dealing with nash
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Dealing with NASH. “mildly abnormal LFTs”. Liver disease is a national epidemic. Contribution of alcoholic liver disease to overall liver deaths. and a local disaster. Liverpool S.Tyne Knowsley Blackpool - PowerPoint PPT PresentationTRANSCRIPT
Dealing with NASHDealing with NASH
““mildly abnormal LFTs”mildly abnormal LFTs”
Liver disease is a national epidemicLiver disease is a national epidemic
Contribution of alcoholic liver disease to Contribution of alcoholic liver disease to overall liver deathsoverall liver deaths
and a local disasterand a local disaster
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Liverpool S.Tyne Knowsley Blackpool Manchester Wirral Gateshead Sunderland Sefton Newcastle Heywood Hartlepool Halton Blackburn Bolton Salford Oldham
The North of England cluster hashigher rates of Thiamine prescribing
than the other SHA clusters
Are LFTs a useful Are LFTs a useful test ?test ?
How are LFTs ranges How are LFTs ranges decideddecided
►LFT values a continuumLFT values a continuum
►Abnormal are the extreme 2.5% endsAbnormal are the extreme 2.5% ends
►““Normal” is shifting Normal” is shifting 8% of Americans have high LFTs8% of Americans have high LFTs
(Clark AJG 2003)(Clark AJG 2003)
►““Normal” may not represent “healthy”Normal” may not represent “healthy”
Normal LFTsNormal LFTs► High “normal” LFTs High “normal” LFTs
assoc. with assoc. with increased liver increased liver mortalitymortality
(Kim BMJ 2004) (Kim BMJ 2004)
► 20% of HCV will 20% of HCV will have “normal” ALThave “normal” ALT
(Kelly MJA 2002)(Kelly MJA 2002)
► 58% abn LFTs never 58% abn LFTs never investigated in investigated in primary careprimary care
(Sherwood BMJ 2001)(Sherwood BMJ 2001)
ALTALT RR liver deathRR liver death
MM FF
<20<20 1.01.0 1.01.0
20-20-2929
2.92.9 3.83.8
30-30-3939
9.59.5 6.66.6
How good are we at How good are we at investigating abnormal LFTs ?investigating abnormal LFTs ?
►Retrospective audit of primary careRetrospective audit of primary care NottinghamNottingham Jan - Jun 1995Jan - Jun 1995
►342 consecutive abnormal LFTs342 consecutive abnormal LFTs►157 suitable for FU (not normalised, 157 suitable for FU (not normalised,
RIP or moved)RIP or moved)
91 (58%)91 (58%) no further investigationno further investigation 97 (62%) 97 (62%) significant pathologysignificant pathology
What are the What are the commonest causes of commonest causes of
LFT abnormalities LFT abnormalities
Causes of abnormal LFTsCauses of abnormal LFTs42 Alcoholic liver disease (23 with
cirrhosis)26 Fatty liver / NASH (11 fibrotic on
biopsy)12 PBC / AIH / PSC6 Haemochromatosis2 Hepatitis B6 Hepatitis C3 Common bile duct stones1 α1-antitrypsin deficiency6 Cryptogenic hepatitis
(Sherwood BMJ 2001)
Basics of NASHBasics of NASH
►NASH is commonNASH is common►Most NASH is undetectedMost NASH is undetected
UntestedUntested Normal LFTsNormal LFTs
►NASH is “metabolic syndrome in the NASH is “metabolic syndrome in the liver”liver” Associated with obesity / DMAssociated with obesity / DM
►Most patients with NASH don’t die of Most patients with NASH don’t die of liver diseaseliver disease
ButBut
►Obesity / NASH potent cofactor for Obesity / NASH potent cofactor for fibrosisfibrosis
►NASH cirrhosisNASH cirrhosis Poor prognosisPoor prognosis High risk of HCCHigh risk of HCC
Cumulative risk of HCC in Cumulative risk of HCC in 820,000 male veterans in 820,000 male veterans in
hospital ’85-90hospital ’85-90
El-Serag 2004
Practical management Practical management
►Exclude other disease – aetiological Exclude other disease – aetiological screenscreen Diagnosis other than NASHDiagnosis other than NASH Other synergistic pathologiesOther synergistic pathologies
►Assess severityAssess severity►Treat cofactorsTreat cofactors►Weight and lifestyle management Weight and lifestyle management ►(Specific therapy) (Specific therapy)
Liver aetiological screenLiver aetiological screen
► Hep B S-AgHep B S-Ag► Hep C antibodiesHep C antibodies► Ferritin / Iron studiesFerritin / Iron studies
► AutoantibodiesAutoantibodies
► Coeliac diseaseCoeliac disease► A1-ATA1-AT► Copper studiesCopper studies
Assessment of severityAssessment of severity
►LFTs - virtually useless !!!LFTs - virtually useless !!!
►FBC (platelets)FBC (platelets)
►US screenUS screen
Specific assessmentSpecific assessment
►FibroscanFibroscan
►FibrotestFibrotest
►Traffic lightsTraffic lights
►Other indicesOther indices
Southampton Traffic light Southampton Traffic light testtest
►HA >30HA >30μμg/l or P3NP >5.5g/l or P3NP >5.5μμg/lg/l +1+1►HA >75HA >75μμg/lg/l +2+2►Platelets <150Platelets <150 +1+1
► Score Score 00 GreenGreen 0% risk liver death0% risk liver death
11 AmberAmber 3% risk liver death3% risk liver death
2+2+ RedRed 18% risk liver death18% risk liver death
ManagementManagement
►Refer if evidence of Refer if evidence of Advanced fibrosisAdvanced fibrosis Other diseaseOther disease
►Lifestyle adviceLifestyle advice WeightWeight DiabetesDiabetes AlcoholAlcohol
►Lipid RLipid Rxx
►Specific RxSpecific Rx
Thank youThank you
►NASH is 2-3% of population.NASH is 2-3% of population.►10-30% of NASH has the potential of 10-30% of NASH has the potential of
developing into cirrhosis within 10 years. developing into cirrhosis within 10 years. ►The emergence of significant fibrotic The emergence of significant fibrotic
disease in developing countries, even in disease in developing countries, even in patients of normal weight or who are patients of normal weight or who are underweight is particularly concerning.underweight is particularly concerning.
►More HCC in patients with Childs A More HCC in patients with Childs A undiagnosed NASH.undiagnosed NASH.