Worldwide lack of early referral of patients with alcoholic liver disease

Results from a worldwide analysis of over 3,000 patients highlights that there is significant disparity in the referral of patients with liver disease, and that those with alcoholic liver disease (ALD) are 12 times more likely to present at an advanced rather than early stage. The study, presented at The International Liver Congress 2017 in Amsterdam, The Netherlands, showed that in those patients with two causes of cirrhosis, alcohol abuse also leads to a more advanced stage of presentation.

Alcoholic liver disease refers to liver damage caused by excessive alcohol intake, and encompasses several stages of severity (alcoholic fatty liver disease, alcoholic hepatitis and cirrhosis) with a range of symptoms.1 It is the most prevalent cause of advanced liver disease in Europe.2 Young people account for a disproportionate amount of ALD disease burden, with over 10% and 25% of alcohol-related deaths in female and male youths respectively.2

"This study showed that there is a significant disparity worldwide in the referral of patients with liver disease, with ALD patients being seen at more advanced stages than those with viral hepatitis or non-alcoholic fatty liver disease," said Dr. Neil Shah, UNC Hospitals, Chapel Hill, United States, and lead author of the study. Senior author, Dr. Ramon Bataller, added "ALD is an important issue to address as the consequences of the disease can be grave. The results of our study clearly indicate that programmes for early detection and referral of ALD are urgently needed worldwide."

This study, which analysed results from the global alcoholic liver disease survey (GLADIS), involved 16 gastrointestinal and liver centres from six continents, and aimed to investigate disparities regarding the causes of liver disease among patients referred with early and advanced disease. Each centre enrolled 100 outpatients with early liver disease and 100 inpatients with advanced liver disease. Early liver disease was defined as liver disease without evidence of advanced fibrosis (scarring) or cirrhosis, liver cancer (hepatocellular carcinoma) or history of liver-related complications. Advanced liver disease was defined as decompensated cirrhosis (the liver cannot perform all its functions properly), liver cancer or acute liver failure. Patients were excluded from the study if they had a history of liver transplant. The study analysed 1,551 patients with early liver disease and 1,597 with advanced disease.

Of all patients, 84% had one cause of liver disease and 15% had two causes. The most common single causes of early liver disease were Hepatitis C virus in 31.2%, Hepatitis B virus in 22.63% and non-alcoholic fatty liver disease in 18.5%, while only 2.8% had ALD. Contrasting with this, among single causes of advanced liver disease, the most frequent wasalcohol abuse, present in 31% of patients. Alcohol was also involved in 84% of cases with two causes of liver disease. Patients with ALD were 11.5 times more likely to have advanced signs of liver disease compared with early disease. Patients with two causes of disease, of which one was alcohol-induced, also presented significantly more often as 'advanced' patients.

"This is an important study as it demonstrates that patients with ALD are significantly more likely to be referred at a very late stage of disease, thus reducing the possible interventions which may halt disease progression. This demonstrates the need for earlier detection strategies, such as screening of populations at higher risk", said Prof Helena Cortez-Pinto, Department of Gastroenterology, from Faculdade de Medicina da Universidade de Lisboa, Portugal and EASL Governing Board Member.