The state of our liver health

A meeting overview report on the 2nd Annual Irish Liver Foundation Study Day, which took place in the RCSI, Dublin, on 18 January

The Irish Liver Foundation (ILF) was set up in December 2022 by healthcare professionals working in liver disease in Ireland. One of the goals of the ILF is to support continuous education and our study days are short but vital. They are a fantastic way to get the most up-to-date, evidence-based information on liver disease in Ireland. The charity has been expanding rapidly and held a patient-specific study day in October 2024 in collaboration with another charity called the Liver Ireland Support Network (LISN), a peer support charity aimed at those with liver disease, in particular anyone on a liver transplant journey.

On behalf of the ILF, we wish to acknowledge the profound loss of Mr Brendan McAtamney, co-founder of LISN, who sadly passed in December 2024. The Annual Study Day in January was dedicated to his memory.

Opening remarks

Prof John Ryan, Consultant Hepatologist, Beaumont Hospital, Dublin, ILF Co-Founder and Director, opened the meeting, saying: “Since the 1970s, the death rates of most major diseases, including cardiovascular disease, diabetes, heart attacks, and strokes have reduced. Whereas deaths from liver disease have risen, with death rates four times higher than in 1970. A spotlight needs to be shone on liver disease in Ireland. While we know that prevention and early detection of liver disease leads to better outcomes for patients, we must have a clear evidence-based plan in place to identify how we do this and where resources are most needed.”

Prof Ryan explained how the ILF have been able to sponsor research in liver disease in Ireland by establishing the very first ILF Fellow position. The current ILF Fellow is Dr Clare Foley, who Prof Ryan noted won the best oral presentation and best clinical abstract at the Irish Society of Gastroenterology Winter Meeting in November 2024 in relation to her research so far.

Burden of liver disease on hospitals over six years in Ireland

Dr Clare Foley, ILF Fellow, gave an overview on her research to date, which focuses on the burden of liver disease on our acute hospitals. This has involved analysing data from the previous six years and identifying areas that need investment the most. Dr Foley’s preliminary findings suggest that between 2017 and 2023, there was a total of 21,528 inpatient hospital admissions for liver disease in the acute hospital system. These admissions had an average length of stay of 11 days and sadly 1,733 inpatient liver disease deaths were recorded. Dr Foley had some very startling statistics. These included that patients admitted to acute hospitals with a liver disease had mortality rates of up to 18 per cent in some centres, and a 30-day readmission rate of 18 per cent. Over the studied six years of admissions, this equated to 245,961 inpatient bed days, with 13,197 of those being critical care bed days. Dr Foley’s research is still in its infancy, however, her take-away points were:

1. The burden of liver disease on acute Irish hospitals is significant.

2. Alcohol-related liver disease had:

a. Longer lengths of stay, including

in critical care.

b. High mortality.

c. High readmission rates within

30 days.

d. Higher cost of care.

3. Inpatient cirrhosis death rates are double that of COPD and heart attacks.

4. The inpatient mortality rates in those with liver disease are unacceptable. Rates vary across the country and we need to determine why that is.

5. Patients admitted to hospital with liver disease cost more than other common conditions.

Prevention and early detection of liver disease will be imperative to have a real impact on the burden of liver disease in Ireland.

Early detection of liver disease (in primary care)

Dr Paul Brennan, Clinical Lecturer, University of Dundee, Scotland, explained that the European Association for the Study of the Liver (EASL)-Lancet Commission have recognised that more than 300,000 lives are prematurely lost to liver disease each year in Europe. The focus, therefore, should be on prevention and early detection of liver disease, implementing appropriate treatment and management to reduce overall morbidity and mortality.

Dr Brennan gave us a run down on an approach used in primary care in Scotland to aid in this process. They used a tactical algorithm called iLFT (intelligent liver function test), which was activated on individuals presenting to primary care who had abnormal liver function blood tests. These patients then had a more robust assessment (iLFT) that looked at clinical details, including the individual’s alcohol consumption, BMI, and identifying any metabolic syndrome. The patients then also undergo reflex testing which includes virology screening, iron studies, liver antibody testing, caeruloplasmin, Alpha 1 anti-trypsin and fibrosis staging. By conducting these tests, and acting appropriately as per their algorithm, Dr Brennan’s research identified a more than 80 per cent reduction in GP contacts and a 75 per cent reduction in the need to refer to secondary care. The application of the iLFT model was widely accepted within primary care and its diagnostic accuracy was over 90 per cent.

Dr Brennan demonstrated how clever use of widely-available blood tests can be helpful in primary practice. Furthermore, the use of non-invasive testing such as Fibroscan is of enormous potential benefit and stakeholders should be looking at ways in which we can make this more accessible in the primary care setting.

MASLD therapy

During her presentation, Dr Marie Boyle, Consultant Gastroenterologist/Hepatologist, Tallaght University Hospital, noted that sometimes it is hard to keep up with changing nomenclature in medicine. None more so than when it comes to the condition now referred to as MASLD (metabolic associated steatotic liver disease) formerly known as NAFLD. The American Association for the Study of Liver Diseases (AASLD) announced the change in June 2023 and this move has been significant. NAFLD was a diagnosis of exclusion: It is not alcohol causing this issue. Whereas with MASLD, it is a diagnosis of inclusion.

Dr Boyle described the current lifestyle interventions available to those with MASLD, which encompass weight loss (diet, bariatric surgery, exercise), supplements, and alcohol reduction/elimination. Dr Boyle explained that in a 2017 study, it was demonstrated that with a 10 per cent total body weight loss, 100 per cent of patients saw improvement in the amount of steatosis in their liver; 81 per cent experienced fibrosis regression; and 90 per cent saw a resolution of steato-hepatitis. Unfortunately, only 10 per cent of the patient cohort achieved a 10 per cent total body weight loss, which proves that while weight loss is extremely beneficial, it is also extremely difficult to achieve.

Dr Boyle gave us a run down on the top three current diets that patients are using to aid weight loss, including the Mediterranean diet, intermittent fasting, and the ketogenic diet. While it is possible to lose weight with all three approaches, the Mediterranean diet has the best outcomes in terms of longevity. Both intermittent fasting and ketogenic diets are difficult to maintain long-term and can have deleterious effects such as micro-nutrient deficiencies and unsuitability for those with diabetes.

Supplements were also discussed, including vitamin D, vitamin E, Omega 3 fatty acids, antioxidants, and alpha-lipoic acid. The evidence is still unclear as to the benefit of these vitamins in liver disease; however, one interesting recommendation was coffee. Coffee, which contains antioxidants, caffeine, and polyphenols, has been shown to have a positive impact on decreasing metabolic syndrome, reducing fibrosis progression, and a reduction in overall mortality. Coffee drinkers rejoice! The optimal dose of coffee is ‘three cups a day, keeps the fat away’!

Finally, novel therapies such as semaglutide (a GLP-1 analogue), which are associated with significant weight loss and an associated reduction in liver fat and fibrosis, show promise in an area desperate for novel treatment. In addition, a recently US FDA-licenced thyroid hormone receptor agonist called resmetirom has shown benefit in MASLD, but its use may be limited by cost.

Therapies for alcohol-related liver disease

We were spoiled this year to have international expert speakers. Dr Stephanie Rutledge, Hepatologist, New York Presbyterian, US, gave an overview on therapies commonly used in alcohol-related liver disease (ArLD) and alcohol use disorder (AUD). She opened with a brief overview of the coveted STOPAH trial, which changed how we treat alcohol-related hepatitis. While steroids still play a role in treatment, not every patient will respond. The optimal liver score (rather than the typically used Maddrey’s Discriminant Function) is the MELD score, with those with a MELD 25-39 most likely to benefit from steroids, and the Lille score used to reassess progress after seven days to identify non-responders, and stop or continue steroids as appropriate.

Dr Rutledge then explained the various pharmacotherapies available for AUD that are safe in the presence of ArLD. These include acamprosate, naltrexone, baclofen, and gabapentin.

AUD and ArLD are both on the rise, she  noted. While alcohol use spiked during the pandemic, ArLD is now the leading cause for liver transplantation. Treating AUD reduces the potential progression to ArLD cirrhosis. Clinicians should be more confident and encouraged in using pharmacotherapy in AUD. Dr Rutledge did caution however, that multidisciplinary team input is essential for overall long-term success.

Paediatric liver disease

Dr Emer Fitzpatrick, Consultant Paediatric Hepatologist, Children’s Health Ireland, took us on a whirlwind journey through paediatric liver disease. Approximately 700 children in Ireland have liver disease, which presents as a mix of congenital, genetic, or metabolic liver disease. One of the most critical paediatric liver conditions is biliary atresia. Dr Fitzpatrick took us through surgical and medical biliary diversion methods. We heard about the work being conducted in gene identification and its implications on diseases such as Alagille syndrome.

What was really striking about Dr Fitzpatrick’s presentation was the increase in steatotic liver disease among children. When we talk about early identification and prevention of liver disease, it should include the whole human life cycle, not just the adult population. While the aetiology of childhood-onset liver disease may be different to adults, there is a final common pathway. Young people with liver disease are at an increased risk of growth, development, and psychological impairment. Success in paediatric hepatology is measured in achievement of childhood milestones and personal goals. As Dr Fitzpatrick concluded: “We should be pushing the boundaries in diagnosis and liver transplantation.”

Portal hypertension

Dr Audrey Dillon, Consultant Hepatologist, St Vincent’s University Hospital, Dublin, highlighted the important topic of portal hypertension in liver disease. For anyone who has any experience of treating a patient with portal hypertension, it can be a complex journey where patients can experience episodes of decompensation very frequently, such as refractory ascites. However, portal hypertension can also lead to other complications such as variceal bleeding and portal vein thrombus. Liver transplantation is life-changing for these patients, however, not all patients are suitable for transplant.

Dr Dillon explained the role of TIPSS (trans-jugular intrahepatic porto systemic shunt). A TIPSS procedure essentially ‘shunts’ blood through the liver relieving the pressure on the portal vein; thereby, reducing the risks of further episodes of decompensation. It is not without its caveats, however. Dr Dillon explained how when deciding on TIPSS, it is essential to balance the risk of improved ascites, nutrition, renal function, and bleeding vs the risk of hepatic encephalopathy, cardiac overload, and liver function.

The takeaway points for portal hypertension include:

1. Identify and treat the aetiology, if possible.

2. Carvedilol, the non-selective beta blocker, is the drug of choice.

3. If a patient requires large volume paracentesis (LVPs) in quick succession, TIPSS should be considered. Patients who undergo TIPSS have better outcomes then those who have frequent LVPs.

4. Liver transplant candidates with portal vein thrombus should be anticoagulated.

Hepatocellular carcinoma therapy

Our final speaker of the day was Prof Grainne O’Kane, Medical Oncologist, SVUH, and Professor of Oncology, UCD. It was both fascinating and reassuring to see the strides that have been made in treating hepatocellular carcinoma (HCC). Strikingly, Prof O’Kane explained that over one million new HCC diagnoses are expected globally in 2025. There is now a higher incidence of non-cirrhotic HCC cases. Prof O’Kane summarised the most recent treatments for HCC and the research currently ongoing. Immunotherapy has been remarkably successful in recent times. Even though incredible strides have been made and the standard care has improved and updated, there are still important complications that we need to be aware of. Diagnostic work-up of individuals with suspected adverse events depend on the affected organ.

Prof O’Kane highlighted the need to monitor thyroid and liver function tests to identify adverse events in a timely manner. Other common adverse events include vitiligo, arthralgia, arthritis, and myocarditis. Prof O’Kane suggested that a national policy is needed for variceal management while patients are receiving treatment for HCC. SVUH is the national referral centre for HCC treatment and the multidisciplinary liver cancer clinic is on every Thursday afternoon in the liver unit.

Conclusion

The study day was an enormous success, as was reflected in our feedback. There were over 150 attendees from varying areas within healthcare and from all over the country. A special thank you to our speakers, attendees, our hosts the RCSI, and our sponsors and volunteers. See you all again next year!

For more information on the work of the ILF and resources on liver disease, see www.liverfoundation.ie