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Editorial| Volume 63, ISSUE 2, P297-299, August 2015

Liver disease in the UK: Startling findings & urgent need for action

  • Roger Williams
    Correspondence
    Address: Institute of Hepatology, 69-75 Chenies Mews, London C1E 6HX, United Kingdom. Tel.: +44 207 2559832; fax: +44 207 3800405.
    Affiliations
    Institute of Hepatology, London & Foundation for Liver Research, United Kingdom
    Search for articles by this author
Open AccessPublished:April 30, 2015DOI:https://doi.org/10.1016/j.jhep.2015.04.022

      Abbreviations:

      EASL (European Association for Study of the Liver), NCEPOD (National Confidential Enquiry into Patient Outcomes and Death), NAFLD (Non-alcoholic Fatty Liver Disease), HCV (Hepatitis C Virus), HBV (hepatitis B virus), DGH (district general hospitals), AST/ALT (aspartate/alanine transaminase), WHO (World Health Authority)

      Keywords

      The report of the Lancet Commission [
      Lancet Commission Report. Addressing liver disease in the UK: a blueprint for attaining excellence in healthcare and reducing premature mortality from lifestyle issues of excess consumption of alcohol, obesity and viral hepatitis.
      ] published in the Lancet on November 27th 2014, makes for interesting reading. It was entitled “Addressing the Crisis of Liver Disease in the UK: A blueprint for obtaining excellence in healthcare for liver disease and reducing premature mortality from the major lifestyle issues of excess alcohol consumption, obesity and viral hepatitis”. The findings in the UK are also relevant to current concerns over liver disease in Europe. An important milestone at the European policy level is the launch in the European Parliament [] last month, by the European Association for the Study of the Liver (EASL), of the ‘Research Roadmap for Liver Disease’ (HEPAMAP). In 2013, 29 million people in the EU were documented as suffering from a chronic liver condition and HEPAMAP identifies opportunities to significantly reduce liver mortality and decrease the burden of liver conditions in the EU by the end of 2020, with particular emphasis on tackling alcohol- and obesity-related liver conditions with evidence-based policy measures.
      The recommendations of the Lancet report, with nearly two hundred references, are based on the work of some fifty experts from a wide variety of disciplines. They reviewed in detail epidemiological and clinical data, including an important report from the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD) [

      National confidential enquiry into patient outcome and death. Measuring the units a review of patients who died with alcohol-related liver disease; 2013. <http://www.ncepod.org.uk/2013arld.htm>.

      ], of an audit carried out in hospitals around the country on the care of adult liver patients admitted to hospital. Major deficiencies in the available facilities and lack of expertise in those caring for the patients were documented. Only 2.9% of the patients had been seen by a consultant Hepatologist on arrival. Care was judged to have been good in less than half the cases and deaths were considered avoidable in over 10%.
      The statistics for the UK are horrifying. Liver disease stands out as the one glaring exception to the vast improvement over the past 30 years in health and life expectancy for chronic disorders such as strokes, heart disease and many cancers. Mortality rates have increased 400% since 1970 and in those under the age of 65 years have risen almost five-fold (Fig. 1). Liver disease currently constitutes the third commonest cause of premature death in the UK and the rate is considerably higher than for other countries in Europe. The UK overtook France, Italy and Spain in terms of liver mortality some years ago and only Finland, where the availability of alcohol, as in the UK, was liberalised, has seen a similar upward trend in liver mortality [
      • Jewell J.
      • Sheron N.
      Trends in European liver death rates: implications for alcohol policy.
      ].
      Figure thumbnail gr1
      Fig. 1Percentage changes in standardised UK mortality rates (age 0–64) normalised to 100% in 1980. Standardised Mortality Rate data for the UK was downloaded from the World Health Organisation Health for All Database (http://data.euro.who.int/hfadb/) and normalised to 100% in 1980. (Nick Sheron, October 2013).
      Over 1 million hospital admissions a year are the result of alcohol related conditions and both the number of admissions and the increase in mortality closely parallels the rise in alcohol consumption in the UK during recent decades [

      All-Party Parliamentary Hepatology Group (APPHG) Inquiry into Improving Outcomes in Liver Disease. LIVER DISEASE: today’s complacency, tomorrow’s catastrophe; 2014. <http://www.allparty.org/all-party-groups/hepatology>.

      ,

      Academy of Medical Sciences. Calling time – The nation’s drinking as a major health issue. Academy of Medical Sciences, London; 2004. <www.acmedsci.ac.uk>.

      ].
      Similarly, with 25% of the population now categorised as obese, the numbers of patients being diagnosed with type II diabetes and other medical consequences of the metabolic syndrome including non-alcoholic fatty liver disease (NAFLD) are staggering [

      Statistics on obesity, physical activity and diet: England; 2014. <http://www.hscic.gov.uk>.

      ]. 10–15% of NAFLD patients have ongoing inflammation and fibrosis leading finally to cirrhosis and to primary hepatocellular carcinoma. A substantial proportion of obese subjects will also be drinking heavily, adding to the risk of developing hepatocellular carcinoma. Obesity and alcohol consumption act synergistically in producing liver damage and obesity is known to accelerate progression of liver diseases from other aetiologies including hepatitis C and haemochromatosis. NAFLD is now thought to be the cause of many instances of what was previously termed cryptogenic cirrhosis.
      The number of chronically infected HCV and HBV subjects in the country is another major disease burden. Annual deaths from hepatitis C have almost quadrupled since 1996 and around 75% of an estimated 160,000 infected cases in the country are still unrecognised [
      • Martin N.K.
      • Foster G.R.
      • Vilar J.
      • Ryder S.
      • Cramp M.
      • Gordon F.
      • et al.
      HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact.
      ,
      • Harris R.J.
      • Thomas B.
      • Griffiths J.
      • Costella A.
      • Chapman R.
      • Ramsay M.
      • et al.
      Increased uptake and new therapies are needed to avert rising hepatitis C-related end stage liver disease in England: Modelling the predicted impact of treatment under different scenarios.
      ,
      • Martin N.K.
      • Vickerman P.
      • Grebely J.
      • Hellard M.
      • Hutchinson S.J.
      • Lima V.D.
      • et al.
      Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals.
      ]. Similarly, for chronic hepatitis B infection, the pool of silent infected subjects in the UK is increasing each year as a result of immigration from countries with a high prevalence of infection. No testing for HBV or HCV infection at the time of visa application is in place as in many countries around the world [
      • Williams R.
      • Holt A.
      Screening immigrants for tuberculosis—why not for HBV infection?.
      ] (Table 1).
      Table 1Summary of four major problems identified by the Lancet Commission.
      The costs to the National Health Service are equally staggering, with estimates of £3.5 billion a year for alcohol health problems and £5.5 billion for the consequences of obesity [

      Statistics on obesity, physical activity and diet: England; 2014. <http://www.hscic.gov.uk>.

      ]. Those for obesity are almost certainly an underestimate as obesity is such an important risk factor in a number of common cancers including breast and colon, as shown in a recent cohort study of 5.24 million UK adults [
      • Bhaskaran K.
      • Douglas I.
      • Forbes H.
      • dos-Santos-Silva I.
      • Leon D.A.
      • Smeeth L.
      Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults.
      ]. Furthermore, it is the poorest and most vulnerable in society, living in areas of highest social deprivation, who have the highest incidence of liver conditions, making it a major health inequalities issue.
      The seven sections of the report provide a comprehensive account of liver disease in the UK. Each of the sections has detailed recommendations from which ten were selected as those most likely to have the greatest impact on disease burden and which were strongly endorsed for urgent action.
      Section 1, in giving statistics on the extent of the problem and the current deficiencies in hospital and primary care, recommends strengthening detection of early liver disease in primary care through positioning of liver disease within the ‘Big 5’ major chronic diseases to maximise the impact of general interventions. Section 2 provides a blueprint for improving hospital care through enhanced 7-day acute liver services in DGHs and 30 regional specialist centres distributed equitably around the country. A national review of liver transplant services is recommended to provide sufficient capacity for the anticipated 50% increase in availability of donor organs by 2020. Proposals for increasing medical and nurse training in hepatology to enable the necessary increase in staffing levels in hospitals and primary care, are also detailed (Table 2).
      Table 2Summarising actions needed to address major issues of liver disease care and prevention as recommended in the report of the Lancet Commission.
      Section 3 deals with measures for scaling up national action to reduce the country’s overall alcohol consumption including implementation by Government of a Minimum Unit Price policy for alcohol, along with restrictions on advertising and alcohol promotions in supermarkets [
      • Zhao J.
      • Stockwell T.
      • Martin G.
      • Macdonald S.
      • Vallance K.
      • Treno A.
      • et al.
      The relationship between minimum alcohol prices, outlet densities and alcohol attributable deaths in British Columbia, 2002 to 2009.
      ,
      • Holmes J.
      • Meng Y.
      • Meier P.S.
      • Brennan A.
      • Angus C.
      • Campbell-Burton A.
      • et al.
      Effects of minimum unit pricing for alcohol on different income and socioeconomic groups: a modelling study.
      ]. Legislative action on the food industry to reduce sugar content in food and soft drinks was considered essential. Based on results of modelling techniques, eradication of HCV by 2030 using the new antiviral drugs was considered to be a feasible proposition [
      • Martin N.K.
      • Foster G.R.
      • Vilar J.
      • Ryder S.
      • Cramp M.
      • Gordon F.
      • et al.
      HCV treatment rates and sustained viral response among people who inject drugs in seven UK sites: real world results and modelling of treatment impact.
      ,
      • Harris R.J.
      • Thomas B.
      • Griffiths J.
      • Costella A.
      • Chapman R.
      • Ramsay M.
      • et al.
      Increased uptake and new therapies are needed to avert rising hepatitis C-related end stage liver disease in England: Modelling the predicted impact of treatment under different scenarios.
      ,
      • Martin N.K.
      • Vickerman P.
      • Grebely J.
      • Hellard M.
      • Hutchinson S.J.
      • Lima V.D.
      • et al.
      Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals.
      ] but was dependent on the scaling up of screening programmes to identify the large numbers of currently undiagnosed infected subjects. The introduction of universal infant vaccination against HBV in accordance with the WHO policy was yet again recommended. Section 4 reports on what is needed to obtain greater engagement of primary care in the early detection and treatment of liver disease including guidelines and defined care bundles. Addition of the AST/ALT ratio to the standard liver function tests to facilitate triage of significant liver disease and use of confirmatory liver elastography, were also recommended. Section 5 on Paediatric Liver Disease, in stressing the value of having three designated national centres in achieving excellent outcomes for biliary atresia, emphasised the need for better transitional care facilities for the increasing number of children with liver disease, including liver transplant recipients surviving to adulthood.
      An economic analysis of the costs of liver disease to the NHS is developed in section 6, with the potential savings obtainable through preventative and better treatment measures, and the final section 7 looks at promoting better public understanding of liver issues including the establishment of a web-based information portal carrying data on standards of care and clinical outcomes.
      Following on from publication of the report, the editor of the Lancet decided that work should continue through a Standing Commission, with a follow-up report to be published in November on progress with implementation of the recommendations. An additional working group on Diagnostic and Invasive Radiological Services including surveillance for primary hepatocellular cancer, has been set up and important collaborations put into place with Public Health England bringing together nationwide activities on public health.

      Conflict of interest

      The work of the Lancet Commission and the author were unfunded, the author declared he was solely and wholly responsible for the content of this editorial.

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      2. HEPAMAP: Prospects for Liver Disease Research in the EU <http://www.easl.eu/assets/application/files/EASL_HEPAMAP_Full%20Report.pdf>.

      3. National confidential enquiry into patient outcome and death. Measuring the units a review of patients who died with alcohol-related liver disease; 2013. <http://www.ncepod.org.uk/2013arld.htm>.

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      5. Academy of Medical Sciences. Calling time – The nation’s drinking as a major health issue. Academy of Medical Sciences, London; 2004. <www.acmedsci.ac.uk>.

      6. Statistics on obesity, physical activity and diet: England; 2014. <http://www.hscic.gov.uk>.

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