Liver Disease in Ireland – An Update
Chronic liver disease has steadily become one of the leading causes of death worldwide, resulting in an estimated 2 million deaths annually.1 Cirrhosis is the 10th leading cause of death in the United States.2 This piece aims to discuss the main causes of chronic liver disease in Ireland, discuss recent advances in the management of liver disease and highlight some areas of interest for patients and healthcare providers.
Although there are many causes of liver disease, the most common aetiological conditions driving chronic liver disease development include alcohol related liver disease, viral hepatitis and increasingly metabolic dysfunction associated steatotic liver disease (MASLD).3 These conditions of course can occur simultaneously and can have a deleterious synergistic effect resulting in increased liver inflammation and development of liver scarring. Internationally the incidence and prevalence of chronic liver disease is increasing significantly, bringing with it significant implications for healthcare systems.4 The natural history of the disease is no different in Ireland and is becoming a significant public health issue that needs urgent action!
Liver inflammation, regardless of cause, results in the development of liver scarring also known as fibrosis. Ongoing inflammation/liver injury can result in the progression of fibrosis from little to no scarring (stage 1) through to advanced fibrosis/cirrhosis (Stage 4). The complications of advanced cirrhosis include; variceal bleeding, ascites, encephalopathy and liver cancer/hepatocellular carcinoma (HCC) pose a significant impact on patient morbidity and mortality. These complications result in frequent hospitalisations and significantly impair quality of life and for select patients the only curative option is liver transplantation.
In Ireland the aetiology of chronic liver disease is similar to that of modern western populations. In the late 20th Century alcohol related liver disease and viral hepatitis were the main contributors to cirrhosis development. However, in recent times the prevalence of MASLD, formally known as non-alcoholic fatty liver disease, has increased significantly. A new category of liver disease has been described termed Metabolic/Alcohol related liver disease (Met/ALD) which defines those with MASLD who consume greater amounts of alcohol per week.5
Unfortunately, similar to our neighbours in the United Kingdom, alcohol related liver disease (ARLD) remains the biggest driver of chronic liver disease in this country. In the UK, ARLD resulted in almost 14,000 premature deaths between 2017 and 2019 alone.6 A similar study evaluating ARLD and inpatient hospital admissions in Ireland between 2006 and 2016 demonstrated that deaths from ARLD rose by 29% over the 10-year period.7 ARLD hospital admissions have remained consistently elevated in more recent years, representing just over 50% of inpatient liver disease admissions. ARLD admissions are associated with longer lengths of stay, increased 30-day readmission rates and higher mortality.
The COVID-19 pandemic saw an increase in ARLD admissions and deaths internationally, this was echoed here in Ireland especially between 2020 and 2021.6 Drinking practices changed with an increase seen in at-home alcohol consumption which is felt to have precipitated some of these ARLD admissions and deaths. This highlights the use of alcohol as a common maladaptive coping strategy worldwide. There are however successful treatment strategies which require multidisciplinary input from liver specialists, general medical physicians, psychiatry and public health. An avenue of development in recent years in Ireland in ARLD includes the implementation of Alcohol care teams in hospital and in the community which are an invaluable resource for patients with alcohol use disorder regardless of their liver disease status.
Ireland is not immune to the global obesity epidemic which has been shown to contribute to many chronic illness such as cardiovascular disease, diabetes mellitus and of course metabolically associated steatotic liver disease.8
MASLD which encompasses metabolic dysfunction associated steatohepatitis (MASH), the silent inflammatory process which drives fibrosis development and cirrhosis progression, is rapidly becoming one of the leading causes of chronic liver disease worldwide. Currently an estimated 30-40% of the world’s population is affected.8, 9 Not only does MASLD related liver cirrhosis pose a risk to patients in the form of decompensation and liver failure there is also a significant association with liver cancer development.8
In an international meta-analysis Thomas et al10 showed that the hepatocellular cancer (HCC) incidence rate was 1.25 per 1000 person-years. The HCC incidence rate was remarkably higher in patients with MASLD with advanced fibrosis or cirrhosis (14.5 per 1000 person-years) than in their counterparts without advanced fibrosis/cirrhosis. Demonstrating that although MASLD without fibrosis has a lower risk of HCC development a risk still remains. Further highlighting the need to act early to manage obesity and reverse MASLD, which is possible.
Successful treatment strategies for MASLD rely predominantly on weight loss. Adoption of the Mediterranean style diet and exercise programmes were the main stay of MASLD management previously but most recently bariatric surgery and certain drugs such as the glucagon-like-peptide 1 (GLP-1) agonists have begun to revolutionise the treatment of MASLD. However accessing these treatments and dietetic support can be increasingly difficult in the public health system in Ireland. This highlights the need for systemic change in order to prevent the potential avalanche of not only advanced liver disease but other health conditions secondary to obesity which could place a significant burden on our healthcare system in the near future.
New treatments in viral hepatitis in the last decade have improved so significantly that a single course of a direct acting antiviral therapy can result in the complete cure of hepatitis C and complete reduction in the risk of developing cirrhosis. These treatments have significantly reduced the need for liver transplantation for decompensated cirrhosis secondary to hepatitis C.
Hepatocellular carcinoma (HCC), is a primary liver cancer that occurs as a complication of advanced cirrhosis. Previous treatments for HCC were suboptimal and ultimately a diagnosis of HCC was terminal if the patient was not a candidate for liver transplantation. New interventional radiological procedures, advances in surgical resection techniques, systemic chemotherapies and especially immunotherapies have revolutionised the management of HCC even in patients with decompensated liver disease.
Given the significant constraints that remain on the healthcare system in Ireland, there are limitations that exist in relation to accessing speciality care. With the implementation of the HSE Slainte care model in 2021 more focus has shifted towards disease prevention, identification and community based care. An example of this model in action includes community based viral hepatitis clinical nurse specialists (CNS) who work closely with general practitioners identifying and treating viral hepatitis C in the community.
Significant advancement in the field of liver disease has occurred in the 21st century. The use of non-invasive markers of fibrosis has radically changed the community management of liver disease and provided referral guidance to general practitioners. Transient elastography, Fibroscan, is a non-invasive method now widely used to evaluate liver fibrosis and quantify the volume of fatty infiltration. Similarly blood test based scoring systems such as the FIB-4 score are useful in determining whether there is a significant risk of advanced liver fibrosis which would require further evaluation and specialist input.11 These methods have helped to identify and determine which patients can be managed at a GP/community level versus those that require hepatology review.
However it must be mentioned that it is not all bad news in relation to liver disease and it’s management in this country. The establishment of the Irish Liver Foundation charity in 2022 has been an excellent source of information and support for patients with chronic liver disease, their families and their healthcare providers. This charity has developed an easily accessible website (www.liverfoundation.ie) and easy to understand patient information leaflets which aim to give patients some autonomy over their chronic health condition. The Irish liver foundation also supports liver related research in order to drive improvements in liver related healthcare management in this country.
Similarly, the newly developed Liver Ireland Support Network (LISN) is a not for profit organisation which aims to provide support to patients and their families on the liver transplant journey (www.lisn.ie). This organisation is offering free counselling services for liver transplant patients, providing some holistic care to patients during a very stressful period.
The HSE alcohol programme is also actively engaging and developing strategies which target alcohol related harm. These strategies are crucial in order to prevent the development of the chronic irreversible alcohol related liver cirrhosis and it’s complications. Online information in relation to alcohol is available through their website and can be a valuable resource for patients and their loved ones. (https://www2.hse.ie/living-well/alcohol/)
Although liver disease in Ireland, especially alcohol related and MASLD, remains a huge burden with significant morbidity and mortality, this author is hopeful that through research and collaboration improvement is possible. We need to work together as a healthcare community to tackle alcohol use disorder and the obesity epidemic nationally.
References available on request
Written by Dr Clare Foley, Irish Liver Foundation Research Fellow, Gastroenterology SPR, Mater Misericordiae University Hospital
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