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Non Alcoholic Fatty Liver Disease Service

Information

Non acoholic fatty liver disease (NAFLD) includes a spectrum of conditions which range from  simple fat accumulation in the liver called steatosis to fat accumulation and inflammation called Non alcoholic Steato Hepatitis (NASH) which can cause further scarring and finally lead to end stage liver disease or cirrhosis.  NAFLD is a consequence of the metabolic syndrome constituting an elevated lipid profile, the presence of insulin resistance or diabetes and high blood pressure along with an increased waist circumference. The metabolic syndrome in turn is a consequence of the obesity epidemic. 25% of the UK population are now categorised as obese and by 2030, almost 40 million adults in the UK will be obese. It is estimated that consequences of obesity cost the NHS £5.5 billion per year.

Non-alcoholic fatty liver disease (NAFLD) is present in 80-90% of obese individuals, out of which 10-15% will progress to fibrosis and cirrhosis. NAFLD currently is the commonest cause for referrals for investigation of abnormal LFTs from primary care to secondary care. It is estimated that by 2020 NAFLD will be the leading cause for end stage liver disease, transplantation and liver cancer in the western world. The impact of NAFLD is not limited to morbidity and mortality due to liver failure. The commonest causes of early mortality in patients with NAFLD are cardiovascular events therefore highlighting the need for a holistic and individualised approach to the management of these patients to improving outcomes. This is made challenging due to lack of evidence in best practice in screening patients for risk. NAFLD guidelines recommend cardiovascular risk screening in patients with NAFLD though there is no guidance on the best strategy to offer this to patients.

Current management of NAFLD is mainly focussed on optimising lifestyle choices with the aim of weight loss both by improving dietary choices and increasing activities. A number of studies have shown that 10% weight loss in 6 months improves liver inflammation and can help prevent progression of NAFLD to NASH. Goals such as these are difficult to achieve in the real world setting and even more challenging to maintain in the long term. In addition, for a number of NAFLD patients there exist real and patient perceived barriers to increasing activity and making better life style choices. These barriers include mental health issues, physical disabilities or chronic conditions limiting activity and stigmatisation due to a non conformist body type and resulting dysmorphic body type disorder. In addition, a fair proportion of patients are unaware of food labelling connotations and the calorific value / nutrient composition of their food choices. Interventions aimed at changing lifestyle, behaviour, awareness and identifying barriers to enabling these changes are difficult to deliver in large busy secondary care general liver clinics.

Pharmacotherapy in NAFLD is reliant on improving components of the metabolic syndrome. Optimal management of diabetes and hyperlipidaemia for these patients usually requires specialist input and multidisciplinary approaches are required to ensure desired outcomes are achieved and more importantly, sustained.

Whilst some agents have shown promise in improving liver inflammation such as vitamin E and pioglitazone, their use is limited by the paucity of evidence and possible attendant adverse effects with long term use. This area is therefore, a large unmet need in the management of the condition and trials and research are ongoing to find an agent which will effectively treat NASH and in doing so reduce the burden on disease on healthcare. A number of drugs in development (phase II/III) have been given “Fast track” status by the FDA and this highlights the real lack of any proven therapy in this field. We are in a unique position in the Northwest to address this. The Royal Liverpool University Hospital has fully equipped Phase I approved CRU which is one of only 2 such units in the country and allows a unique opportunity to offer research to patients with NAFLD and bring visibility to this condition by increasing awareness.

The NAFLD service at the Royal is the only one of its kind in the North West and aims to provide individualised, holistic and patient centred care in a multidisciplinary setting to patients with the metabolic syndrome and NAFLD.

Aims of the service:

  1. Offer strategies to screen for NAFLD in high risk patients with and without abnormal LFTs
    1. Abnormal LFTs pathway for primary care
    2. Non-invasive scoring systems in secondary care
    3. Transient elastography where appropriate
    4. Identify mechanisms via research to improve current prediction scoring systems
  2. In patients identified with liver disease, allow better characterisation of nature of damage (Simple steatosis vs NASH vs cirrhosis) to enable appropriate follow up / management strategies including where needed liver biopsy staging of disease
  3. Offer all patients a full review of their lifestyle choices and enable change where required:
    1. Dietary review with dietician referral
    2. Activity assessment and brief intervention on sustainable activity programs
    3. Assessment of barriers to effecting change and address if possible
  4. Optimise risk from components of the metabolic syndrome and address them
    1. Assessment of cardiovascular risk by means of a QRISK2 score and referral for CT C scores in high risk patients via collaborations with cardiology (Dr. S. Murray)
    2. Assessment of diabetic control and discussion in joint MDT for challenging to treat patients with use of oral anti diabetic drugs known to improve liver disease as well such as gliptins (Dr. D Sharma)
    3. Assessment of hyperlipidaemia and referral to metabolic medicine (Professor Ranganath)
  5. Assessment for suitability of each patient for pharmacotherapy specific for NASH such as vitamin E and pioglitazone and a risk / benefit discussion with patients to enable informed choice
  6. Offering a review of health and wellbeing with tie ups with local council sponsored initiatives to overcome barriers precluding better lifestyle choices.
  7. Create a cohort of patients to study the natural history of NAFLD and NASH and to offer trial participation for new drug discovery or re purposing where appropriate.