Trends in the management and burden of alcoholic liver disease

Abstract

Alcoholic liver disease (ALD) is the most prevalent cause of advanced liver disease in Europe and is the leading cause of death among adults with excessive alcohol consumption. There is a dose-response relationship between the amount of alcohol consumed and the risk of ALD. The relative risk of cirrhosis increases in subjects who consume more than 25 g/day. The burden of alcohol-attributable liver cirrhosis and liver cancer is high and is entirely preventable. Health agencies should develop population-based policies to reduce the prevalence of harmful and/or hazardous alcohol consumption and foster research in this field to provide new diagnostic and therapeutic tools. Disease progression of patients with ALD is heavily influenced by both genetic and environmental factors. Non-invasive methods for the diagnosis of fibrosis have opened new perspectives in the early detection of advanced ALD in asymptomatic patients. Alcoholic hepatitis, the most severe form of ALD, carries a high short-term mortality (around 30-50% at 3 months). Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis but duration of therapy should be adapted to early response. Liver transplantation is the best option for patients with severe liver dysfunction. However, alcohol relapse after transplantation remains a critical issue and drinking habits of transplanted patients need to be routinely screened.

Keywords: Alcoholic hepatitis; Burden of alcoholic liver disease; Cirrhosis; Liver transplantation; Natural history; Non-invasive diagnosis.

Fig. 1. Relationship between standard liver death rate and overall alcohol consumption in several European countries

The relationship between standard liver death rate (SDR) (per 100,000) and overall alcohol consumption (pure alcohol litres per capita, age 15+) in the four countries in the EU (pre-2004) with the largest rises or falls in liver deaths between 1970 and 2008. Data from the World Health Organization, European Health for All database (HFA-DB): http://data.euro.who.int/hfadb/. Reproduced with permission from [17].

Fig. 2. Natural history of alcoholic liver disease from steatosis to cirrhosis and hepatocellular carcinoma (HCC)

The percentage represents the patients who progress from one stage to the next. Most patients with persistent alcohol abuse develop some degree of hepatic steatosis. If the alcohol abuse persists, liver fibrosis progressively develops, ultimately resulting in cirrhosis. Cirrhosis can lead to severe complications related to portal hypertension (ascites, variceal bleeding and encephalopathy), bacterial infections and also predisposes to HCC. The development of alcoholic steatohepatitis (ASH) predisposes patients to progress to advanced liver fibrosis, and when this develops in patients with severe disease it results in AH.

Fig. 3. The Alcoholic Hepatitis Histological Score (AHHS) allows prognostic stratification of patients with biopsy-proven AH

AHHS categories are as follows: mild, 0–3; intermediate, 4–5; severe, 6–9. The Kaplan-Maier graph shows 90-day survival in each the three categories. Reproduced with permission from [47].