Alcoholic Liver Disease in sub-saharan Africa- Overview of Epidemiology Olufunmilayo Lesi Lagos, Nigeria Cape town, November 2015
Outline Introduction and background Risk factors for ALD Perspectives from Africa- iron, aflatoxins Interplay with viral hepatitis
Alcohol is a colorless volatile flammable liquid which is the intoxicating constituent of wine, beer, spirits, and other drinks, and is also used as an industrial solvent and as fuel. In moderation, beer and wine have natural antioxidants called phenols, which help protect against heart disease and lowers the risk of hypertension Ethanol helps the neurons in the brain resist wear and tear that can lead to Alzheimer's and dementia later in life
I drink Champagne when I win, to celebrate. And I drink Champagne when I lose, to console myself. ~Napoleon Bonaparte
Alcohol Is third leading cause of preventable and premature disease and disability worldwide (WHO 2009) Accounted for 2.5m (3.8%) deaths and 4.6% of global burden of disease (Rehm 2009) Accounted for about half of the number of deaths attributable to tobacco (WHO 2009)
Alcohol 2 billion consume alcohol 76.3 million have alcohol misuse problems Global per capita alcohol consumption is 6.13 litres per year. The WHO Africa region s per capita alcohol consumption is only 0.02 litres higher at 6.15 litres a year. This is lower than Europe and the Americas, which consume 12.18 litres and 8.67 litres respectively.. 30% of alcohol consumption globally is unrecorded
Alcoholic liver disease Excessive intake is a major cause of liver disease in Western countries. The spectrum of ALD includes simple steatosis, alcoholic steato- hepatitis (ASH), progressive fibrosis, cirrhosis, and the development of hepatocellular cancer (HCC) In the USA, about two-thirds of the population is estimated to consume alcohol, of whom 14 million fit arbitrary criteria of alcohol abuse. The prevalence of ALD in the US is estimated at >2 million people Only limited data available from low/middle income countries
Importance of ALD in SSA Author No of subjects Finding Krige JE et. al Ann Surg. 2006 Nov;244(5):764-70. 287 alcoholic cirrhotic patients btw 1984-2001 Variceal recurrence, rebleeding, and survival after endoscopic injection sclerotherapy in 287 alcoholic cirrhotic patients with bleeding esophageal varices. Seebaran AR et. al S Afr Med J. 1988 Dec 17;74(12):622-4. Opio CK et. al Pan Afr Med J. 2013 May 13;15:23. doi: 10.11604/pamj.2013.15.2 3.2040. ecollection 2013. 46 patients btw 1977-1981 This study suggests that alcohol is the predominant cause of cirrhosis in Natal Indians. 380 patients study suggests a link between alcohol misuse or alcoholic liver disease and male gender, region of origin, number of sexual partners, and serum albumin below 3.5mg/dl.
Importance of ALD in SSA Author No of subjects Finding Nwokediuko et. al Nigerian Journal of Clinical Practice. Jul-Sept 2013, 16,3 Ndububa etal Niger J. Clinical Practice 2010 Dec, 13(4):360-4 Lesi et. al Nig Quart. J of Hosp Med Okeke et.al WAJM Vol 20 No 1, January March 2002 652 The major putative risk factors are alcohol consumption, hepatitis B virus infection, use of herbs and roots and smoking. 145 The proportion of CLD directly attributable to alcohol (i.e. ALD) is low among the patients studied 148 Alcohol is an independent predictor of CLD 51 It is likely that alcohol is very important cause of cirrhosis of the liver seen in Jos.
ALD: Risk of liver disease Amount & duration of alcohol consumed Type of alcohol Drinking pattern Gender Ethnicity Obesity Iron overload Concomitant infection HBV, HCV Co existing conditions-obesity, metabolic syndrome Genetic factors
Role of dose on development of ALD Amount ingested is the most important risk factor Relative risk of cirrhosis at 25, 50 or 100g alcohol/day Meta-analysis of 14 studies Corrao et al 1999 NB: ALD is not completely dose dependent
Role of duration and pattern of drinking on development of ALD daily or regular heavy drinking vs episodic or binge drinking 90% of long-term drinkers-develop Fatty liver 10-35% develop Alcoholic hepatitis 8-20% will progress to Cirrhosis Drinking outside mealtimes associated with a 3 x than mealtime drinkers Gramenzi et al. Ailment PharmacolTher 2006
Alcohol content of standard and local alcoholic beverages s/ no Country Brand of Brew Alcohol content 1 Madagascar Three horse beer 2 Ghana Akpeteshie, Palm wine 5% 20.5%, 4.5% 3 Nigeria Burukutu, Pito Ogogoro 4.6%, 37.6% 4 Kenya Chang aa 34% 5 South Africa Utshwala 3% 6 Cameroon Amgba 7%
TYPES OF ALCOHOL PITO Palm wine tree and indigenous tapper
Other contents of local brew
Maize and barley, both of which are used for producing locally brewed alcoholic beer, are frequently contaminated by mycotoxin-producing moulds
Iron & Aflatoxin contamination of native alcoholic beverages. Higher among Africans with liver cancer Iron hepatotoxicity may be associated with genetic polymorphism in the ferroportin-1 Aflatoxins in sorghum, sorghum malt and traditional opaque beer in southern Malawi All malt and beer samples, 15% and 43% of the sorghum and thobwa samples, respectively, were contaminated with aflatoxins. The average aflatoxin content in the beer was 22.32 μg/l, which is higher than the permissible maximum level. Limbikani Matumba Gordeuk VR, etal. Iron overload in Africans and African-Americans and a common mutation in the SCL40A1 (ferroportin 1) gene. Blood Cells Mol Dis 2003; 31: 299-304
Overlapping etiology of Viral hepatitis with Alcohol in subjects with liver cirrhosis in Nigeria. Hepatitis B virus: 57.4% Alcohol consumption 67% of CLD 23 % of subject with alcohol as the only risk factor 67.5% of subjects with HBV infection also consumed alcohol 57 % of subjects with HCV infection also consumed alcohol Hepatitis C virus 11% Owoseni, Lagos, 2015-unpublished data
Alcohol was significantly more prevalent in cirrhotic adults > 35 years (p=0.04) Age greater than 35 Age less than 35 72% 53% HBV HCV Alcohol 44 % 75% HBV HCV Alcohol Owoseni, Lagos, 2015-unpublished data
In Summary Alcohol is freely consumed in Africa by both Men and women and is a significant cause of CLD Locally brewed Alcohol is popular and contains hepatotoxic materials like Iron & Aflatoxins B1 Possible potentiation of Liver disease with interaction of alcohol, HBV,HCV and alcohol Very few published studies
Thank you for your attention
Acknowledgements Prof Edith Okeke Dr Owoseni, Lagos