The EASL–Lancet Liver Commission: protecting the next generation of Europeans against liver disease complications and premature mortality (original) (raw)
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Unacceptable failures: the final report of the Lancet Commission into liver disease in the UK
The Lancet, 2019
This final report of the Lancet Commission into Liver Disease in the UK stresses the continuing increase in disease burden of liver disease from excess alcohol consumption and obesity, with high levels of hospital admissions and a worsening in deprived areas. It concludes that only with comprehensive food and alcohol strategies based on fiscal and regulatory measures including the Minimum Unit Price (MUP) for alcohol and the alcohol duty escalator, as well as an extension of the sugar levy on food content which has been proven by previous experience in this country, can the disease burden be curtailed. Further evidence of the value of MUP is shown by initial published results (1) of its introduction in Scotland showing an overall 3% reduction in consumption, with the major effect as predicted on heavy drinkers of low-cost alcohol products The major contribution of obesity and alcohol to the high rates of the ten most common cancers is also discussed. The measures outlined by the departing Chief Medical Officer, Dame Sally Davies, to combat rising levels of obesitythe highest of any country in the Westare described along with the estimated health costs. The latest audit analysis of unacceptable levels of mortality for severely ill patients with liver disease in District General Hospitals (DGHs)(2) indicates the need for developing a masterplan for improving hospital care and such a plan is proposed in this report based around specialist hospital centres linked to DGHs by Operational Delivery Networks (ODNs). It has received strong backing from the British Association for Study of the Liver (BASL) and British Society of Gastroenterology (BSG) but is held up at NHS England (NHSE). The value of day-case care bundles to reduce high hospital readmission rates with greater care in the community is described, along with examples of locally derived schemes for the early detection of disease and in particular schemes to allow general practitioners (GPs) to refer patients directly for elastography assessment. New funding arrangements for GPs will be required if these are to be taken up more widely around the country, as is recommended. A new ComRes poll, to be published in autumn 2019, shows an appalling lack of understanding of harm to health from lifestyle causes, with a poor knowledge of alcohol consumption and dietary guidelines. The Commission has serious doubts as to whether the initiatives described in the Prevention Green Paper(3), with the onus placed on the individual based on the use of information technology and the latest in behavioural science will be effective. The final section of the report raises questions of meaningful survival in paediatric liver disease where despite excellent overall survival results, there are high levels of cognitive impairment. In the Conclusion, a strong plea is made for greater coordination between the various official and non-official bodies that have expressed views on the unacceptable disease burden from liver disease in this country in presenting a single, strong voice to the higher echelons of Government. It is those making the final decisions and whom the Commission can only presume are not yet convinced of the need. Not included in the report are the continuing efforts to eradicate hepatitis C virus (HCV) infection based on the extension of treatment by the new antiviral drugs to previously unidentified patient groups. Hepatitis B Virus (HBV) infection is also not considered as the efficacy of the new potentially curative agents remains to be established in multi-centre clinical trials. Box 4: The Commission's Key Messages and Priorities for 2019-20 Key Messages:- There is a further increase in the disease burden from excess alcohol consumption and overweight/obesity The mortality for acutely sick liver patients admitted to District General Hospitals is unacceptably high An early detection programme in general practice based on elastography is a feasible and logical proposition The public awareness of liver health hazards is extraordinarily poor as shown in the new ComRes poll Key Priorities:- Convincing upper echelons of Government of the need for fiscal regulatory measures including MUP, tax duty escalator and levy on food content Implementation by NHS of Masterplan for hospitals and day-care treatments based on specific guideline bundles Further investigation into causes of cognitive impairment and consideration of meaningful survival in paediatric liver disease Widening the impact of expert opinion on the present burden of liver disease through greater coordination with the Academy of Medical Sciences, the Royal Colleges and Royal Society of London
The Lancet
Much has been achieved over the past five years in describing the escalating burden of liver disease from lifestyle causes and the impact on hospital and primary care. The section on alcohol in this report reiterates the need for fiscal regulation by Government if overall consumption in the country is to be reduced to improve health, voluntary agreements with the drinks industry having repeatedly been shown to fail. The influence of the industry in its lobbying activities is highlighted in a separate account and myths around the 'nanny state' are also exposed, with the Minimum Unit Pricing (MUP) policy having little influence on average drinkers, affecting mainly heavy drinkers of low cost alcohol products. Results from Scotland following introduction of MUP and with Wales to follow, are likely to seriously expose the weakness of England's position. Further data on the prevalence of obesity makes the need for a policy on adults even more apparent. The number of people with Type 2 diabetes and its complications continue to rise, as do cases of end-stage liver disease and primary liver cancers from Non-Alcoholic Fatty Fiver Disease (NAFLD). Also covered are the increased risks of co-existing obesity and alcohol as causes of the ten most common cancers, including breast and colon. An indepth analysis of both NHS and total societal costs is summarised, showing the extraordinarily large sums that could be saved or redeployed elsewhere in the NHS. On the plus side are the excellent results being obtained with the new antiviral drugs for hepatitis C (HCV) infection, making elimination of chronic infection a real possibility ahead of the World Health Organisation (WHO) target of 2030. Efforts to improve standards of hospital care for liver disease are described and new commissioning arrangements for primary and community care represent some progress in effective screening of high-risk subjects and the early detection of liver disease.
Worldwide patterns and trends in mortality from liver cirrhosis, 1955 to 1990
Annals of Epidemiology, 1994
Trends in mortality rates for liver cirrhosis between 1955 and 1990 have been analyzed for 38 countries (two from North America, six from Latin America, five from Asia, 23 from Europe, and Australia and New Zealand) on the basis of official death certification data derived from the World Health Organization database. Chile and Mexico had exceedingly high rates (around 60/100,000 males and 15/100,000 females in the late 1980s), while in Canada, the United States, and Latin American countries that provided data, cirrhosis death rates were between 5 and 17/100,000 males and 3 and 5/100,000 females over the same calendar period. The pattern of trends was, however, similar in all American countries, with some increase between the 1950s and the 1970s, and declines thereafter. A similar trend was observed in Japanese males, whose rate was 13.6 in 1990. Conversely, cirrhosis mortality declined steadily from 8.0 to 4.6 in Japanese females. Appreciable downward trends were observed in Hong Kong and Singapore, whereas mortality increased in Thailand. In Europe, in the late 1950s, the highest rates were registered in Portugal (33.6/100,000 males and 14.6/100,000 females), followed by France (31.8/100,000 males and 14.1/100,000 females), Austria, Italy, Spain, and Germany. Most of these countries, however, after some further rise up to the 1970s, showed reversal of the trends over most recent years. Thus, in the late 1980s or early 1990s, only Austria, Italy, and Portugal had cirrhosis mortality around 30/100,000 males and 10/100,000 females. Britain, Ireland, and Nordic countries started from much lower values (2 to 4/100,000 males), but showed some, although discontinuous, upward trend.(ABSTRACT TRUNCATED AT 250 WORDS)
New metrics for the Lancet Standing Commission on Liver Disease in the UK
Lancet (London, England), 2016
Panel 1: The 8 Recommendations R1: Improving expertise & facilities in primary care to strengthen detection of early disease and its treatment, & screening of high-risk patients in the community. R2: Establishment of acute liver services in district general hospitals linked with 30 regional specialist centres for complex investigations & treatment, & increased provision of medical & nursing training in hepatology R3: A national review of liver transplantation to ensure better access for patients to increase capacity R4: Specialist paediatric services & continuity of care in transition arrangements for children with liver disease reaching adult life. R5: Measures to reduce overall alcohol consumption in the country R6: Promotion of healthy lifestyles to reduce obesity & the burden of NAFLD R7: Eradication of chronic HCV infection from the country by 2030 & a major reduction in the burden of disease for hepatitis B. R8: Increasing awareness of liver disease in the general population & within the NHS; work of liver patient support groups.
EASL Clinical Practical Guidelines: Management of Alcoholic Liver Disease
2012
Burden of ALD Burden of alcohol-related disease and injury Alcohol consumption is responsible for 3.8% of global mortality and 4.6% of disability-adjusted life-years (DALYs) lost due to premature death [4]. The attributable burden in Europe, with 6.5% of all deaths and 11.6% of DALYs attributable to alcohol, is the highest proportion of total ill health and premature deaths due to alcohol of all WHO regions [4,5]. Europe shows particularly large sex differences in burden: the deaths attributable to alcohol being 11.0% and 1.8% for men and women, respectively. The young account for a disproportionate amount of this disease burden, with an alcohol-associated mortality over 10% and 25% of female and male youth, respectively [6]. Burden of ALD in Europe The burden of compensated alcohol cirrhosis among the general population and heavy drinkers is not well known. The development of non-invasive methods to detect significant liver fibrosis (e.g., elastography, serum markers) should help in elucidating this issue. A recent study in France indicates that alcohol abuse accounts for up to one third of liver fibrosis cases [7]. The best comparative proxy for the burden of ALD is mortality from liver cirrhosis as a whole, although as discussed later this has its limitations. Mortality rates from liver cirrhosis vary considerably between European countries [8] with a 15-fold variation between the highest and lowest national rates [9]. However, Europe is essentially divided into two, with Eastern European states tending to have higher rates than the others [8]. Time trends in liver cirrhosis mortality over the past 30 years show very heterogeneous patterns between countries. About half
Worldwide mortality from cirrhosis: An update to 2002
Journal of Hepatology, 2007
Background/Aims: Cirrhosis mortality has registered large changes over the last few decades. Methods: Age-standardized (world standard) cirrhosis mortality rates per 100,000 were computed for 41 countries worldwide over the period 1980-2002 using data from the WHO mortality database.
Epidemiology and natural history of non-alcoholic liver disease (NAFLD)
Annals of Hepatology, 2009
The authors summarize and update the most recent knowledge in the field of prevalence, natural history and incidence of Non Alcoholic Fatty Liver Disease (NAFLD) and Non Alcoholic Steatohepatitis (NASH). These novel diseases, firstly recognized at the beginning of the second millennium, arose suddenly to the attention of the clinicians, because they are the hepatic expression of the "so-called" metabolic syndrome. Due to the epidemic burden of obesity, diabetes, and metabolic diseases, NAFLD and NASH will become soon probably the most common hepatic disease worldwide, and they surely will keep busy our future young hepatologists.
A rapid review of liver disease epidemiology, treatment and service provision in England
2007
Telephone: 0191 2227884. Liver disease -A rapid review of epidemiology, treatment and service provision 2 EXECUTIVE SUMMARY This rapid review of the evidence relating to liver disease epidemiology, treatment and service provision was conducted by a research team at Newcastle University between August and October 2007. This work was commissioned by the Department of Health. The aims of this review were: to summarise from published literature and relevant unpublished data what is currently known about liver disease; to identify gaps in the evidence-base; and to suggest what might be done to tackle liver disease in England.