Abnormal LFTs in migrant populations Dr Doug Macdonald Consultant Hepatologist Royal Free Hospital
www.migrationobservatory.ox.ac.uk Migrants in London
Migrants in London
Migrants in London
Common liver diseases in migrant populations Viral Hepatitis Alcoholic liver disease Non-alcoholic steatohepatitis (NASH) Diagnostic and treatment challenges specific to migrant populations
Scottish Macedonian English Indian Bulgarian Burmese
Summary of Pathway Isolated hyperbilirubinaemia Gilbert s. Exclude haemolysis Jaundice with other abnormal LFTs (Bilirubin>40) urgent referral ALT>300 urgent discussion and referral Cholestatic LFTs (raised GGT, ALP) or hepatitic picture (ALT<300) request USS and liver panel then refer if abnormalities detected: HBsAg HCV Ab Autoantibodies Ferritin/ TF saturation Caeruloplasmin Immunoglobulins α1-antitrypsin If normal screen for alcohol excess give lifestyle advice and monitor LFTs If fatty liver on USS is the only abnormality see NAFLD pathway
Liver disease with normal LFTs Alazawi W et al. Br J Gen Pract 2014;64:e694-e702
Prevalence of NAFLD, ALD, HBV and HCV in different ethnic groups within the general population. Alazawi W et al. Br J Gen Pract 2014;64:e694-e702
NAFLD Pathway
Summary of NAFLD Pathway Use the FIB4 test to identify patients at high risk of advanced fibrosis ( Age x AST ) / ( Platelets x ALT ) Non-invasive tests (e.g. ELF) for patients with intermediate FIB4 score High FIB4/positive non-invasive test should be referred to hepatology Low FIB4/negative non-invasive fibrosis test managed in primary care: Treat metabolic syndrome components (hypercholesterolaemia, diabetes, hypertension) Lifestyle modification diet, exercise, alcohol Aim 10% weight loss Annual LFTs and reassess fibrosis risk if LFTs remain abnormal
Weight loss a level playing field? 3 components: Reduced calorie diet Increased physical activity Maintenance strategy (e.g. group monitoring) Tailored delivery by trained interventionalist (physical trainer, dietician, psychologist) produces better weight loss than advice alone BUT Short-term weight loss (6 months) almost always followed by slow regain of initial weight over 1-2 years No evidence for weight loss programmes tailored to ethnic or cultural minorities
Weight loss a level playing field? Gill JM, Celis-Morales CA, Ghouri N. Physical activity, ethnicity and cardio-metabolic health: does one size fit all? Atherosclerosis. 2014 Feb;232(2):319-33.
Alcohol Alazawi W et al. Br J Gen Pract 2014;64:e694-e702
WHO status report on alcohol and health in 35 European countries 2013 ALD in the EU
Alcohol in Migrant Populations Pattern Low rates of drinking but high consumption in drinkers High rates of drinking and high consumption Low rates of drinking and low consumption in drinkers Rising rates and consumption Ethnic Group Pakistani men, mixed ethnicity men White ethnicities (Irish, Scottish, Polish, English), Sikh Men, Chinese, Bangladeshi, Hindu Indian women and Irish women of high socioeconomic status Ethnicity and alcohol: A review of the UK literature. Middlesex University 2010
Alcohol in Migrant Populations Rates and pattern of consumption in country of birth is a poor indicator of alcohol consumption in the UK Migrants adopt local consumption patterns 2 nd generation not distinguishable from general population Alcohol use associated with migration itself- social isolation, anxiety and depression Ethnicity and alcohol: A review of the UK literature. Middlesex University 2010
Alcohol screening and treating A QOF for alcohol consumption screening and brief intervention? - Currently under development by NICE, but only in patients with hypertension SIPS study: 3 cluster randomised controlled trials of brief interventions in primary care, emergency departments and probation services. Brief lifestyle counselling tool, patient information leaflet, Brief advice tool. Follow-up at 6 months and 12 months (AUDIT questionnaire)
SIPS study in Primary Care
Screening and treating the migrant population EACH - Ethnic Alcohol Counselling Hounslow Eastern Europe Advice Centre AA meetings for Polishspeaking attendees Tailored patient information leaflets?
Marian Bogusz, Stop Drinking! Come With Us and Build a Better Tomorrow, 1952. Jacek Cwikla, Untitled, 1984. American Journal of Public Health November 2010, Vol 100, No. 11
Hepatitis B Alazawi W et al. Br J Gen Pract 2014;64:e694-e702
Primary Care Management of Viral Hepatitis B Guidance This guidance has been been developed in collaboration with local specialists in Camden and Islington This is to assist GPs in decision making and is not intended to replace clinical judgment Newly Diagnosed Hepatitis BsAg positive patient Offer testing and immunization of the household Offer lifestyle advice regarding alcohol, obesity and hepatitis B Test for Hepatitis A and offer vaccination if not immune Consider Urgent referral if US demonstrates HCC ALT> 300 Evidence of decompensated liver disease i.e. ascites/ encephalopathy, jaundice Perform following tests in primary care: FBC, INR LFT (inc AST and ALT) & AFP HBeAg, HBeAb, HBV DNA viral load Hepatitis C, Hepatitis D HIV (offer) Ultrasound Liver scan Refer to secondary care Document co-morbidities. Special attention to psychiatric, cardiovascular and immune Attach all blood and US scan results See next page for guidance regarding secondary care pathway
Hepatitis B ~350 million worldwide >8% 2-8% <2% Adapted from Centre for Disease Control, USA
Hepatitis B in Migrants Late presentation (HCC, decompensated cirrhosis) Ethnicity confers additional HCC risk. 6 monthly AFP and USS: - Cirrhosis - Asian men >40 - Asian women >50 - African > 20 Do our responsibilities for contact tracing end at the border?
Hepatitis C Alazawi W et al. Br J Gen Pract 2014;64:e694-e702
Hepatitis C ~150 million worldwide >10% 2.5-10% 1-2.5% <1% Adapted from Centre for Disease Control, USA
Primary Care Management of Viral Hepatitis C Guidance This guidance has been been developed in collaboration with local specialists in Camden and Islington This is to assist GP s in decision making and is not intended to replace clinical judgment Newly Diagnosed Hepatitis C antibody patient HCV antibody positive patient discharged post treatment (RNA negative) Offer hepatitis A testing and vaccination Offer lifestyle advice regarding alcohol, obesity and hepatitis C Perform following tests in primary care including: FBC, INR AFP, LFT s (inc AST and ALT), TFT s HCV RNA viral load, HCV Genotype HIV (offer), HAV, HBV, HDV Ultrasound Liver scan Annual Review for Chronic Liver Disease FBC, LFT s, AFP Abnormal Tests If rising LFT s, follow abnormal LFT pathway and ensure relevant blood tests done (do not need repeat genotype) Refer to secondary care Document co-morbidities. Special attention to psychiatric, cardiovascular and immune Attach all results See next page for guidance regarding secondary care pathway Consider Urgent referral if US demonstrates HCC ALT> 300 Evidence of decompensated liver disease i.e. ascites/ encephalopathy, jaundice
Hepatitis C in Migrants Under-diagnosis Not being tested at the point of care Under-treatment Poor response to treatment Unequal access to care, lack of awareness of new treatments, Poor information management by Secondary care. Genotype 3 now the most difficult to treat, especially when cirrhotic
Summary The study of migrant populations is inherently reductionist and often conflates ethnicity, genetics, country of origin and even religion. An awareness of prevalence in country of origin is useful for targeted screening, particularly for viral hepatitis, but this must encompass patients with normal LFTs Certain migrant populations are at greater risk of NASH and a lack of response to lifestyle interventions does not necessarily indicate non-compliance. Studies of drinking patterns in migrant populations are of questionable utility, but interventions for ALD may be more effective if tailored to the target population There is an urgent issue with unequal access to diagnosis and treatment of HCV