Kieron Lim | Senior Consultant, Gastroenterology & Hepatology; Director, Mount Elizabeth Hospital Liver Transplant Program, Mount Elizabeth Hospital, Singapore; Visiting Consultant, National University Hospital Singapore
Was there a defining moment, or series of moments, during your medical degree at St Bart’s in London, that influenced your decision to pursue a medical career within the field of hepatology and gastroenterology?
Without a doubt – it was Prof Parveen Kumar. We had a lecture during our pre-clinical undergraduate years on gastrointestinal bleeding from Prof Parveen Kumar. She brought in a bucket of ‘melena’ and asked for volunteers who would take a look and a ‘whiff’. I thought that was a very impactful way of introducing the topic to us! I was fortunate to have her as my consultant when I was a medical student and again as a House Officer. Her passion for gastroenterology and teaching inspired me and piqued my own interest in gastroenterology. Our paths were destined to cross again years later in Singapore during the postgraduate MRCP exams where Kumar was the external examiner. At our first meeting I was a trainee registrar helping to organise the exams. At our second meeting I had ‘evolved’ to become the Head of Gastroenterology at the National University Hospital in Singapore and was a fellow co-examiner. She had the same energy and passion when she spoke, commanding deep respect and admiration from her audience. I never fail to ask her what was really in the bucket that she brought into the lecture theatre… and she never fails to answer with just a cheeky laugh!
Since you started your medical career, how has the approach and attitude changed to interdisciplinary care in hepatology?
It has evolved tremendously to the benefit of our patients. Doctors and health professionals from different specialties are now more willing to discuss and proactively co-manage these complex liver patients. This is best seen in the context of multidisciplinary team (MDT) meetings for tumour boards and liver transplant listing meetings. Each member of the MDT can provide their input and share important perspectives about our patients’ care. Indeed, there are published literature to show that hepatocellular carcinoma (HCC) patients have superior outcomes if an MDT approach is adopted.
How has research progressed in recent years to improve the prognosis of HCC?
Research in the field of HCC has enabled us to better understand the molecular signatures, tumour biology, and hence treatments that translate to patient outcome and survival. It further drives home the fact that HCC is a complex disease: having to treat both the cancer and in most cases the underlying liver cirrhosis and the associated complications. It is worth mentioning that the proliferation of data and approved therapies for advanced HCC has also provided clinicians with more treatment options to offer our patients.
How has your research and work in the field of liver transplantation contributed to the advancements and recent innovations we see today?
I have been fortunate to have been involved in a few clinical trials and studies looking at various aspects of liver transplantation and immunosuppression. The results achieved and experience gained have helped to deepen the understanding in: firstly, immunosuppression and post-transplant metabolic complications; secondly, the role of mTORs in liver recipients; and thirdly, hepatitis E in transplant recipients of Asian heritage.
What do you think the future holds for non-alcoholic fatty liver disease (NAFLD) treatment, and what particular treatment advances would you like to see?
I think treatments for NAFLD/non-alcoholic steatohepatitis (NASH) will be as game-changing as the direct-acting antiviral agents were for hepatitis C virus (HCV). In fact, I think drug development for NAFLD/NASH will be bigger than for HCV, from the sheer number of individuals around the world with NAFLD/NASH. The data has established that NAFLD/NASH affects 20–40% of the world’s population and is the fasting rising indication for liver transplantation. I hope that we will soon have effective therapies that can not only prevent the progression of NAFLD/NASH to cirrhosis but effectively result in regression to a normal and healthy liver.
You recently published a paper on the management of patients with liver disease during the COVID-19 pandemic; what are the main considerations and your recommendations to doctors treating these patients in the pandemic?
COVID-19 has impacted everyone around the world. The situation is fluid as evidenced by recurrent waves and emerging variant strains. Despite the availability of multiple vaccines, the pandemic rages on in various parts of the world. Liver patients, especially those with advanced disease, liver transplant recipients, and those with hepatobiliary cancer, are at increased risk for a severe disease course of COVID-19. As advised by recommendations from multiple professional bodies and societies, the benefits of the COVID-19 vaccination greatly outweigh the risks. My recommendations to both healthcare colleagues and patients are to get vaccinated when the opportunity arises, continue to take the necessary precautions even after vaccination, and seek medical attention early if you feel unwell. Indeed, no one is safe until the whole world is safe.
You have worked in the UK, USA, and Singapore; can you discuss how the working environments differ? What have you learnt from the different cultures in regard to treatment innovation and patient care that you apply to your work today?
This is a tricky question to answer as all three countries have different healthcare systems. However, I have had the privilege of working in tertiary centres with ‘giants’ in the field of hepatology as mentors and colleagues. The opportunity to learn from these mentors in their respective institutions has shaped my outlook and attitude in clinical and academic medicine. I usually never name-drop, but I will take great pride in doing so here: Profs Geoffrey Dusheiko (Royal Free London), Scott Friedman and Thomas Schiano (Mount Sinai New York), and Lim Seng Gee (National University Hospital Singapore) all imparted knowledge, experience, and an ethos that are truly invaluable. Their vision and leadership are evident in their academic and clinical achievements. They have taught me to ask the right clinical and research questions and to be a strong advocate for our liver patients. I try not to lose sight of those pearls when the going gets tough!
You are actively involved with postgraduate education and the training of future specialists; if you could give one piece of advice to your younger self as an aspiring medical student, what would it be and why?
I would have two pearls of wisdom are enjoy medical school as life will get tougher as you progress through postgraduate training; and learn to manage your time well as we cannot bring back those missed moments in life.