Liver Disease Is it a big problem? Who is affected What causes it What is required Change of Tempo & Style Community Hepatology Practical tips
Transplants ~700 HCC ~3000 Liver Failure ~5000 Deaths ~12000 Recurrent admissions ~50,000 Cirrhosis ~60,000 Alcohol-related disease, NAFLD, Hepatitis C, Chronic liver diseases etc Silently progressing Liver Disease Predictable & Preventable Liver Disease
Figure 8 : Cause of death ( underlying cause) by age: Average annual proportion of all deaths (by type) in each age group in England, 2001 09 12% s th a e D f o e g ta n e rc e P 10% 8% 6% 4% 2% 0% 0-39 40-49 50-59 60-69 70-79 80+ Age Group Alcoholic liver disease Fatty liver disease Liver Cancer Other Chronic liver disease Pancreatitis LFTs or Jaundice Viral Liver Disease Source: ONS mortality data
15-34 age group dying of alcoholic liver disease 35-69 age group dying of alcoholic liver disease
Chronic Liver Disease (1) Mortality - 1993 & 2009 Rates per 100,000 population North East 5.7 up to 13.7 North West 7.3 up to 15.2 Yorks & Humber 4.8 up to 10.2 Rapid increase across the country in the last 16 years (1) Metric: Mortality from chronic liver disease including cirrhosis (ICD v10: K70, K73, K74) Source: National Centre for Health Outcomes Development (NCHOD), part of NHS Information Centre Data: SHA level data, standardised for age and gender using European Standard population. Figures are rates per 100,000 population.
Mortality from chronic liver disease LA IMD Average Score IMD Rank of Average Score All <75 yrs Months Life Lost omortality from chronic liver disease including cirrhosis (ICD10 K70, K73-K74) odirectly age standardised rates (DSR) 2005-07 o14 of top 20 (70%) LAs' where chronic liver disease results in loss of life are in NW England! Blackpool 37.66 12 33.52 33.99 78.56 Isles of Scilly 19.72 149 25.46 26.52 54.89 Liverpool 46.97 1 22.65 22.84 50.52 Wolverhampton 33.02 28 21.84 21.81 49.82 Preston 29.78 48 21.34 21.92 52.74 Manchester 44.50 4 21.26 21.07 48.57 Wirral 27.90 60 20.00 20.14 48.95 Blackburn with Darwen 35.83 17 19.90 20.21 47.98 Oldham 30.82 42 19.56 19.25 41.51 Burnley 34.61 21 19.53 18.87 41.72 Sandwell 37.03 14 19.28 19.36 43.15 Hyndburn 30.91 40 19.09 19.33 43.22 Halton 32.61 30 18.68 18.02 43.97 Salford 36.51 15 17.83 17.81 38.63 Newcastle upon Tyne 31.36 37 17.70 17.79 37.98 Barrow-in-Furness 32.69 29 17.44 16.68 36.25 Lambeth 34.94 19 17.41 16.94 31.7 Nottingham 37.46 13 17.28 17.01 38.43 Rochdale 33.89 25 17.27 17.32 39.95 St. Helens 29.82 47 17.13 17.1 38.23
Liver Disease Causes & Risks Obesity or alcohol at hazardous levels 7-12 million Alcohol consumption Obesity (& DM2) Chronic hepatitis B Hepatitis C Systemic inflammatory Congenital/Genetic Adverse medication (Biliary & Pancreatic disease) Alcohol at harmful levels 1-2 million Chronic or significant liver disease 600,000 Non-viral Non-Life style OLT 600
Alcohol related liver disease 2,000,000 1,800,000 1,600,000 1,400,000 Alcohol related admissions (NI39) Trends 2002-2012 and beyond Public Health Interventions NHS response to Problems & Admissions 1,200,000 1,000,000 ALCOHOL 800,000 600,000 400,000 200,000-20 02/03 20 03/04 20 04/05 20 05/06 20 06/07 20 07/08 20 08/09 20 09/10 20 10/11 20 11/12 20 12/13 20 13/14 20 14/15 10,000 extra pa 27 extra per day 20 15/16 20 16/17 20 17/18 20 18/19 10 19/20 Social behaviours & attitudes Public Policy & regulation
Acute 15% Behaviour 21% Chronic 64% (NWPHO) Alcohol-related admissions England 2008/9 Alcohol specific (Acute) Alcohol specific (Chronic) Digestive incl Liver Cancer Other Alcohol specific (Behavioural) Accident/Injury Violence Cardiac (chronic) Hypertens ive (chronic)
100% Pattern of deaths in England, by age, in 2007 Total: 500,000 deaths 90% Other Genitourinary 80% 70% Mental Alcohol GI & Liver RESPIRATORY 60% Endocrine SUICIDE CIRCULATORY 50% 40% 30% ACCIDENTAL DEATH Alcohol Alcohol GI cancers 20% Alcohol ALL CANCERS 10% 0% < 1 01-04 05-09 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85+ Source: ONS Death Registry Deaths from mental disorders - For younger people (under 50) - these deaths are mostly people dying from mental/behavioural disorders associated with alcohol or drug use. For older people (over 50) these deaths are almost entirely due to dementia
? Back to France 20 year lag? Next 20 year lag Death due to ALD/Cirrhosis age 35-69 per 100,000 living in UK 2020-2040
288 seats Liver Disease = 1 Dreamliner EVERY WEEK January 1 st until 12 th October Plus one plane every year: PLANE CRASH EVERY SINGLE WEEK FOR A FULL YEAR by 2024!
Alcohol and obesity Pint of strong lager = 335 calories Pint of continental lager = 256 calories Pint of cider = 239 calories Large glass of wine = 185 calories Pint of lager = 182 calories Alcopop = 179 calories
AFLD, NAFLD and Cirrhosis
Football stadia capable of seating all 10 years olds with NAFL 52,000 60,000 76,000 90,000
1. Prevent further infections 2. Continue to find undiagnosed cases 3. Get better at offering treatment to diagnosed cases i. Reduce variability (clinical judgement!) ii. Community treatment iii. Prison treatment iv. Engagement services 4. Develop & use more effective treatments 5. More care in treating previous non-svr patients 6. Optimise prevention of premature mortality
WHERE ARE WE NOW & WHERE DO WE WANT TO HCV Analysis 2012 Not yet diagnosed SVR (of total) ESLD Deaths Not yet treated - comorbid/esl D Not yet treated - variability? Not yet diagnosed Not yet treated - patient choice Treated non- SVR (of total) ESLD Best 'Ambition' Outcome (Find 90%, Treat 90%, SVR 90%) SVR (of total) Treated non- SVR (of total) Not yet treated - patient choice Deaths
What matters to patients? Mortality Survival Experience (incl. trust, safety) Access Information
Outcomes Framework Domains
NHS Ten steps to address Liver disease Test Assess Conserve Think Refer / Monitor Support Patients & Carers & EOLC LIVER Monitor / Review Rescue events Surveillance for Complication Treat
Community Liver Disease Typical GP pop 10,000 (<75yrs=9,210) Expect 88 deaths pa Age <75 dying per annum = 29 Lung Cancer: 2.8 Acute myocardial infarction: 1.6 Breast cancer: 1.8 Liver disease 2.2 Chronic liver disease 60 Established cirrhosis: 6.0 Hepatocellular cancer: 0.6 Dependent drinkers: 640 Risk cirrhosis from NASH: 250 Number with hepatitis C: 40+ Number with hepatitis B: 30+ Total at risk 16-75 years: >10% Abnormal liver tests if checked: 10*20% Mortality <75 yrs Trends 1996-2008 NW Mths 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0 M-Heart M-CA lung M-Liver Female Heart Female CA Lung 1996-97 1998-00 2001-03 2004-06 2006-08 Female Liver
Brief Interventions Ryder et al, Nottingham
Thiamine vs. Combined Acamprosate and Disulfiram 4000 3500 3000 Thiamine Prescriptions 2500 2000 1500 y = 0.3916x + 733.57 R² = 0.2515 PCT Linear (PCT) 1000 500 0 0 1000 2000 3000 4000 5000 6000 Combined Acamprosate and Disulfiram Prescriptions
Per capita: Alcohol Consumption ^22% 92-97 ^14% 97-07 ^abstention rates Dependent drinkers 1.6m (^24% 10y) Lag time for dependence 10-15yrs 5-7% treatment (US: 10% Low, 15% Med, 20% Hi) GP-BI ASN Spec services Combination
Activity upstream reduces costs, reduces the need for complex interventions and improves outcomes Potential for intervention Risk assess Early diagnosis Stop insult Treat Monitor for cancer or complics Treat for cancer or complications incl transplant Liver insult Liver inflammation Liver fibrosis Cirrhosis Consequences of cirrhosis Impact on individual/ health services over time (10-20 years)
Reducing Liver Deaths 3,000 Intuitive 800 300
MUP @50p: 3000 lives Better secondary care 800 Surveillance for HCC 300 (Transplantation 700+) Hepatitis C 3%...10%pa Chronic Hepatitis B? Obesity strategy
Liver Disease: Community Care Assess the risk Alcohol > limits BMI>25, DM, Trigs Immigrant/Ethnic pop Current/Ex PWID Current/Ex Offenders Do the Test ^Liver enzymes Specific Liver disease Incl Cirrhosis (stable) Consider Stage of disease Consider Function Symptoms/Signs Complications Refer Rpt BI s, LFTs Rpt Lifestyle adv etc Test HCV, HBV Liver panel: AA, Igs, B&C, Fn, a1at Monitor, FTs, USS, Bone, OGD Treatment & monitor AE
Hepatic Structure & Metabolism
Summary: Liver is complex, its clinical management is not! Damage: enzymes (& USS) Function: Bili, Alb, PT (& clinical etc) Fibrosis: (Platelets), P3P, HA, Fibroscan Complications: ascites, haem, enceph
Cirrhosis Reduce damage Preserve function Monitor for Liver Failure Alb, Bili, PT Ascites, Jaundice Encephalopathy Portal Hypertension?Varices (OGD 3yrs)?Ascites (weight) HCC USS 6 mthly, AFP
10 things to think about in primary care Identify those at risk: (Alc Xs, Obese & DM, Ex- & current PWID, Ethnic groups) Test liver damage: liver enzymes Test liver function: albumen, bilirubin, INR, glucose, urea Test liver fibrosis: platelets Test the liver structure: USS Offer patients information & lifestyle advice Monitor progression of liver disease Watch out for complications: ascites, jaundice, encephalopathy, HCC Refer appropriately: opinion, treatment Always find the explanation for Jaundice!