenter study spanning 13 centers at nine locations was designed to identify features and outcomes of HILI temporally associated with Giloy use. Chemical and toxicological analyses of retrieved Giloy samples using state‐of‐the‐art methods were also performed. We report 43 patients, of whom more than half were female, with a median time from initial Giloy consumption to symptom onset of 46 days. Patients presented with acute hepatitis, acute worsening of chronic liver disease (CLD, the most common clinical presentation), or acute liver failure. Causality assessment revealed probable liver injury in 67.4%. The most common autoantibody detected was anti‐nuclear antibody. Liver biopsy in a subset revealed HILI associated with autoimmune features and hepatocyte and canalicular cholestasis and neutrophilic and eosinophilic infiltration. Conclusion: Giloy is associated with acute hepatitis with autoimmune features and can unmask autoimmune hepatitis (AIH) in people with silent AIH‐related CLD. Further studies on the safety (and efficacy) of untested but heavily promoted herbals in alternative systems of medicine are an unmet need in the interests of public health and are especially important during this global health emergency.

Progressive deterioration of liver functions for more than 6 months is considered Chronic liver disease (CLD). Hepatic fibrosis occurs in response to chronic liver injury. The gold standard for assessment of hepatic fibrosis is Liver biopsy, which is an invasive and painful procedure. and rarely can pass on potential life-threatening complications. Thus non-invasive tests that can correctly indicate the severity of liver fibrosis is essential. A number of non-invasive markers have been developed which are useful supplements to assess stages of fibrosis. These are biomarkers (aspartate transaminase (AST) to alanine transaminase (ALT) ratio (AAR), AST to Platelet Ratio Index (APRI), fibrosis index (FI), fibrosis-4 (FIB-4), Age Platelet Index (API), Pohl score, Fibrosis Cirrhosis Index (FCI)) and transient elastography. In our study, we will compare Novel Fibrosis Index (NFI) with other available noninvasive serum indices and transient elastography in predicting Liver Fibrosis Stages. NFI=[(bilirubin×(ALP)2)/ (platelet count (albumin)2)]-n, where n=2000 is a constant.MATERIALIn this study, a total of 142 cases of confirmed Chronic liver disease were included. All the patients underwent transient elastography and routine hematological and biochemical investigations. Fibrosis staging was done according to Metavir staging (F0-F4) using the fibroscan score. Then the serum indices for predicting liver fibrosis were calculated and compared for various fibrosis stages with Novel Fibrosis index.OBSERVATIONOut of 142 patients, the majority of the patients belonged to age above 40 years and were males(65%). The majority of the patients belonged to F4 fibrosis stage(77.4%) and the most common etiology of Chronic liver disease was Viral hepatitis(47%), the most common being Hepatitis B.The optimum cutoff of NFI for F4 stage was ≥6670 with a sensitivity of 75.8% and specificity of 81.8%. The optimum cutoff of NFI for F3 stage was ≥2112 with a sensitivity of 63.6% and specificity of 72.7%.%. The optimum cutoff of NFI for F2 stage was ≥1334 with a sensitivity of 100% and specificity of 5.3%.The NFI had maximum area under the curve compared to other indices in predicting F2,F3 and F4 stage.CONCLUSIONNFI was the best index in predicting various fibrosis stages in chronic liver disease patients compared to other available serum indices and had maximum accuracy in predicting F4 stage.

Background and aims : Body fluids such as saliva, tears and urine from patients with hepatitis B virus (HBV) infection are well known to be infectious. However, the infectivity of internal body fluids like ascitic fluid from patients with HBV infection has not been established. So, we conducted this study to know the infectivity of ascitic fluid for hepatitis B in decompensated cirrhosis by detecting HBV DNA in it. Methods: Patients with HBV related cirrhosis with ascites were enrolled. The levels of HBV DNA in the ascitic fluid from these patients were quantified by real-time PCR, and compared with HBV DNA levels in serum. Clinical and laboratory parameters to predict HBV DNA positivity in ascitic fluid were also assessed. Results : Twenty one patients (mean age 45.43±13 years) with HBV related cirrhosis with ascites were enrolled. HBV DNA in ascitic fluid was detected in 4/21 (19 %) patients. The ascitic fluid HBV DNA levels ranged from 4.8 to 6.4 log copies/mL (mean ± SD = 5.27 ± 0.55). High levels of serum HBV DNA was significantly associated with HBV DNA detectability in ascitic fluid (p=0.001). Patients with HBV DNA detected in ascitic fluid had significantly higher serum protein levels as compared to those having undetectable HBV DNA in ascitic fluid (6.83 ± 0.33 versus 5.70 ± 0.77 g/dl, p=0.011). Conclusions : HBV DNA is detectable in ascitic fluid in about one fifth of HBV related cirrhosis patients with ascites so it may not be considered an important source for HBV transmission. High serum HBV DNA and high serum protein levels were positively associated with HBV DNA detectability in ascitic fluid.

Dear Editor, Garg et al.,[1] suggest ways for strengthening the public healthcare system in India and emphasise to learn lessons in the ongoing Covid-19 pandemic in the Dec 2020 issue of the journal. Their analysis is based on the framework of six health system building blocks as proposed by the World Health Organization. Under a building block of ‘Health Service Delivery and Financing’, the authors highlight that design and creation of public facilities that ensure the health and well-being of inhabitants maintaining the standards of ventilation and lighting are essential. However, design of buildings of our newly constructed medical college and attached hospital leave a lot to this basic necessity. The newly constituted National Medical Commission regulates standards of medical education in our country and it runs its website. There it sets the minimum standard requirements for a medical college all over India. On logging on to that webpage, it shows that it was amended about two years ago. There on page number 5 under a point number A.1.4, the Commission sets the minimum requirements for having a central library in a medical college building.[2] There the regulatory body wants the library to be air conditioned. We wonder that in a poor country like ours, why should a regulatory body insist to have an air-conditioned library. Not only from the point of view of the best utilization of limited public resources for the maximum benefit of society, the requirement also has sustainability and health issues when it lacks concurrent ventilation standards. The Commission should think that from where a massive energy guzzler like central AC system draw energy if it’s working in a remote village which does not have in campus powerhouse. Although some power back-up is available there, how will it run as massive a machine such as a central AC, should have a pragmatic consideration. Now we are rapidly recognizing that a poorly designed ventilation system of a building wreaks havoc with the health of its occupants. Rajat Mittal et al.,[3] of Johns Hopkins University, Baltimore, US highlight that poorly constructed buildings increase the risk of aerosol transmission of Coronavirus. Rajesh K Bhagat et al.,[4] of University of Oxford, UK assess effects of ventilation on the indoor spread of Covid-19 in their research paper on Focus on Fluids. These authors argue that poorly ventilated places are considered to put us at high risk of propagation of airborne respiratory infections. Hospitals are common places where people usually visit when they catch some infection. And if design of the buildings is such that it does not remove pathogens in its ambience, it poses a risk for its all the occupants. Requirement of a central AC is a paradox in public places for our generation. Under Cop-15 Paris agreement, we promised to reduce our GHG emissions.[5] Whereas we are installing power hungry machines now in remote villages where we are establishing medical colleges. Our policy makers should put their heads together to consider that when a new mutated virus lurks in the air inside these buildings, what should be our best escape plan. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Background: Liver cirrhosis is among the leading causes of morbidity and mortality worldwide. Although liver biopsy is the gold standard for the assessment of liver fibrosis in cirrhosis, it has its own limitations. Therefore, noninvasive methods to detect liver fibrosis are widely preferred. However, they also have their own limitations. Thus, there is always a need to extend the battery of serum-based assays. Kallistatin is a protein synthesized primarily in the liver. As it is a negative acute-phase protein, its blood level decreases with a decline in liver function. In our study, we explored the relationship between serum kallistatin and radiological evidence of liver fibrosis by transient elastography to determine if kallistatin levels can be used as a diagnostic marker of liver fibrosis. Materials and Methods: A cross-sectional study of 1-year duration was conducted at a leading tertiary care hospital in northern India. Patients between 15 and 75 years of age having evidence of chronic liver disease were enrolled. All enrolled patients were evaluated by detailed history, physical examination, and relevant investigations. Serum kallistatin levels were quantified using the ELISA method. Grading of liver fibrosis was done using transient elastography. A FibroScan scoring card was used to convert FibroScan results measured in kPa into the Metavir scale F1–F4. Results: A total of 128 subjects, including 64 patients with cirrhosis and 64 healthy controls, were enrolled. Our study suggested that FibroScan values were significantly higher in cases as compared to controls. The kallistatin level of cases was significantly lower than that of controls. An inverse correlation was found between FibroScan value and kallistatin level among cases. Conclusion: We conclude that serum kallistatin levels are low in patients with liver fibrosis and can be used as a potential marker of liver fibrosis.