Climate change and liver diseases: from infectious disease dynamics to metabolic and malignant liver disorders, and sustainable healthcare solutions

i

This article has been updated. A Correction to this article was published on .

i

The Original Article was published on

i

The Original Article was published on

i

This article has been updated

i

This article was retracted on

i

This article has been updated

Abstract

Climate change (CC) affects our health in ways especially when it comes to liver diseases. Rising temperatures and changing weather patterns are altering the spread and severity of liver diseases. CC can affect health, especially liver diseases, in direct and indirect ways. Hepatic infections such as viral hepatitis and schistosomiasis, metabolic dysfunction-associated steatotic liver disease (MASLD), hepatocellular carcinoma, and acute on chronic liver failure (ACLF) are examples. The movement of infected individuals from areas where diseases are endemic, prompted by ecological disasters, introduces these diseases to previously unexposed regions. CC serves as an early warning for shifts and the necessity to re-evaluate hepatic diseases, which is crucial for health policymakers. Ambient temperature and its variability have a major influence on the pathogenesis of MASLD, demonstrating nonlinear exposure–response relationships. Long-term temperature exposure follows a reverse J-shaped pattern, while temperature variability shows a U-shaped association, with both extremes independently increasing disease susceptibility. Prolonged exposure to cold and fluctuations in temperature could worsen various liver diseases. Gaining a deeper insight into these CC-related risks for our patients and practice is essential to optimize their care both now and in the warmer temperatures ahead. Incorporating climate resilience into public health initiatives may aid in alleviating the growing prevalence of liver diseases linked to CC. Aside from increasing awareness, which should take precedence, there is a pressing need to investigate innovative ways to frame the educational message and eliminate financial incentives that contribute to environmental damage. Common climate strategies for healthcare systems include reducing and managing waste, utilizing cleaner and less energy, offering and endorsing planet-friendly food options, and addressing transportation issues related to

CHANGE HISTORY

A Correction to this paper has been published:
https://doi.org

The Retraction Note was updated to reflect reception of statements of disagreement from all authors.

This article has been retracted.Please see the Retraction Notice for more detail:
https://doi.org

References

[1] Romanello M, McGushin A, Di Napoli C, Drummond P, Hughes N, Jamart L, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. Lancet. 2021; 398: 1619-62.

[2] Ribeiro T, Macedo G. Climate change and liver disease: a mini review. Front Gastroenterol (Lausanne). 2024; 3: 1334877.

[3] COP26 special report on climate change and health: the health argument for climate action [Internet]. WHO; c2026 [cited 2025 Dec 3]. Available from: https://www.who.int/publications/i/item/9789240036727

[4] Climate change 2022: impacts, adaptation and vulnerability [Internet]. [cited 2025 Dec 3]. Available from: https://www.ipcc.ch/report/ar6/wg2/

[5] Emissions pathways to 2011 [Internet]. [cited 2025 Dec 3]. Available from: https://climateactiontracker.org/global/emissions-pathways/

[6] Intergovernmental Panel on Climate Change (IPCC), editor. Climate Change 2022-Impacts, Adaptation and Vulnerability: Working Group II Contribution to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge: Cambridge University Press; 2022.

[7] UN75: Shaping our future together [Internet]. [cited 2025 Dec 16]. Available from: https://www.un.org/en/un75/finalreport

[8] Meinshausen M, Lewis J, McGlade C, Gütschow J, Nicholls Z, Burdon R, et al. Realization of Paris Agreement pledges may limit warming just below 2°C. Nature. 2022; 604: 304-9.

[9] Matthews HD, Wynes S. Current global efforts are insufficient to limit warming to 1.5°C. Science. 2022; 376: 1404-9.

[10] Romanello M, Walawender M, Hsu SC, Moskeland A, Palmeiro-Silva Y, Scamman D, et al. The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. Lancet. 2024; 404: 1847-96.

[11] Exposure to household air pollution for 2017 [Internet]. [cited 2025 Dec 16]. Available from: https://cdn.who.int/media/docs/default-source/air-pollution-documents/air-quality-and-health/2017_hap_exposure_results_final.pdf?sfvrsn=3e6daedf_3

[12] Mar KA, Unger C, Walderdorff L, Tim Butler T. Beyond CO₂ equivalence: The impacts of methane on climate, ecosystems, and health. Environ Sci Policy. 2022; 134: 127-36.

[13] Bera M, Nag PK. Global research trends on climate change-induced heat stress and its impacts on health and productivity of outdoor workers: a systematic review. Theor Appl Climatol. 2026; 157: 1.

[14] Kjellstrom T, Freyberg C, Lemke B, Otto M, Briggs D. Estimating population heat exposure and impacts on working people in conjunction with climate change. Int J Biometeorol. 2018; 62: 291-306.

[15] Flouris AD, Dinas PC, Ioannou LG, Nybo L, Havenith G, Kenny GP, et al. Workers’ health and productivity under occupational heat strain: a systematic review and meta-analysis. Lancet Planet Health. 2018; 2: e521-31.

[16] Working on a warmer planet: The impact of heat stress on productivity and decent work [Internet]. Geneva: International Labour Organization (ILO); c1996-2026. [cited 2025 Dec 16]. Available from: https://www.ilo.org/publications/major-publications/working-warmer-planet-effect-heat-stress-productivity-and-decent-work

[17] Chevance G, Minor K, Vielma C, Campi E, O’Callaghan-Gordo C, Basagaña X, et al. A systematic review of ambient heat and sleep in a warming climate. Sleep Med Rev. 2024; 75: 101915.

[18] Ebi KL, Capon A, Berry P, Broderick C, de Dear R, Havenith G, et al. Hot weather and heat extremes: health risks. Lancet. 2021; 398: 698-708.

[19] Vrijheid, M. Understanding environmental exposures in early life for lifelong health. Nat Health. 2026; 1: 777-80.

[20] Sulser T, Wiebe KD, Dunston S, Cenacchi N, Nin-Pratt A, Mason-D’Croz D, et al., editors. Climate change and hunger: Estimating costs of adaptation in the agri-food system. International Food Policy Research Institute; 2021.

[21] Healy JP, Castro E, Danesh Yazdi M, Rice MB, Chang H, Steenland K, et al. Heat waves and annual mortality among older adults (aged ≥65 years) in the USA. Lancet Planet Health. 2026; 10: 101432.

[22] van Daalen KR, Tonne C, Semenza JC, Rocklöv J, Markandya A, Dasandi N, et al. The 2024 Europe report of the Lancet Countdown on health and climate change: unprecedented warming demands unprecedented action. Lancet Public Health. 2024; 9: e495-522.

[23] van Daalen K, Jung L, Dhatt R, Phelan AL. Climate change and gender-based health disparities. Lancet Planet Health. 2020; 4: e44-5.

[24] Karlsen TH, Sheron N, Zelber-Sagi S, Carrieri P, Dusheiko G, Bugianesi E, et al. The EASL-Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality. Lancet. 2022; 399: 61-116.

[25] World report on the health of refugees and migrants: summary [Internet]. WHO; c2026. [cited 2025 Dec 16]. Available from: https://www.who.int/publications/i/item/9789240054462

[26] Kälin W, Weerasinghe S. Environmental migrants and global governance: facts, policies and practices. In: IOM, editor. Migration Research Leaders’ Syndicate. Geneva: International Organization for Migration; 2017. pp. 37-47.

[27] Myran DT, Morton R, Biggs BA, Veldhuijzen I, Castelli F, Tran A, et al. The Effectiveness and Cost-Effectiveness of Screening for and Vaccination Against Hepatitis B Virus among Migrants in the EU/EEA: A Systematic Review. Int J Environ Res Public Health. 2018; 15: 1898.

[28] Ballester J, Quijal-Zamorano M, Méndez Turrubiates RF, Pegenaute F, Herrmann FR, Robine JM, et al. Heat-related mortality in Europe during the summer of 2022. Nat Med. 2023; 29: 1857-66.

[29] Willow Master Development Plan Supplemental Environmental Impact Statement [Internet]. [cited 2026 May 16]. Available from: https://eplanning.blm.gov/Project-Home/?id=f07b7ab1-a7f2-f011-8407-001dd80b1f5f

[30] Asrani SK, Devarbhavi H, Eaton J, Kamath PS. Burden of liver diseases in the world. J Hepatol. 2019; 70: 151-71.

[31] Devarbhavi H, Asrani SK, Arab JP, Nartey YA, Pose E, Kamath PS. Global burden of liver disease: 2023 update. J Hepatol. 2023; 79: 516-37.

[32] Orru H, Ebi KL, Forsberg B. The Interplay of Climate Change and Air Pollution on Health. Curr Environ Health Rep. 2017; 4: 504-13.

[33] Xu J, Wang Q, Anikeeva O, Zhu P, Bi P, Huang C. Effects of extreme heat on physiology, morbidity, and mortality under climate change: mechanisms and clinical implications. BMJ. 2025; 391: e084675.

[34] Mora C, Counsell CWW, Bielecki CR, Louis LV. Twenty-Seven Ways a Heat Wave Can Kill You: Deadly Heat in the Era of Climate Change. Circ Cardiovasc Qual Outcomes. 2017; 10: e004233.

[35] Vergunst F, Berry HL, Minor K, Chadi N. Climate Change and Substance-Use Behaviors: A Risk-Pathways Framework. Perspect Psychol Sci. 2023; 18: 936-54.

[36] Iaccarino J, Mignini I, Maresca R, Giansanti G, Esposto G, Borriello R, et al. The Impact of Air Pollution on the Lung-Gut-Liver Axis: Oxidative Stress and Its Role in Liver Disease. Antioxidants (Basel). 2025; 14: 1148.

[37] Malig BJ, Wu XM, Guirguis K, Gershunov A, Basu R. Associations between ambient temperature and hepatobiliary and renal hospitalizations in California, 1999 to 2009. Environ Res. 2019; 177: 108566.

[38] Melaram R. Environmental Risk Factors Implicated in Liver Disease: A Mini-Review. Front Public Health. 2021; 9: 683719.

[39] Law AV, Sakharkar P, Zargarzadeh A, Tai BW, Hess K, Hata M, et al. Taking stock of medication wastage: Unused medications in US households. Res Social Adm Pharm. 2015; 11: 571-8.

[40] Or Z, Seppänen AV. The role of the health sector in tackling climate change: A narrative review. Health Policy. 2024; 143: 105053.

[41] Bosurgi R. Climate crisis: healthcare is a major contributor, global report finds. BMJ. 2019; 366: l5560.

[42] Lacroute J, Marcantoni J, Petitot S, Weber J, Levy P, Dirrenberger B, et al. The carbon footprint of ambulatory gastrointestinal endoscopy. Endoscopy. 2023; 55: 918-26.

[43] Janik-Karpinska E, Brancaleoni R, Niemcewicz M, Wojtas W, Foco M, Podogrocki M, et al. Healthcare Waste-A Serious Problem for Global Health. Healthcare (Basel). 2023; 11: 242.

[44] The CAT thermometer explained [Internet]. Climate Analytics and New Climate Institute.; c2025 [cited 2025 Dec 19]. Available from: https://climateactiontracker.org/global/cat-thermometer/

[45] Whitmee S, Green R, Belesova K, Hassan S, Cuevas S, Murage P, et al. Pathways to a healthy net-zero future: report of the Lancet Pathfinder Commission. Lancet. 2024; 403: 67-110.

[46] Mora C, McKenzie T, Gaw IM, Dean JM, Hvon Hammerstein H, Knudson TA, et al. Over half of known human pathogenic diseases can be aggravated by climate change. Nat Clim Chang. 2022; 12: 869-75.

[47] Mills JN, Gage KL, Khan AS. Potential influence of climate change on vector-borne and zoonotic diseases: a review and proposed research plan. Environ Health Perspect. 2010; 118: 1507-14.

[48] Tambo E, Chen JH, Zhou XN, Khater EI. Outwitting dengue threat and epidemics resurgence in Asia-Pacific countries: strengthening integrated dengue surveillance, monitoring and response systems. Infect Dis Poverty. 2016; 5: 56.

[49] Lindh E, Argentini C, Remoli ME, Fortuna C, Faggioni G, Benedetti E, et al. The Italian 2017 Outbreak Chikungunya Virus Belongs to an Emerging Aedes albopictus-Adapted Virus Cluster Introduced From the Indian Subcontinent. Open Forum Infect Dis. 2018; 6: ofy321.

[50] Calba C, Guerbois-Galla M, Franke F, Jeannin C, Auzet-Caillaud M, Grard G, et al. Preliminary report of an autochthonous chikungunya outbreak in France, July to September 2017. Euro Surveill. 2017; 22: 17-00647.

[51] Paaijmans KP, Blanford S, Bell AS, Blanford JI, Read AF, Thomas MB. Influence of climate on malaria transmission depends on daily temperature variation. Proc Natl Acad Sci U S A. 2010; 107: 15135-9.

[52] Gao L, Zhang Y, Ding G, Liu Q, Wang C, Jiang B. Projections of hepatitis A virus infection associated with flood events by 2020 and 2030 in Anhui Province, China. Int J Biometeorol. 2016; 60: 1873-84.

[53] Dengue-global situation [Internet]. WHO; c2026 [cited 2024 Dec 21]. Available from: https://www.who.int/emergencies/disease-outbreak-news/item/2023-DON498

[54] Stanaway JD, Shepard DS, Undurraga EA, Halasa YA, Coffeng LE, Brady OJ, et al. The global burden of dengue: an analysis from the Global Burden of Disease Study 2013. Lancet Infect Dis. 2016; 16: 712-23.

[55] Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, Moyes CL, et al. The global distribution and burden of dengue. Nature. 2013; 496: 504-7.

[56] Clarke J, Lim A, Gupte P, Pigott DM, van Panhuis WG, Brady OJ. A global dataset of publicly available dengue case count data. Sci Data. 2024; 11: 296.

[57] Rocklöv J, Tozan Y. Climate change and the rising infectiousness of dengue. Emerg Top Life Sci. 2019; 3: 133-42.

[58] Kraemer MUG, Reiner RC Jr, Brady OJ, Messina JP, Gilbert M, Pigott DM, et al. Past and future spread of the arbovirus vectors Aedes aegypti and Aedes albopictus. Nat Microbiol. 2019; 4: 854-63.

[59] Data and Statistics on Dengue in the United States [Internet]. [cited 2025 Dec 22]. Available from: https://www.cdc.gov/dengue/data-research/facts-stats/index.html

[60] Brown JJ, Pascual M, Wimberly MC, Johnson LR, Murdock CC. Humidity-The overlooked variable in the thermal biology of mosquito-borne disease. Ecol Lett. 2023; 26: 1029-49.

[61] Siraj AS, Santos-Vega M, Bouma MJ, Yadeta D, Ruiz Carrascal D, Pascual M. Altitudinal changes in malaria incidence in highlands of Ethiopia and Colombia. Science. 2014; 343: 1154-8.

[62] Lyon B, Dinku T, Raman A, Thomson MC. Temperature suitability for malaria climbing the Ethiopian Highlands. Environ Res Lett. 2017; 12: 064015.

[63] Grover-Kopec EK, Blumenthal MB, Ceccato P, Dinku T, Omumbo JA, Connor SJ. Web-based climate information resources for malaria control in Africa. Malar J. 2006; 5: 38.

[64] Heidecke J, Lavarello Schettini A, Rocklöv J. West Nile virus eco-epidemiology and climate change. PLOS Clim. 2023; 2: e0000129.

[65] Erazo D, Grant L, Ghisbain G, Marini G, Colón-González FJ, Wint W, et al. Contribution of climate change to the spatial expansion of West Nile virus in Europe. Nat Commun. 2024; 15: 1196.

[66] Baker RE, Mahmud AS, Miller IF, Rajeev M, Rasambainarivo F, Rice BL, et al. Infectious disease in an era of global change. Nat Rev Microbiol. 2022; 20: 193-205.

[67] Walker RJ, Kingpriest PT, Gong J, Naisanga M, Ashraf MN, Roberti J, et al. Global perspectives on infectious diseases at risk of escalation and their drivers. Sci Rep. 2025; 15: 38630.

[68] Dupke S, Buchholz U, Fastner J, Förster C, Frank C, Lewin A, et al. Impact of climate change on waterborne infections and intoxications. J Health Monit. 2023; 8: 62-77.

[69] Froelich BA, Daines DA. In hot water: effects of climate change on Vibrio-human interactions. Environ Microbiol. 2020; 22: 4101-11.

[70] Archer EJ, Baker-Austin C, Osborn TJ, Jones NR, Martínez-Urtaza J, Trinanes J, et al. Climate warming and increasing Vibrio vulnificus infections in North America. Sci Rep. 2023; 13: 3893.

[71] Su X, Zheng L, Zhang H, Shen T, Liu Y, Hu X. Secular Trends of Acute Viral Hepatitis Incidence and Mortality in China, 1990 to 2019 and Its Prediction to 2030: The Global Burden of Disease Study 2019. Front Med (Lausanne). 2022; 9: 842088.

[72] Hepatitis E virus-Republic of South Sudan [Internet]. WHO; c2026 [cited 2025 Nov 19]. Available from: https://www.who.int/emergencies/disease-outbreak-news/item/hepatitis-e-virus-republic-of-south-sudan

[73] Modabbernia G, Meshgi B, Kinsley AC. Climatic variations and Fasciola: a review of impacts across the parasite life cycle. Parasitol Res. 2024; 123: 300.

[74] Zanaty N, Ibrahim N, Ramadan HK, Ahmad AA, Saad-Hussein A. Significance of climate change in the emergence of human fascioliasis in Upper Egypt. Trop Dis Travel Med Vaccines. 2024; 10: 24.

[75] Karanasiou A, Moreno N, Moreno T, Viana M, de Leeuw F, Querol X. Health effects from Sahara dust episodes in Europe: literature review and research gaps. Environ Int. 2012; 47: 107-14.

[76] Ramalli L, Mulero S, Noël H, Chiappini JD, Vincent J, Barré-Cardi H, et al. Persistence of schistosomal transmission linked to the Cavu river in southern Corsica since 2013. Euro Surveill. 2018; 23: 18-00017.

[77] Fox NJ, White PCL, McClean CJ, Marion G, Evans A, Hutchings MR. Predicting impacts of climate change on Fasciola hepatica risk. PLoS One. 2011; 6: e16126.

[78] Stensgaard AS, Vounatsou P, Sengupta ME, Utzinger J. Schistosomes, snails and climate change: Current trends and future expectations. Acta Trop. 2019; 190: 257-68.

[79] McCreesh N, Nikulin G, Booth M. Predicting the effects of climate change on Schistosoma mansoni transmission in eastern Africa. Parasit Vectors. 2015; 8: 4.

[80] De Leo GA, Stensgaard AS, Sokolow SH, N’Goran EK, Chamberlin AJ, Yang GJ, et al. Schistosomiasis and climate change. BMJ. 2020; 371: m4324.

[81] Yang GJ, Bergquist R. Potential Impact of Climate Change on Schistosomiasis: A Global Assessment Attempt. Trop Med Infect Dis. 2018; 3: 117.

[82] da Silva BM, Ferreira AF, Silva JAMd, da Amorim RG, Domingues ALC, Pinheiro MCC, et al. High schistosomiasis-related mortality in Northeast Brazil: trends and spatial patterns. Rev Soc Bras Med Trop. 2022; 55: e0431.

[83] Scholte RGC, Gosoniu L, Malone JB, Chammartin F, Utzinger J, Vounatsou P. Predictive risk mapping of schistosomiasis in Brazil using Bayesian geostatistical models. Acta Trop. 2014; 132: 57-63.

[84] Younossi ZM, Koenig AB, Abdelatif D, Fazel Y, Henry L, Wymer M. Global epidemiology of nonalcoholic fatty liver disease-Meta-analytic assessment of prevalence, incidence, and outcomes. Hepatology. 2016; 64: 73-84.

[85] Riazi K, Azhari H, Charette JH, Underwood FE, King JA, Afshar EE, et al. The prevalence and incidence of NAFLD worldwide: a systematic review and meta-analysis. Lancet Gastroenterol Hepatol. 2022; 7: 851-61.

[86] Swinburn BA, Kraak VI, Allender S, Atkins VJ, Baker PI, Bogard JR, et al. The Global Syndemic of Obesity, Undernutrition, and Climate Change: The Lancet Commission report. Lancet. 2019; 393: 791-846.

[87] Wheeler T, von Braun J. Climate change impacts on global food security. Science. 2013; 341: 508-13.

[88] Trentinaglia MT, Parolini M, Donzelli F, Olper A. Climate change and obesity: a global analysis. Glob Food Secur. 2021; 29: 100539.

[89] Farrell P, Thow AM, Abimbola S, Faruqui N, Negin J. How food insecurity could lead to obesity in LMICs: When not enough is too much: a realist review of how food insecurity could lead to obesity in low- and middle-income countries. Health Promot Int. 2018; 33: 812-26.

[90] McLaren DS, Bitar JG, Nassar VH. Protein-calorie malnutrition and the liver. Prog Liver Dis. 1972; 4: 527-36.

[91] Devi MJ, Malhotra A, Ranjan P, Sabharwal M, Byloppilly G. MASLD in the next generation: metabolic and lifestyle factors shaping the disease in young adults. Int J Health Sci Res. 2025; 15: 79-92.

[92] Donnelly MC, Stableforth W, Krag A, Reuben A. The Negative Bidirectional Interaction Between Climate Change and the Prevalence and Care of Liver Disease: A Joint BSG, BASL, EASL, and AASLD Commentary. Gastroenterology. 2022; 162: 1561-7.

[93] Shi L, Du X, Liu H, Chen X, Ma Y, Wang R, et al. Update on the adverse effects of microcystins on the liver. Environ Res. 2021; 195: 110890.

[94] Wang Y, Gao X, Wang Q, Li Y, Li Q, Xing Y, et al. Nonlinear climate-Liver gradients: Non-optimal temperature and variability increase risk of metabolic dysfunction-associated steatotic liver disease. Glob Transit. 2026; 8: 259-68.

[95] Wu Y, Li S, Zhao Q, Wen B, Gasparrini A, Tong S, et al. Global, regional, and national burden of mortality associated with short-term temperature variability from 2000-19: a three-stage modelling study. Lancet Planet Health. 2022; 6: e410-21.

[96] Straat ME, Jurado-Fasoli L, Ying Z, Nahon KJ, Janssen LGM, Boon MR, et al. Cold exposure induces dynamic changes in circulating triacylglycerol species, which is dependent on intracellular lipolysis: A randomized cross-over trial. EBioMedicine. 2022; 86: 104349.

[97] Lei T, Hua H, Du H, Xia J, Xu D, Liu W, et al. Molecular mechanisms of artificial light at night affecting circadian rhythm disturbance. Arch Toxicol. 2024; 98: 395-408.

[98] Meléndez-Fernández OH, Liu JA, Nelson RJ. Circadian Rhythms Disrupted by Light at Night and Mistimed Food Intake Alter Hormonal Rhythms and Metabolism. Int J Mol Sci. 2023; 24: 3392.

[99] Araneda OF, Carbonell T, Tuesta M. Update on the Mechanisms of Pulmonary Inflammation and Oxidative Imbalance Induced by Exercise. Oxid Med Cell Longev. 2016; 2016: 4868536.

[100] Romanos M, Garcia Cordova JM, Villamarin J, Pazmino Zurita JD, Acosta A. Obesity and Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD): A Literature Review on Pathophysiology and Treatment. Diabetes Obes Metab. 2026; 28: 19-30.

[101] Liew WP, Mohd-Redzwan S. Mycotoxin: Its Impact on Gut Health and Microbiota. Front Cell Infect Microbiol. 2018; 8: 60.

[102] Gan T, Bambrick H, Ebi KL, Hu W. Does global warming increase the risk of liver cancer in Australia? Perspectives based on spatial variability. Sci Total Environ. 2023; 859: 160412.

[103] Horvatits T, Tamminga M, Liu B, Sebode M, Carambia A, Fischer L, et al. Microplastics detected in cirrhotic liver tissue. EBioMedicine. 2022; 82: 104147.

[104] Pedersen M, Andersen ZJ, Stafoggia M, Weinmayr G, Galassi C, Sørensen M, et al. Ambient air pollution and primary liver cancer incidence in four European cohorts within the ESCAPE project. Environ Res. 2017; 154: 226-33.

[105] Lin S, Han L, Li D, Wang T, Wu Z, Zhang H, et al. The Association between Meteorological Factors and the Prevalence of Acute-on-chronic Liver Failure: A Population-based Study, 2007-2016. J Clin Transl Hepatol. 2019; 7: 341-5.

[106] McMillin M. Can Weather Influence the Prevalence of Acute-on-chronic Liver Failure? J Clin Transl Hepatol. 2019; 7: 285-6.

[107] Žūkienė R, Naučienė Z, Šilkūnienė G, Vanagas T, Gulbinas A, Zimkus A, et al. Contribution of mitochondria to injury of hepatocytes and liver tissue by hyperthermia. Medicina (Kaunas). 2017; 53: 40-9.

[108] Fadhlillah F, Turner J, Reddy U. Therapeutic hypothermia and acute brain injury. Anaest Intens Care M. 2022; 23: 760-3.

[109] Fani Marvasti F, Stafford RS. From sick care to health care-reengineering prevention into the U.S. system. N Engl J Med. 2012; 367: 889-91.

[110] The 90% Prevention Rule: Simple Steps to Protect Your Liver Health [Internet]. London: Leaders in Liver Health; c2025 [cited 2026 Mar 7]. Available from: https://www.leadersinliverhealth.com/liver-disease-prevention-90-percent-preventable/

[111] Wyper GMA, Mackay DF, Fraser C, Lewsey J, Robinson M, Beeston C, et al. Evaluating the impact of alcohol minimum unit pricing on deaths and hospitalisations in Scotland: a controlled interrupted time series study. Lancet. 2023; 401: 1361-70.

[112] Hudson B, Round J, Georgeson B, Pring A, Forbes K, McCune CA, et al. Cirrhosis with ascites in the last year of life: a nationwide analysis of factors shaping costs, health-care use, and place of death in England. Lancet Gastroenterol Hepatol. 2018; 3: 95-103.

[113] Springmann M, Wiebe K, Mason-D’Croz D, Sulser TB, Rayner M, Scarborough P. Health and nutritional aspects of sustainable diet strategies and their association with environmental impacts: a global modelling analysis with country-level detail. Lancet Planet Health. 2018; 2: e451-61.

[114] Mazidi M, Kengne AP. Higher adherence to plant-based diets are associated with lower likelihood of fatty liver. Clin Nutr. 2019; 38: 1672-7.

[115] Sung KC, Ryu S, Lee JY, Kim JY, Wild SH, Byrne CD. Effect of exercise on the development of new fatty liver and the resolution of existing fatty liver. J Hepatol. 2016; 65: 791-7.

[116] Brand C, Götschi T, Dons E, Gerike R, Anaya-Boig E, Avila-Palencia I, et al. The climate change mitigation impacts of active travel: evidence from a longitudinal panel study in seven European cities. Glob Environ Chang. 2021; 67: 102224.

[117] Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT-Lancet Commission on healthy diets from sustainable food systems. Lancet. 2019; 393: 447-92.

[118] Greening the OR [Internet]. Practice Greenhealth; c2025 [cited 2025 Dec 19]. Available from: https://practicegreenhealth.org/topics/greening-operating-room/greening-or

[119] MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planet Health. 2017; 1: e381-8.

[120] Baddeley R, Aabakken L, Veitch A, Hayee B. Green Endoscopy: Counting the Carbon Cost of Our Practice. Gastroenterology. 2022; 162: 1556-60.

[121] Vaccari M, Tudor T, Perteghella A. Costs associated with the management of waste from healthcare facilities: An analysis at national and site level. Waste Manag Res. 2018; 36: 39-47.

[122] Namburar S, von Renteln D, Damianos J, Bradish L, Barrett J, Aguilera-Fish A, et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut. 2022; 71: 1326-31.

[123] Sheffield KM, Han Y, Kuo YF, Riall TS, Goodwin JS. Potentially inappropriate screening colonoscopy in Medicare patients: variation by physician and geographic region. JAMA Intern Med. 2013; 173: 542-50.

[124] Meshram KK. The circular economy, 5R framework, and green organic practices: pillars of sustainable development and zero-waste living. Discov Environ. 2024; 2: 147.

[125] Sharif K, de Santiago ER, David P, Afek A, Gralnek IM, Ben-Horin S, et al. Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape. Lancet Gastroenterol Hepatol. 2024; 9: 550-63.

[126] Yong KK, He Y, Cheung HCA, Sriskandarajah R, Jenkins W, Goldin R, et al. Rationalising the use of specimen pots following colorectal polypectomy: a small step towards greener endoscopy. Frontline Gastroenterol. 2022; 14: 295-9.

[127] Pal P, Mateen MA, Pooja K, Marri UK, Gupta R, Tandan M, et al. Leveraging existing mid-end ultrasound machine for point-of-care intestinal ultrasound in low-resource settings: Prospective, real-world impact on clinical decision-making. Aliment Pharmacol Ther. 2024; 60: 633-47.

[128] de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Faculty BV, et al. Baveno VII-Renewing consensus in portal hypertension. J Hepatol. 2022; 76: 959-74.

[129] Eckelman MJ, Huang K, Lagasse R, Senay E, Dubrow R, Sherman JD. Health Care Pollution And Public Health Damage In The United States: An Update. Health Aff (Millwood). 2020; 39: 2071-9.

[130] Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019; 322: 1501-9.

[131] Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med. 2020; 382: 1679-81.

[132] Pradeep A, Barker F, Ramos K, Littlejohn W, Tavabie OD, Nicholson C, et al. Virtual liver transplant assessment: a novel pathway that is likely safe, effective and optimises access to transplantation. Frontline Gastroenterol. 2021; 13: 360-2.

[133] Eqbal A, Wickremeratne T, Turner S, Higgins SE, Sloss A, Mitchell J, et al. One-stop shop for variceal surveillance: integration of unsedated ultrathin endoscopy into the routine clinic visit. Frontline Gastroenterol. 2021; 12: 545-9.

[134] Hartl L, Semmler G, Hofer BS, Schirwani N, Jachs M, Simbrunner B, et al. COVID-19-Related Downscaling of In-Hospital Liver Care Decreased Patient Satisfaction and Increased Liver-Related Mortality. Hepatol Commun. 2021; 5: 1660-75.