How to tackle rising rates of liver disease in the UK

The new chief medical officer for England’s first annual report in November 2012 highlighted that liver disease is a growing clinical burden and public health priority in the United Kingdom.1 Although death from liver disease is decreasing in other European populations, deaths from chronic liver disease and cirrhosis in the under 65s in England increased by around 20% from 2000 to 2009, making it the fifth leading cause of death (fig 1⇓). Because the major drivers of increasing liver disease are all potentially preventable (particularly high alcohol consumption, but also obesity and chronic hepatitis B and C infection), comprehensive action is clearly needed to deal with the problem.

Deaths caused by liver disease in under 65s. EU=European Union member countries before 20042 3

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What can healthcare practitioners do to help stem the rising tide of liver disease? The best way to promote optimum liver health is to facilitate behavioural change in those at risk. Every clinical encounter can be used—for example, to screen for alcohol use disorders or to look proactively for early signs of liver disease (rather than assuming that this is another stakeholder’s responsibility).

The current recommended upper limits for alcohol consumption for men and women are 3-4 units and 2-3 units per day, respectively, including at least two alcohol-free days. Consumption in excess of these levels is associated with death from liver disease at a population level. It is now also clear that brief interventions—such as information on the harms of alcohol overconsumption and advice on reducing harmful drinking, directed towards people at high risk,4 can reduce harmful drinking. Health professionals can use validated tools, such as the alcohol use disorders identification test, to screen for alcohol dependence and harmful drinking.5 Hence, it is important that the assessment of high risk alcohol consumption and behavioural counselling are performed routinely in relevant health settings, such as emergency departments and primary care, where they have been shown to be effective.6 Integrated alcohol treatment specialist teams in hospitals and the community also play a valuable role. These teams will require continued support and resources, as will research into evidence based treatments for those with alcoholic liver disease.

A large scale prospective study of middle aged women in the UK has provided evidence that obesity and excess alcohol consumption together provide “two hits” when it comes to the development of liver disease.7 However, it is now widely recognised that non-alcoholic fatty liver disease, associated with the metabolic syndrome, is an increasingly common cause of chronic liver dysfunction, accounting for at least a quarter of all secondary care referrals in a large prospective study.8 Raising awareness of non-alcoholic fatty liver disease, especially as cardiometabolic risk factors such as obesity and diabetes are already part of the quality outcomes framework, is important considering the substantial burden of this disease.

According to current estimates, more than 450 000 adults in England are infected chronically with hepatitis B or hepatitis C virus, both of which are associated with an increased risk of cirrhosis and hepatocellular cancer in later life.9 Serological testing for people in high risk groups (injecting drug users (current and past), sexual partners of infected people, and immigrants or ethnic groups in which hepatitis B or C is common) is crucial, because many chronically infected people are asymptomatic.9 Prevention of hepatitis B infection by vaccination (for example, in children at risk) already occurs in some groups, but no effective vaccine is currently available for the hepatitis C virus. However, exciting new drugs seem to be successful in clearing the hepatitis C virus, which now makes detection of silent infection even more important than before.10

It is important for general practitioners, doctors in all specialities, and associated health professionals to take responsibility for promoting their patients’ liver health. Although appropriate referral to specialists is important, education and clinical competence in the diagnosis and simple management of common liver diseases (such as alcohol related liver disease, viral hepatitis, and non-alcoholic fatty liver disease) will be paramount for non-specialists.9 For example, it is common for primary care practitioners to refer patients to a specialist on the basis of persistent liver enzyme abnormalities (such as raised serum alanine transferase).11 These are insensitive measures of the degree of liver injury, however, and do not necessarily reflect synthetic liver function. Instead, referral should be based on an assessment of factors that contribute to absolute risk of liver damage, such as alcohol intake, risk factors for viral hepatitis and non-alcoholic fatty liver disease, and signs of chronic liver disease.9 Novel solutions to configuring patient pathways for appropriate referrals to liver specialists for opinion and treatment may include evaluation of simple inexpensive tools for stratifying risk that would be accessible to every practitioner12 and the development of community clinics (moving the specialist into the population).

Although deaths from liver disease have increased across the whole of England and Wales, substantial inequalities exist. For example, rates in the north of England are higher than in the south, and this is thought to be driven mainly by excess consumption of alcohol (web fig). Striking rates of death from liver cirrhosis in Scotland have prompted concerted policy changes to tackle this, and prevention policies in England could also be targeted to areas of greatest disease burden.13 Of course, clinicians must play a role in advocating evidence based regulatory policies, such as alcohol marketing (particularly its price and availability).14 Nevertheless, greater awareness of the key responsibility that all health professionals have in their day jobs to detect risk factors and intervene early to prevent alcohol, viral, and obesity related liver disease is crucial if we are to tackle the UK’s growing burden of liver disease.