Showing posts with label liver health. Show all posts
Showing posts with label liver health. Show all posts

Wednesday, August 1, 2018

In Case You Missed It

10 TERRIFIC WAYS TO LOVE YOUR LIVER THIS SUMMER
Ever considered living your best liver fitness summer yet? Dive in. Transform. Shine on! There’s no better season to kick-start a liver positive lifestyle! Summer, with its delicious ripe produce and array of outdoor activities, provides a perfect backdrop to consider and revamp how your daily routines can create the space to practice and promote liver wellness. With chronic hepatitis, fatty liver disease (NAFLD), and cirrhosis on the rise, particularly in at-risk communities, it’s time to change our relationship to liver health awareness. Earlier this month, the CDC reported that the mortality rate for liver cancer has gone up by 43% over the past 15 years – and that’s despite the recent development of new treatments for hepatitis C and the availability of vaccines for hepatitis A and B! So now, more than ever, we all need to incorporate a healthy dose of liver lovin’ into our daily lifestyles.

Monday, April 2, 2018

Hepatitis Victoria Podcast: Eating for a healthy liver

Hepatitis Victoria Podcast: Nutrition and liver health
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Nutrition and liver health with dietitian Priscilla Hiromi Correa
March 31, 2018
Priscilla Hiromi Correa is a Brazilian dietitian with a special interest in the liver and people living with liver disease. Mark Pearce, Hepatitis Victoria's Communications Manager, spoke with her on a recent visit to our offices. She recommends against 'fad' diets and is in favour of eating based on Australia's dietary recommendations, for optimum liver and general overall health. "Nutrition is so important that through a better diet a patient might even be removed from the transplant waiting list," she says. All Priscilla's recommendations come with a caveat for listeners; consult with your health practitioner about your personal circumstances before following any advice.

Friday, March 23, 2018

8 recent reports on diet’s protective, risk-increasing effects on liver health

8 recent reports on diet’s protective, risk-increasing effects on liver health
March 23, 2018

Diet and lifestyle play a large role in liver health. Lately, researchers have made several important discoveries regarding the ties between diet and the gut microbiome, and identified specific dietary components that either have protective qualities for liver health or increase the risk for liver disease and cancer.

The following reports include details on diet’s effect on the gut microbiome, the increased risk for fatty liver disease among individuals with a high intake of red and processed meat, the protective effects of early childhood vitamin E intake and moderate coffee intake for adults, and a recent CDC report on adult binge drinking.

Thursday, March 1, 2018

Shifting from concern to crisis: 1 in 4 Canadians may be affected by liver disease

In case you missed it
2018
Fatty Liver Disease articles available on this blog:
Watch videos, or review research in this current collection of articles

Shifting from concern to crisis: 1 in 4 Canadians may be affected by liver disease
TORONTO, March 1, 2018 /CNW/ - An estimated eight million Canadians may be affected by liver disease, an illness that exhibits little to no symptoms, involves everyone from newborns to seniors, and is rarely tested by doctors during annual checkups.



Canadian Liver Foundation
Published on Mar 1, 2018

Recent indicators gathered by the Canadian Liver Foundation (CLF) show that an increased prevalence of liver diseases including non-alcoholic fatty liver disease (NAFLD), chronic hepatitis B & C, and liver cancer are why in just ten years, the statistic that was once 1 in 10, is now 1 in 4.

"The reason we are seeing this increase in liver disease is partially due to lifestyle choices we don't always associate with causing us a tremendous amount of harm," says Gary Fagan, President of the CLF. "From supersizing your meal, to binge-watching a television series, these ordinary activities can seriously compromise the well-being of your liver."

Fast facts of liver disease:
There are over 100 known liver diseases; only one is directly caused by alcohol.

1 in 7 Canadians are obese. 23% of obese Canadians are at risk of developing serious liver damage from fatty liver disease.

NAFLD is the most common liver disease in Canada, affecting over 7 million people.

The virus that causes hepatitis B is 100 times more infectious than HIV, and is the second leading cause of cancer worldwide.

Many Canadians with hepatitis C are not diagnosed until decades after being infected.

Liver diseases such as NAFLD or chronic hepatitis can lead to scarring (cirrhosis), liver cancer, and ultimately, liver failure. The CLF believes the key to shrinking this 1 in 4 statistic is through knowledge.

"The investment of research is a critical step in improving the prevention, diagnosis, and treatment of these diseases," says Fagan. "However, educating the general public without delay about the severity of liver disease and how one may avoid it can literally be the difference in a life or death situation."

March is "Liver Health Month", and the CLF is taking the opportunity to get Canadians familiarized with the facts, risks, and actions they will need to ward off liver disease. In the Check Your Engine campaign, the CLF is comparing the human body to a high-performance vehicle, and the liver as that vehicle's engine. The goal is that this example will resonate with the public and motivate them to avoid the risks associated with liver disease.

The public can view and share our video (English & French) and visit www.liver.ca/CheckYourEngine to receive practical tips, read stories behind those who are affected, and join in the CLF's awareness efforts by posting photos on Facebook and Twitter with the hashtag #CheckYourEngine.

About the Canadian Liver Foundation
Founded in 1969 by a group of doctors and business leaders concerned about the increasing incidence of liver disease, the Canadian Liver Foundation (CLF) was the first organization in the world devoted to providing support for research and education into the causes, diagnoses, prevention, and treatment of all liver disease. Today, we are bringing liver research to life by promoting liver health, improving public awareness and understanding of liver disease, raising funds for research, and providing support to individuals affected by liver disease.

Thursday, February 22, 2018

Young men's drinking tied to later liver disease risk

Young men's drinking tied to later liver disease risk
Last Updated: 2018-02-22
By Lisa Rapaport (Reuters Health)

Men who drink alcohol in late adolescence are more likely to develop severe liver disease decades later than young people who don't drink at all, a Swedish study suggests.

Researchers examined data on alcohol consumption for 43,296 men entering military service in 1969 and 1970 when they were 18 to 20 years old.

After an average follow-up of almost 38 years, a total of 383 men were diagnosed with severe liver disease, including 208 who died.

Each daily gram of alcohol men typically consumed in their youth was associated with a 2% increase in the risk of severe liver disease, even after researchers accounted for other independent risk factors for liver damage like obesity, smoking and cardiovascular disease.

Continue reading: http://www.chronicliverdisease.org/reuters/article.cfm?article=20180222Other1195795296

Sunday, January 7, 2018

Considering A Dry January? If Not - Let's Talk About Liver Disease

Considering A Dry January? If Not - Let's Talk About Liver Disease
Greetings, will you be changing any bad habits this year? If you consume too much alcohol why not take part in the "Dry January" campaign. Could one month of giving up alcohol improve your heath? Today over at NPR, Dr. Rajiv Jalan, talks about the science behind just that, listen to program, here.

The Effects Of Alcohol On The Body
The benefits of participating in a Dry January may be an effective stepping stone to giving up alcohol completely in the future. If you abuse alcohol consider this, the effect of alcohol on your body begins early on, but long-term use of alcohol can take a serious toll on your liver causing fibrosis, cirrhosis and liver cancer. Rather you drink a little or a lot, alcohol use increases your risk of developing not just liver cancer, but other cancers such as head and neck cancers, colorectal cancer, esophagus and female breast cancers. In addition, people with alcoholic liver disease and cirrhosis die more frequently from decompensation of cirrhosis than patients with cirrhosis related to chronic HCV infection or fatty liver disease, and alcohol-related liver disease has now surpassed HCV as the most common indication for liver transplant in the United States.

HCV & Alcohol 
Numerous studies have demonstrated the progression of liver disease for people with both alcohol abuse and HCV is worse when compared to people with only one disease. Those who have HCV and abuse alcohol show an increased rate of fibrosis and liver cancer, and have a higher rate of early death, compared to people with HCV who do not abuse alcohol. According to a 2016 prospective study published in the Journal of Hepatology drinking even low levels of alcohol is connected with increase risk for liver cancer in people with HCV related cirrhosis;
Whether alcohol intake increases the risk of complications in patients with HCV-related cirrhosis remains unclear. In this prospective study, light-to-moderate alcohol intake was associated with the risk of hepatocellular carcinoma in multivariate analysis. No patients who did not use alcohol and who reached viral eradication developed hepatocellular carcinoma during follow-up. The risk of hepatocellular carcinoma increased with alcohol intake or in patients without viral eradication and was highest when alcohol intake was present in the absence of viral eradication. Patients with HCV-related cirrhosis should be strongly advised against any alcohol intake. Patient care should include measures to ensure abstinence.
Read a nice summary of the article over at Healio.

In a more recent 2017 review, which explores risk of alcohol use in people with liver diseases other than alcoholic liver disease, that is people with hepatitis C, hepatitis B, fatty liver disease, and autoimmune hepatitis reported; alcohol consumption of more than 30 g per day in men and 20 g per day in women is associated with fibrosis progression, development of cirrhosis and hepatocellular carcinoma, and mortality in most liver diseases, view the article here.

How Do I Know If I Have Liver Disease Related To Alcohol?
In many cases, people who have developed liver disease associated with alcohol abuse just don't have any noticeable symptoms until their liver is badly damaged. 

What Is ALD? 
Alcohol-related liver disease or ALD, is caused by excessive consumption of alcohol overtime, the earliest stage of ALD is fatty liver disease, also called steatosis, and is the most common alcohol-related liver disorder. The next stage is alcoholic hepatitis, in which the liver cells become inflamed, finally alcoholic cirrhosis, develops when normal liver tissue is replaced by nonliving scar tissue.

Whilst many people who consume more than 60 g of alcohol a day (equivalent to half a bottle of wine or more than a litre of beer) will develop steatosis (accumulation of fat in the liver), only a minority will go on to develop the more serious condition of alcoholic liver inflammation (alcoholic hepatitis) and between 10 to 20% will develop cirrhosis (irreversible scarring of the liver). Alcohol consumption is responsible for nearly 5.9% of all deaths globally and 139 million disability-adjusted life-years lost due to premature death from alcohol.
How much Alcohol - Is Too Much?
Watch - All About Alcohol: Dr. Joe Galati
In 2017, Dr. Joe Galati discussed cutting down on alcohol and the importance of knowing the amount of alcohol in various types of alcohol and serving sizes.

The Bottom Line
Remember the best treatment for alcoholic liver disease is to not drink, hopefully your liver isn't too far damaged and can repair itself, prolonged alcohol misuse (drinking too much) over many years can reduce its ability to regenerate. As for people with HCV, not drinking is the on the list of the most important thing you can do for your liver. But you already know that. 

Again, HAPPY NEW YEAR!
Tina

Tuesday, October 3, 2017

BMJ Case Reports - Man developed serious liver damage after taking epsom salts to treat gallstones


Man develops severe liver damage after taking epsom salts
October 02, 2017
A 38-year-old man developed serious liver damage after taking epsom salts to treat gallstones, reveal doctors in the journal BMJ Case Reports.

The man had lost his appetite and was jaundiced. He was tested for a range of common liver diseases, all of which were negative. But a biopsy specimen showed that he had signs of liver damage.

It emerged that he had been taking three tablespoons of Epsom salts in lukewarm water for 15 days. He had been advised by a naturopath that this would dissolve his gallstones.

Taking too much Epsom salts can cause diarrhoea, abnormal heart rhythm, and kidney damage.

In this case, the man took a large quantity of salts over two weeks, which prompted rapid worsening of fibrosis (tissue scarring).

And the doctors caution that certain conditions might heighten the risk of liver damage when combined with Epsom salts.

The man was advised to stop taking the salts, to drink plenty of fluids, and was given medication to prevent further liver damage. And after around six weeks, his liver function had returned to normal.

View Article Online 
BMJ Case Reports 

Monday, September 4, 2017

Baby Boomers - What About HCV, Vaccinations, Liver Health & All That Jazz 

Baby Boomers - What About HCV, Vaccinations, Liver Health & All That Jazz
Whether you're a baby boomer, new to hepatitis C, thinking about getting tested or just looking to close a few knowledge gaps, thanks for stopping by.

With the flu season on its way, the focus today is on vaccinations for adults with HCV, risk associated with the use of acetaminophen, aspirin and non-steroidal anti-inflammatory drugs (NSAIDs). Also a look at risky drinking and drug misuse among baby boomers in the UK and Australia. As for exercise, NPR talks about the dangers of prolonged sitting and risk of a host of diseases, yep, among baby boomers. Last but not least, getting tested for the hepatitis C virus.

Immunization Action Coalition
Vaccinations for adults with hepatitis C infection
One-page sheet describes vaccinations that HCV-positive adults need

Click On Image To Enlarge

Source Link - http://www.immunize.org/catg.d/p4042.pdf

Get Your Flu Shot
People 65 years and older, living with chronic liver disease, cirrhosis and liver transplant recipients are particularly at risk from the flu and are more susceptible to flu-related complications.

Recommended Reading
Read all past and current Seasonal Flu Vaccine articles posted on this blog.

LINK
More information is available on the CDC website: Frequently Asked Flu Questions 2017-2018 Influenza Season

During The Flu Season Protect Your Liver
When the flu season hits home the first thing we do is run out to purchase an over-the-counter medication to help relieve cold and flu symptoms. According to the FDA, more than 600 medications used to help relieve pain and reduce fever, including prescription and over-the-counter (OTC) medications contain the active ingredient acetaminophen. When checking the label for "acetaminophen" it may not be spelled out in full on the container's prescription label. Abbreviations such as APAP, Acetaminoph, Acetaminop, Acetamin, or Acetam may be used instead.

To lower your risk of liver damage, the FDA suggests the following:
  • Follow dosing directions and never take more than directed; even a small increase in the recommended dose can cause liver damage.
  • Don't take acetaminophen for more days than directed.
  • Don't take more than one medicine that contains acetaminophen at a time. To determine if a medicine contains acetaminophen, read the "Drug Facts" label under "Active Ingredients". It will either say "acetaminophen" or "APAP." (APAP is an acronym for the chemical name, N-acetyl-paraaminophenol.)
  • Talk to your doctor before you take acetaminophen if you drink three or more alcoholic beverages every day, have liver disease, or take warfarin, a blood thinner. Together warfarin and acetaminophen may raise your risk of bleeding.
For a complete list of drug brand names containing acetaminophen, click here.

Tylenol & Viral Hepatitis
Hepatitis C Online is a great site with educational tools to learn more about diagnosis, treatment and HCV management. The following document addresses acetaminophen, aspirin and non-steroidal antiinflammatory drugs (NSAIDs) for people with or without cirrhosis.

Acetaminophen:
Acetaminophen (Tylenol) is a known hepatotoxin that can cause clinically important hepatotoxicity, either through an acute overdose or when taken on a regular basis (even at lower doses): in one large study that examined causes of acute liver failure, patients taking a dose less than 4 grams per day accounted for 7% of the total cases and in some were taking doses as low as 1 gram per day. Among healthy volunteers taking 4 grams per day for 14 days, more than 30% developed alanine aminotransferase (ALT) values in excess of 3 times the upper limit of normal. Concurrent alcohol use greatly increases the chance of acute or chronic acetaminophen-induced hepatotoxicity. Studies have also shown an increased risk of acute liver injury in patients with chronic hepatitis C following acetaminophen overdose, but none have examined the safety of long term, low dosages of acetaminophen in patients with chronic hepatitis C. Guidelines for the safe use of acetaminophen in HCV-infected persons do not exist. Considering many patients with chronic hepatitis C have limited pain treatment options, most experts believe low dosages of acetaminophen (up to two grams per day) can safely be used in most patients with chronic hepatitis C infection without cirrhosis; those with cirrhosis should limit their intake of acetaminophen to one gram per day. Patients drinking excess alcohol should avoid taking acetaminophen altogether. Clinicians should remind patients that many narcotic combination pills and over-the-counter cold and flu medications may contain acetaminophen. Patients taking acetaminophen should have laboratory monitoring for hepatotoxicity every 3 to 6 months.

Aspirin and Nonsteroidal Anti-inflammatory Medications:
A few different types of NSAIDs are available over the counter:
- Aspirin (Bayer, Bufferin, Excedrin) Each caplet of Excedrin Extra Strength Pain Reliever contains 250 milligrams (mg) of acetaminophen, 250 mg of aspirin, and 65 mg of caffeine
- Ibuprofen (Advil, Motrin IB)
- Naproxen (Aleve)

Aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) are generally safe for patients with hepatitis C when taken at standard doses.  The one exception is in patients who have cirrhosis: NSAIDS and aspirin are best avoided in patients with cirrhosis, especially those with decompensated cirrhosis. In patients with decompensated cirrhosis, the use of NSAIDS and aspirin may further increase the inherent risk these patients have for developing nephrotoxicity and gastrointestinal bleeding. Patients with chronic hepatitis C who do not have cirrhosis may take aspirin or NSAIDs at low or standard recommended dosages, with food and water.  Those with cirrhosis who have short-term, minor pain should, in general, avoid taking aspirin or NSAIDs, but can take acetaminophen in this setting as long as the dose does not exceed one gram per day.  In the unfortunate situation involving a patient with cirrhosis who has joint or musculoskeletal pain unresponsive to acetaminophen, NSAIDs can be used for a very brief period of time if given at the lowest daily dose possible.
Download PDF, here.

Of Interest

Harvard Heart Letter
Daily aspirin users 75 or older: Consider taking a stomach-protecting drug
Research we're watching

Roughly half of Americans ages 75 or older take a daily, low-dose aspirin to prevent a heart attack or stroke. New research suggests these people might benefit from taking a stomach-protecting drug to prevent a higher-than-expected risk of gastro-intestinal (GI) bleeding.

The study, published online June 13, 2017, by The Lancet, involved nearly 3,200 people who were prescribed aspirin because of a previous heart attack or stroke. Researchers followed them for up to 10 years to see how many were hospitalized for bleeding — a well-known side effect of aspirin use. Upper GI bleeding usually results from a stomach ulcer, which can cause anemia, heartburn, and abdominal pain.

The risk of serious GI bleeding was much higher among people ages 75 or older compared with people ages 65 or younger. But bleeding events were much less common in people taking prescription heartburn drugs called proton-pump inhibitors, such as omeprazole (Prilosec) and esomeprazole (Nexium). These drugs can reduce GI bleeding by as much as 90%, according to the study authors.

Recommended Reading
HCV Advocate's fact sheet contains information about acetaminophen for people with chronic hepatitis B or C. In this article; It’s Flu Season: When You Have Hepatitis B, Too Much Tylenol Can Damage Your Liver, Christine Kukka explains the dangers of Tylenol for people living with hepatitis B. Or check out this article from Pharmacy Times about general risks associated with over-the-counter pain medications.

Baby Boomers Alcohol & Drug Misuse
A rise in alcohol and drug misuse among the over 50s (commonly known as “baby boomers”) is causing concern, warn experts.
Researchers at South London and Maudsley NHS Foundation Trust and Flinders University in Australia, say the number of people aged over 50 experiencing problems from substance misuse is growing rapidly, with the numbers receiving treatment expected to treble in the United States and double in Europe by 2020.

Commenting on the research, which appeared in the British Medical Journal (BMJ), Vanessa Hebditch, the British Liver Trust Director of Communications and Policy said,

“Urgent action is needed to tackle drink and drug misuse among baby boomers – this research adds to the growing body of data in the UK suggesting that alcohol and other substance misuse is increasing among those in their mid-50s and older.

The over 50s have seen a time when filling up your supermarket trolley with wine and drinking at home has become normalised so that is part of our culture and this all too easily becomes habit forming. Alcohol has become increasingly acceptable and affordable.

The British Liver Trust advises that one easy step that people can take is to make sure that they have two –three consecutive days off every week from drinking – this not only reduces overall units but stops dependency.

However, if we are to turn around the massive increases in liver disease that we are seeing as a result of drinking too much we also need Government measures which tackle the affordability, availability and promotion of alcohol.”

The research found that in both the UK and Australia, risky drinking is declining, except among people aged 50 years and older, they explain. There is also a strong upward trend for episodic heavy drinking in this age group.

With alcohol being the most common substance of misuse among older people, under-detection of alcohol problems is of immediate concern – and may increase further as baby boomers get older because of their more liberal views towards, and higher use of, alcohol, they write.

A lack of sound alcohol screening to detect risky drinking may result in a greater need for treatment, longer duration of treatment, heavier use of ambulance services, and higher rates of hospital admission.

Research suggests that treatment programmes adapted for older people with substance misuse were associated with better outcomes than those aimed at all age groups.

However, the authors point out that clinicians will need improved knowledge and skills in assessing and treating older people at risk of substance misuse.

“There remains an urgent need for better drug treatments for older people with substance misuse, more widespread training, and above all a stronger evidence base for both prevention and treatment,” they write.

“The clinical complexity of older adults with substance misuse demands new solutions to a rapidly growing problem. So far, there has been little sign of a coordinated international approach to integrated care,” they conclude.

Read the full article here

Baby Boomers - Walk A Little Each Day
Get Off The Couch Baby Boomers, Or You May Not Be Able To Later
In a study of sitting and walking ability that surveyed people ages 50 to 71 across 8 to 10 years, those who tended to sit the most and move the least had more than three times the risk of difficulty walking by the end of the study, when compared to their more active counterparts.

Some ended up unable to walk at all. The study appears in the current issue of The Journals of Gerontology: Medical Sciences
Continue reading the article, or listen to the audio posted today over at NPR....

HCV & Baby Boomers
USA Today
Most boomers infected with liver-damaging hepatitis C virus do not know it
Boomers grew up and became young adults before the virus was identified in 1989. So it is likely many were infected through medical procedures and transfusions before improved infection control techniques and blood screening nearly eliminated those risks, CDC says. 
Continue reading...

Most of the 3.5 million Americans living with hepatitis C are baby boomers born from 1945 to 1965. Baby boomers are five times more likely to be infected with hepatitis C than other age groups. 
CDC officials recommend Hepatitis C testing for the following groups of people:

1- People born from 1945 through 1965. 
2- Current or former injection drug users, including those who injected only once many years ago.
3- Recipients of clotting factor concentrates made before 1987, when more advanced methods for manufacturing those products were developed.
4- Recipients of blood transfusions or solid organ transplants before July 1992, when better testing of blood donors became available.
5- Chronic hemodialysis patients.
6- Persons with known exposures to HCV, such as
health care workers after needlesticks involving HCV-positive blood
recipients of blood or organs from a donor who tested HCV-positive

7- Persons with HIV infection.
8- Children born to HCV-positive mothers.
Learn More Here.....

New Hepatitis C Infections Nearly Tripled over Five Years
The rising number of hepatitis C infections are primarily a result of increasing injection drug use associated with America’s growing opioid epidemic, according to the federal Centers for Disease Control and Prevention. Over five years, the number of new infections has nearly tripled, reaching a 15-year high. The highest number of new infections are among 20- to 29-year-olds.

Until next time.
Tina

Saturday, September 2, 2017

Updates - Cochrane Rebuttal, Impact Of HCV Therapy On Fibrosis & OTC Pain Medications

September Newsletters & Blog Updates From Around The Web
Here is another look at must-read articles you might've missed over the last week.

Cochrane Rebuttal
As you may recall in July, a Cochrane Collaboration systematic review concluded achieving SVR (cure) for patients using hepatitis C direct-acting antivirals (DAAs) doesn't correlate with any long term benefits, a highly debated topic, check out each rebuttal, "here."

On Twitter
Sep 21, 2017
Tweeted by  Henry E. Chang: Recently, authors of Cochrane DAA review "changed" their conclusions but remain amazingly tone-deaf to what HCV community & experts are saying.

Click on image to enlarge


From the AGA Reading Room over at MedPage today, in this article: SVR Good Indicator of Hep C Treatment Benefit - just published; Experts blast Cochrane review suggesting inadequate evidence for effectiveness of direct-acting antivirals, read it here.

Recommended Reading
Treatment with DAAs reduces the risk of mortality in the first 18 months after the completion of treatment
Michael Carter
Published:10 August 2017
The study – published in Clinical Infectious Diseases – matched people who received therapy with all-DAA regimens with untreated controls. Mortality rates in the first 18 months after therapy were significantly lower among people who received DAAs. After controlling for other factors, treatment with DAAs was associated with a 57% reduction in the risk of death.

A recent Cochrane Collaboration systematic review concluded that, due to the lack of long-term follow-up studies, there was no evidence that DAAs prolonged life or reduced liver-related ill-health in people who achieved SVR to DAA treatment. The Cochrane review has been strongly criticised by European and United States associations of liver experts for ignoring the short-term nature of the studies of DAAS designed for registration and for ignoring previous evidence from the treatment of hepatitis C, which showed that achieving SVR to interferon-based treatment was associated with a reduction in the risk of death and liver disease......
Continue reading.....

In The Journals

Impact Of HCV Therapy On Fibrosis
In a prospective cohort study evidence suggest SVR (cure) using direct-acting antivirals (DAAs) is associated with regression of liver fibrosis, according to a study published in European Journal of Gastroenterology & Hepatology/Aug 29 2017; "Regression of liver fibrosis over a 24-wk period after completing direct-acting antiviral therapy in patients with HCV receiving care within the national hepatitis C elimination program in Georgia."

Conclusion:
Achieving SVR using direct-acting antivirals (DAAs) is associated with regression in liver stiffness (LS), which could explain the clinical benefits associated with SVR. Our study also showed that irrespective of achieving SVR, liver damage will persist in a significant proportion of patients who had advanced fibrosis and cirrhosis at the time of HCV treatment initiation. Thus, early identification and treatment of patients with HCV infection can significantly prevent residual liver damage leading to the development of eventual hepatic complications.
LINK - Full text article
*PDF provided by Henry E. Chang via Twitter.

New Online

Perspective
New England Journal Of Medicine
A Tale of Two Epidemics — HCV Treatment among Native Americans and Veterans
Brigg Reilley, M.P.H., and Jessica Leston, M.P.H.
PDF Download
Audio Interview
In light of ongoing debates about health care budgets and rising drug prices, a current public health crisis can provide useful insights. For patients who get their health care through two separate federal agencies, the hepatitis C virus (HCV) epidemic is unfolding in vastly different ways. In recent years, the Department of Veterans Affairs (VA) health care system has mounted a response to HCV that should be the envy of any health system, public or private. On the other hand, the Indian Health Service (IHS), an agency that serves American Indians and Alaska Natives, is struggling to meet the needs of its patients with HCV.
Continue reading....

New At Hepatitis C Online
Vosevi and Mavyret
Information on Gilead's newly FDA approved Vosevi and AbbVie's Mavyret is now available.

Australia 
Australian recommendations for management of HCV have recently been updated.

Liver Health

Pharmacy Times
OTC Pain Medications: The Pros and Cons
AUGUST 30, 2017
Kathleen Kenny, PharmD, RPH
Two types of OTC pain medications are available. The first is acetaminophen (N-acetyl-p-aminophenol, or APAP), and the second is nonsteroidal anti-inflammatory drugs (NSAIDs), which include ibuprofen, naproxen, and aspirin.

Acetaminophen works by inhibiting the synthesis of prostaglandins, which help transmit pain signals and induce fever, thereby easing pain and lowering fever. Acetaminophen will not, however, reduce swelling and inflammation.5 Acetaminophen may be a good choice to treat headaches, arthritis pain, and fever.5 Certain patients should not take APAP, including those with liver disease, individuals taking blood thinners, people drinking three or more alcoholic beverages daily, and those with an allergy to APAP.6
Continue reading......

HCV Advocate
Acetaminophen and Your Liver
What does all this mean for people with chronic hepatitis B or C?
Doctors often recommend acetaminophen to relieve symptoms such as body aches and fever, which are common side effects of interferon therapy. For most people, acetaminophen is safe and effective. According to the FDA’s Dr. John Senior, “It’s very clear the average dose for the average person is very safe. But we are not all average people.” For many individuals, acetaminophen is still a good choice, especially considering that other over-the-counter pain relievers can cause problems of their own (such as stomach bleeding with aspirin and nonsteroidal anti-inflammatory drugs). Many HCV providers now recommend that their patients with HCV or other forms of liver disease take a somewhat lower dose than is generally recommended for people with healthy livers.
Continue reading.....

Of Interest
Harvard Heart Letter
Daily aspirin users 75 or older: Consider taking a stomach-protecting drug
Research we're watching

Roughly half of Americans ages 75 or older take a daily, low-dose aspirin to prevent a heart attack or stroke. New research suggests these people might benefit from taking a stomach-protecting drug to prevent a higher-than-expected risk of gastro-intestinal (GI) bleeding.

The study, published online June 13, 2017, by The Lancet, involved nearly 3,200 people who were prescribed aspirin because of a previous heart attack or stroke. Researchers followed them for up to 10 years to see how many were hospitalized for bleeding — a well-known side effect of aspirin use. Upper GI bleeding usually results from a stomach ulcer, which can cause anemia, heartburn, and abdominal pain.

The risk of serious GI bleeding was much higher among people ages 75 or older compared with people ages 65 or younger. But bleeding events were much less common in people taking prescription heartburn drugs called proton-pump inhibitors, such as omeprazole (Prilosec) and esomeprazole (Nexium). These drugs can reduce GI bleeding by as much as 90%, according to the study authors.

Blog Updates

HEP - Blog Updates
Hep is an award-winning print and online brand for people living with and affected by viral hepatitis. Offering unparalleled editorial excellence since 2010, Hep and Hep Magazine are the go-to source for educational and social support for people living with hepatitis.

Hepatitis C and Cirrhosis; Stages of Liver Damage
August 30, 2017 • By Connie M. Welch
Battle scars from hepatitis C. At times they can leave scars after going through a long journey with hepatitis C. No doubt each Hepatitis C patient transforms into a warrior on many fronts. Having hepatitis C is one of the leading causes for cirrhosis, cancer and liver transplants.

Sharing My Deepest Secrets
September 1, 2017 • By Carleen McGuffey
Like most people with Hepatitis-C I didn’t learn my status until decades after I had contracted the virus. By the time I was diagnosed I had changed my life so thoroughly that during the very few times I would even think about my wild years it would literally feel like I was considering a whole other person.

On Overdose Awareness Day, Let’s Choose Treatment Over Punishment
August 29, 2017 • By NVHR
People like Andrea Roberts, a 35-year-old mother of two children. Ms. Roberts had been incarcerated for about 6 weeks at LaPorte County Jail in Indiana, unable to afford bail, and had 2 weeks remaining until her release. Then, on July 15, 2017, a jail supervisor discovered her “unresponsive” in her cell. Within 30 minutes, after CPR was attempted, Ms. Roberts was pronounced dead.

To view a list of all bloggers please click here.

Médecins Sans Frontières/ Doctors Without Borders (MSF)
Médecins Sans Frontières(MSF) is an international, independent, medical humanitarian organisation. We offer assistance to people based on need, irrespective of race, religion, gender or political affiliation. Our actions are guided by medical ethics and the principles of neutrality and impartiality.

My name is Theresa Chan. I’m a family doctor and hospitalist from the United States. Working with MSF in the field has been a long-held dream. For most of 2017, I’ll be in Phnom Penh, Cambodia, where I’ll be working with a multi-national MSF staff to bring cutting-edge hepatitis C treatment to the people of Cambodia.

Fighting Hepatitis in Cambodia: Yellow as a Duck


'“This is the doctor,” said the son, pointing to me. The man in the bed made a weak attempt to greet me with his palms pressed together in the traditional Cambodian manner. “Hello,” I said, “may I listen to you?” He said yes. I listened to his faint breaths. He dozed off despite my prodding, the lids drawing like curtains over his yellow eyes.'

Cambodia: A Lot Happens On Our Days Off


Theresa is in Cambodia, where she's working at the Doctors without Borders / MSF hepatitis C clinic. She blogs about her tiniest patient so far, and why doctors are never entirely off duty...

HEPATITISC.NET
At HepatitisC.net we empower patients and caregivers to take control of Hepatitis C by providing a platform to learn, educate, and connect with peers and healthcare professionals

Pain: The Invisible Symptom
September 1, 2017
Pain is one of the lesser known symptoms many living with hepatitis C or who have undergone treatment experience. Pain can range from muscles aches and joint pain to neuropathy.

Truth and Lies about Hepatitis C
By Karen Hoyt - September 1, 2017
There can be a lot of confusion when you are first diagnosed with the Hepatitis C Virus. It takes time to figure out what is the truth and what is a lie..

Tips for Choosing a Health Care Provider with Hep C
By Karen Hoyt
Do you have faith in your medical provider? Does it seem like they have your best interest at heart, or are you just a number to them? There are few relationships as...

View all blog updates, here.

Hepatitis B Foundation
The Hepatitis B Foundation is a national nonprofit organization dedicated to finding a cure for hepatitis B and helping to improve the lives of those affected worldwide through research, education and patient advocacy. Our monthly electronic newsletter, provides research updates, healthy liver tips, information on public health initiatives, and other HBF news.

Diagnosed with Hepatitis B? Preventing Transmission to Others Learning the HBV Basics, Transmission Part II
Part I discussed how hepatitis B is transmitted and may have helped you determine how you were infected with HBV.   In Part II we will discuss the people closest to you who may be susceptible to your infection.
Continue reading....

View all updates, here.

Creating a World Free of Hepatitis C
Welcome to my website and blog. My name is Lucinda Porter and I am a nurse committed to raising awareness about hepatitis C. I believe that we can create a world free of hepatitis C. We do this together, one step at a time.

New Healthcare Provider? Questions to Ask
Are you going to see a new healthcare provider? If so, you may have questions for her or him.

Acts More Powerful Than Hurricane Harvey
Recently, Hurricane Harvey flooded, buffeted, and devastated southeastern Texas and nearby coastal areas. Then Harvey moved eastward to cause more damage. The toll is enormous and continues to grow as those communities cope with Harvey’s wreckage. Many have donated money and time in response to these needs. However, there is more that you can do—be a blood, tissue and organ donor.

Just For Fun

MD Whistleblower
Michael Kirsch, M.D.
I am a full time practicing physician and writer. I write about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When I'm not writing, I'm performing colonoscopies

Yikes! There's Food Stuck in My Throat! The Steakhouse Syndrome Explained
While I typically offer readers thoughts and commentary on the medical universe, or musings on politics, I am serving up some lighter fare today. Hopefully, unlike the patient highlighted below, you will be able to chew on, swallow and digest this post. If this blog had a category entitled, A Day in the Life of a Gastroenterologist, this piece would reside there.

View additional blog updates, here.

September Newsletters 
Whether you're looking for research, or easy-to-read articles on liver health, these newsletters reflect the most recent updates about viral hepatitis.

HCV Advocate
The HCV Advocate newsletter is a valuable resource designed to provide the hepatitis C community with monthly updates on events, clinical research, and education.

September Issue 
AbbVie’s Mavyret Approved.
Healthwise: Hepatitis C Is Threatening Our Youth
Under The Umbrella: Education in the HCV Treatment
Drug Pipeline

Archives

HCV Advocate Quick Links
Homepage - HCV Advocate
Homepage - HCV Medications Blog
News and Pipeline Blog - HCV Advocate
Homepage - Clinical Trials Reference Guide
Herbal Glossary
Homepage - HBV Advocate

Weekly Bull
HepCBC is a non-profit organization run by and for people infected and affected by hepatitis C. Our mission is to provide education, prevention and support to those living with HCV.

Latest Issue: Weekly Bull

The New York City Hepatitis C Task Force
The New York City Hepatitis C Task Force is a city-wide network of service providers and advocates concerned with hepatitis C and related issues. The groups come together to learn, share information and resources, network, and identify hepatitis C related needs in the community. Committees form to work on projects in order to meet needs identified by the community.

September Hep Free NYC Newsletter

HCV Action - UK
HCV Action brings together hepatitis C health professionals from across the patient pathway with the pharmaceutical industry and patient representatives to share expertise and good practice.

Public Health England has published its ninth annual Hepatitis C in the UK report, providing an update on the number of new hepatitis C infections and efforts to reduce mortality from HCV.

British Liver Trust
The British Liver Trust is the leading UK liver disease charity for adults – we provide information and support; increase awareness of how liver disease can be prevented and promote early diagnosis; fund and champion research and campaign for better services.

September Newsletter

News Updates
New research into end of life care for people with liver disease
Research published today has highlighted limitations in the care provided to people with advanced liver disease who are in the last year of life.

New study finds 86% of public support mandatory labelling on alcohol
As part of the Alcohol Health Alliance (AHA), the British Liver Trust has been …

Concerns over rise of substance misuse in “baby boomers”
A rise in alcohol and drug misuse among the over 50s (commonly known as “baby boomers”) is causing concern, warn experts. Researchers at South London …

The Hepatitis Foundation of New Zealand
The Hepatitis Foundation is a not-for-profit organisation which provides care for people living with hepatitis B. The Foundation provides a long-term follow-up programme for people living with chronic hepatitis B. This Programme provided Hepatitis B patients with ongoing monitoring and follow-up to help improve health outcomes.

Updates
Hepatitis symptom series: Depression and anxiety

Hep C Stories
James Story
I was diagnosed with hepatitis C in 2004. I had gone to my doctor because I was feeling a bit run down and he took some blood and put me on a vitamin supplement. At the time, I was working part time, studying full time and doing volunteer work. Being so busy, I had forgotten all about the blood test until I was contacted by the health department to inform me that I had been diagnosed hepatitis C positive and to get in touch with my doctor.

GI & Hepatology News
Over 17,000 gastroenterologists and hepatologists rely on GI & Hepatology News every month to cover the world of medicine with breaking news, on-site medical meeting coverage, and expert perspectives both in print and online. The official newspaper of the AGA Institute was launched in partnership with IMNG in January 2007.

View all newsletters, here.

Healthy You

NPR
In a study of sitting and walking ability that surveyed people ages 50 to 71 across 8 to 10 years, those who tended to sit the most and move the least had more than three times the risk of difficulty walking by the end of the study, when compared to their more active counterparts.

Some ended up unable to walk at all. The study appears in the current issue of The Journals of Gerontology: Medical Sciences.

Article here, listen below or here

Check back for updates, enjoy the rest of your weekend!
Tina

Sunday, August 27, 2017

Easy Learning With Yogi - 2017 Drug-Induced Liver Injury Conference For Patients

2017 Drug-Induced Liver Injury Conference
June 6-7, 2017
Hi folks, recently a very nice person on Twitter asked if I will be attending the AASLD 2017 meeting, I smiled when I read the message, thinking they would never let me in. I'm just a woman who had HCV, always a patient first, with a passion to pass on information to my readers. However, for a moment I envisioned myself meeting the ever so handsome Ira M. Jacobson. The good doctor is my hero! But how might it all end? Badly. In my state of excitement, I'll attempt to say something clever, I am clever by the way, but under pressure, not so much.

Anyhoo, after coming down to earth, a tweet from @AASLD came through announcing content from the 2017 Drug-Induced Liver Injury Conference is ready to read over at the AASLD website. Off I went to see what I could see - for you and me.

What About The Conference?
In June, experts in clinical hepatology and toxicology gathered to share current information about drug-induced liver injury (DILI). For people outside the medical profession, navigating around this incredible information is time consuming, maybe even boring, unless you know where to look . So with that said, for those of you living with liver disease or viral hepatitis, I have highlighted a few points of interest to share with you.

Learning With Yogi

Well, on second thought, all the great information coming out of the conference isn't boring, some information is even pretty entertaining, for instance this presentation:
Diagnosing DILI in Patients with Active or Advanced Underlying  Liver Disease (with a little help from Yogi)

LINK
Download PDF

So What About HBV Reactivation Associated with HCV Therapy? 
Yep, the conference covered that too. After PDF download, scroll down to the following topics: Reactivation of Hepatitis B in Trials with Immune Suppressive Drug and Detecting, and Evaluating Drug-Induced Liver Injury DILI with Active or Advanced Liver Disease; here is a quick summary.

Opening First Session - Tuesday 6 June 2017

Download PDF
Reactivation of Hepatitis B in Trials with Immune Suppressive Drug
Rajender Reddy
Lastly, I want to talk briefly about what's been going on in the hepatitis C field where there's been hepatitis B reactivation reported in the context of DAA therapy.

Detecting, Evaluating Drug-Induced Liver Injury DILI with Active or Advanced Liver Disease
Jim Lewis
Just to finish up.  The non-DILI causes of jaundice and other events are more common than we think.  Remember, DILI is uncommon.  It's a rare event, but so many other things are more common. People get viral hepatitis, they have gallstone diseases, they have all of the other things that are listed here, all of which confuse someone who's looking at abnormal liver tests.

Of Interest
12 Detection and Management of DILI in NASH/NAFLD
Subjects – Naga Chalasani
As the NAFLD field has heated up, it has come up quite frequently that DILI is more common in patients with NAFLD. How do you monitor for it, given that there are baseline fluctuations in liver chemistries?
LINK - Begin here......

Easy Reading
Abstract I-6_2017: Detection and Evaluation of DILI in Patients with Chronic Liver Disease.
Download Abstract
The specific issue of detecting acute liver injury in patients with underlying chronic liver disease (CLD)  and assigning causality to diagnose DILI remains challenging. The 2009 FDA Guidance FDA detecting and managing hepatotoxicity in patients in clinical trials did not provide any specifics in terms of dealing with patients with CLD. Recent clinical trials evaluating various therapies in patients with chronic hepatitis B, hepatitis C, NAFLD, PBC, malignancy  (with hepatic metastases), among other disorders face the very real issue of assessing hepatic events in the setting of underlying liver disease, which brings with it a potentially different set of rules. As a result, clinicians and drug manufacturers have had to utilize what Dr Senior refers to as “medical reasoning” in order to determine if DILI has occurred, and how usual stopping rules should be modified using the currently available causality assessment methods. The topic at hand can be divided into the historical past, the present and the future.
LINK - Continue reading....

More Easy Reading
Session IV - Consortia for Best Practices to Reduce DILI
General Discussion of Issues [PDF]
4.1 The IQ Initiative
 # 8. And we're all familiar with those areas.  Patients with pre-existing liver diseases are very poorly covered by existing guidelines, and there are many questions regarding how to address drug-induced liver injury in these patients.  It includes Hepatitis C, B, and NASH, and so on. Specific populations such as pediatric populations, geriatric population, oncology patients are, again, not well covered by existing guidelines or guidance or position papers.  Non-hepatocellular DILI is a big topic.  We are almost entirely focused on hepatocellular DILI, but there are 15 other types of drug-induced liver injury that we are not addressing. Specific drug groups are a big issue, such as immunosuppressant drugs, the group of chemotherapy-related immunotherapy.  The question of drug re-challenge that is repeatedly being addressed, but there's no strong, clear guidelines for drug developers. And finally, the huge question of biomarkers is an ongoing question.

We All Know About This Website
4.4 LiverTox update and prospects
Okay, I was asked to give an update on LiverTox, which is an online website dedicated to drug-induced liver disease.  It's been a collaborative effort between NIDDK and the National Library of Medicine, and is meant to be a source of reliable information on the clinical features, courses, and outcomes, and perhaps management of drug-induced liver disease due to both prescription and non-prescription medications, to herbal and dietary supplements. And its aims are to advance knowledge and support research.

 # 8. So how did we come up with a list of drugs to be included in this?  There's no one place that I know that you can go to that lists all the drugs that are available in the United States.  We began with a list provided by the, ah, it's not a pointer, provided by the National Library of Medicine, a computerized list of 28,000 drugs, which was a little bit frightening at the time. But actually, most of them were multiples, like acetaminophen, there were over 1,000 drugs that include acetaminophen.  There were unfortunately 700 varieties of OxyContin that you can purchase in America.  So we took out all the duplicates, and we got down to a total of about 2,800 different compounds, chemical compounds.

And then going through those one at a time, we excluded those that were topical agents only.  We excluded those that were very special.  There were some like vaccines, plasma products, drugs that are not prescribed but are given in very rare situations.  And also we took out veterinary medications and took out drugs that were not approved in the United States. 

We came down with an initial master list of 900 different drugs, which was seen to be achievable.  But in the interim, we've added more, we've added some HDS products, and we've added new agents as they're approved by the FDA each year, # 9. We currently have on my master list about 1236 agents.  And as I said before, 1124 are on the website as of last week. 

So here it is again, 1124 agents, about 91% of those on my list, master list.  And if we take out the herbals and the nutritional supplements, the metals and so forth, we end up with around 1,000 different prescribed drugs.  And looking those, there are some that are really similar, and you can group them together. For instance, all the estrogens we group as estrogens.  All the anabolic steroids.  Some drugs are actually just isomers of each other, like esomeprazole and omeprazole.  We come down to what I think is about 941 different drugs.
LINK - Check Out LIVERTOX Website

4.7 Chinese DILIN experience
# 2. And as we all know, the incidence of DILI in the general population is not very high.  The data from the United States suggests it's less 20 in 100 individuals.  The data suggests the older the age, the higher the incidence.  But one of the most important reasons behind this is the more prescriptions in older people.

# 3. Also, it is not so frequent in the general population.  But in clinical practice, DILI is one of the most common reasons for no-cause liver injury or for a no-cause liver disease because the drug can cause all kinds of liver injury we have ever known. # 4. Some countries have reported their data.  For example, the data from the United States and the European countries,
the most frequent agent to cause DILI is antibiotics.  However, in the Asia region, like Korea or Singapore, the most frequent agent is herbals or the traditional Chinese medicines, TCMs.
LINK - Review above topics, download general discussion here....

Better yet, jump over the AASLD website and sift through vast amounts of information.

Enjoy the rest of your weekend! Bye Ira.
Tina

Friday, August 25, 2017

Dr. Matt and Dr. Mike's Medical Podcast -The basic anatomy and functions of the liver.

Dr. Matt and Dr. Mike's Medical Podcast
August 25, 2017
Episode 8 - The Liver

After a joke, music intro, this patient friendly program will discuss the basic anatomy and functions of the liver.
Why is our poo brown? What is Jaundice and why do people with Jaundice turn yellow?
In this episode, Dr. Matt talks about the embryological origins of the liver and gross anatomy, while Dr. Mike talks about the function of the liver and its diverse role/s in metabolism, protein synthesis, hormone production, and storage.

Listen here...........

Friday, August 11, 2017

Ibuprofen most frequent drug-induced liver injury agent in Spain

Ibuprofen most frequent drug-induced liver injury agent in Spain
Zoubek ME, et al. Clin Gastroenterol Hepatol. 2017;doi:10.1016/j.cgh.2017.07.037.
August 10, 2017
Ibuprofen is one of the most frequent causative agents listed in the Spanish and Latin-American registries of the Drug-Induced Liver Injury Network, according to a recently published study.

“The risk of developing ibuprofen-induced liver injury is low considering the extensive use of this drug worldwide, but should not be overlooked as it can have life-threatening consequences,” the researchers wrote.

Continue reading @ Healio

Common brand names for ibuprofen Brufen, Advil, Motrin, and Nurofen

All News At Healio

Saturday, July 15, 2017

Alcohol Consumption in Concomitant Liver Disease: How Much is Too Much?

Current Hepatology Reports
June 2017, Volume 16, Issue 2, pp 152–157

Alcohol Consumption in Concomitant Liver Disease: How Much is Too Much?\
Hannes Hagström

This article is part of the Topical Collection on Management of the Cirrhotic Patient
Download full text PDF

Abstract
Purpose of Review
High consumption of alcohol can lead to cirrhosis. The risk of a low to moderate consumption of alcohol in the setting of a concurrent liver disease is less clear. The aim of this review is to sum the evidence on the risk of adverse outcomes in patients with liver diseases other than alcoholic liver disease who consume alcohol.

Recent Findings
High alcohol consumption is strongly associated with adverse outcomes in most liver diseases. For hepatitis C, some evidence points to an increased risk for fibrosis progression also with low amounts. For non-alcoholic fatty liver disease, most studies indicate an inverse association between fibrosis and alcohol consumption, but methodological limitations reduce inference.

Summary
High alcohol consumption is associated with an increased risk of fibrosis progression and other adverse outcomes, while less is clear regarding low to moderate consumption. Obtaining high-level evidence on this topic ought to be the objective of future studies. Currently, an individual risk profile should be obtained in patients with liver disease who consume alcohol.

Keywords Alcohol Cirrhosis Fibrosis NAFLD Liver disease

Introduction
Alcohol consumption is deeply embedded in most human societies, with some evidence suggesting that production of alcohol started as early as 10,000 BC [1, 2]. As an extremely available stimulant, the consumption of alcohol is vast, with 86% of US citizens reporting any lifetime alcohol consumption [3], and a mean consumption of 8.6 l of pure alcohol per year in the USA, compared to 6.2 l per year globally [4]. Alcohol has been reported to account for 85,000 deaths per year in the USA [5], and as much as 5.9% of all global deaths can be attributed to alcohol [4].

It has long been known that alcohol has detrimental effects on the liver by inducing alcoholic liver disease (ALD) [6], and alcohol accounts for up to 50% of all deaths in liver cirrhosis on a global scale [4]. However, although 90% of persons who consume more than 60 g of alcohol per day, roughly equivalent to six drinks, develop steatosis [7], significant fibrosis or cirrhosis only develops in up to 30% of this population [8, 9, 10]. In contrast, a low to moderate consumption of alcohol, below two drinks per day in women and three drinks per day in men, has not been associated with an increased risk for liver disease and is currently considered safe in most countries [11, 12], although a more restrictive approach is currently advocated in some countries, including the UK where the recommended maximum intake for men is now two drinks per day [12].

The role of low to moderate consumption in the setting of a concurrent liver disease is controversial, as an interactive effect could be present. This review briefly sums the epidemiological evidence for the risk of alcohol consumption in patients with liver diseases other than alcoholic liver disease.

NAFLD
Non-alcoholic fatty liver disease (NAFLD) is strongly associated with obesity, insulin resistance, and the metabolic syndrome [13, 14, 15]. Tracing the global obesity pandemic, NAFLD is now the most common liver disease, affecting up to 25% of the global population [16•] and is expected to become the leading indication for need of liver transplantation in the USA in the near future [17, 18]. Epidemiological studies have suggested an interactive effect between at least high-grade consumption of alcohol and obesity. In a study of almost 10,000 British men followed for 29 years, an increased risk for death in liver disease was found for consumption of more than 15 drinks of alcohol per week across all BMI categories. However, this risk was accentuated in obese men (RR 18.9, 95% CI 6.84–52.4) compared to normal weight men (RR 3.16, 95%CI 1.28–7.80) [19]. Similar findings have been found for women in the Million Women Study [20], where women who consumed more than 150 g of alcohol per week had a higher risk for development of liver cirrhosis if they also were obese than if they had a normal BMI.

In contrast, in patients with known NAFLD and compared to abstainers, a low to moderate consumption of alcohol has been associated with lower values of ALT [21], lower prevalence of hepatic steatosis [22, 23•, 24, 25], non-alcoholic steatohepatitis (NASH) [26], carotid plaques [27], and lower stages of fibrosis [26, 28•]. This is of importance since the most significant predicting factor for mortality in NAFLD is the stage of fibrosis [29, 30]. Contrasting this, a recent Mendelian randomization study found that NAFLD patients with a mutation in the aldehyde dehydrogenase gene, which leads to a slower metabolism of ethanol and therefore making persons with the mutation less likely to consume alcohol due to more side effects, did not have higher stages of fibrosis or prevalence of NASH [31••].

Heavy episodic drinking has been shown to increase the risk of fibrosis progression in biopsy-proven NAFLD [32], although this study did not evaluate lifetime consumption. There have been no randomized controlled trials of alcohol consumption in patients with NAFLD. However, a RCT of moderate red wine consumption in healthy students found that consumption of 33 g per day in men and 16 g per day in women for 3 months did not induce MRI-measured steatosis in single subject, indicating that to develop steatosis, either a higher dose or a longer duration of alcohol consumption is needed to induce steatosis [33••].

Notably, the main cause of death in NAFLD is cardiovascular disease [29]. Epidemiological studies indicate a J-shaped association between the amount of alcohol consumed and the risk of cardiovascular disease [34, 35], indicating that a low to moderate consumption of alcohol might actually be beneficial in NAFLD. A more extensive review on the effect of low to moderate alcohol consumption on NAFLD was recently published for the interested reader [36•].

Hepatitis C
Chronic viral hepatitis C (HCV) is highly prevalent, with data indicating that between 2.7 and 5.2 million persons are infected in the USA [37, 38, 39] and approximately 130 million cases globally [40]. HCV-related disease, including cirrhosis and hepatocellular carcinoma, accounts for around 700,000 deaths each year [41]. Alcohol consumption is high in many patients with HCV, especially those infected through intravenous drug use [42, 43]. A large sum of evidence points toward an interactive effect on the risk for fibrosis progression and development of cirrhosis in patients with HCV and a high consumption of alcohol of at least 30 g per day [44, 45, 46, 47]. The role of low to moderate alcohol consumption in HCV is less clear. A French cross-sectional study of 260 HCV patients found no increased risk of fibrosis progression in subjects consuming below 30 g per day [48]. By contrast, in a group of 78 untreated patients with HCV that underwent paired liver biopsies with a median time of 6.3 years between biopsies, higher alcohol consumption and higher drinking frequency was independently associated with fibrosis progression. All these patients drank below 40 g of alcohol per day (median 4.8 g per day), suggesting that even a low consumption of alcohol is harmful in HCV [49].

Hepatitis B
As for HCV, a high consumption of alcohol corresponding to more than 30 g/day is associated with adverse outcomes, including an increased risk for mortality [50] and development of hepatocellular carcinoma [51, 52]. Regarding low to moderate alcohol consumption, less is clear. In a study of 1045 Chinese patients with hepatitis B investigated with transient elastography, patients who reported consumption of 1–20 g of alcohol per day did not have advanced fibrosis to a higher extent than patients who reported being abstainers [53]. As in many other studies, these are cross-sectional data which is prone to potential misclassification bias due to under-reporting of alcohol consumption in heavy drinkers or recall bias and should be interpreted cautiously.

Autoimmune Liver Diseases
This group of liver diseases includes autoimmune hepatitis (AIH), primary biliary cholangitis (PBC), and primary sclerosing cholangitis (PSC). As these are rare conditions, not much evidence regarding alcohol consumption is available, and results from studies in this area should be interpreted cautiously. In AIH, an inverse association between alcohol consumption and the diagnosis of AIH was seen in a dose-response pattern in a smaller study of 72 AIH patients [54]. For PBC, a case-control study of more than 2,500 PBC patients in the UK found that alcohol use, defined as if a person had ever consumed alcohol regularly, was negatively associated with the presence of PBC [55]. An association between any alcohol consumption and HCC was found in a smaller case-control study of 52 Chinese PBC patients with HCC, where alcohol consumption was more common in HCC cases (31%) than in controls (8%, p = .01) [56]. In a larger European study, however, no association was found between alcohol consumption over 40 g per day and HCC in 716 PBC patients [57].

In PSC, alcohol consumption has been suggested to increase the risk of development of cholangiocarcinoma (CCA) [58]. However, this study included only four PSC patients with CCA and current alcohol consumption, why the dose-response effect is unclear. In a study of 96 Swedish PSC patients, lifetime alcohol consumption was low at 2.6 units of alcohol per week in mean. No association between alcohol consumption and higher values on transient elastography was found [59]. No cases of CCA were included in this cross-sectional study.

Hemochromatosis
Hereditary hemochromatosis (HH) is a genetic disorder of iron metabolism leading to inappropriate iron absorption and iron loading in various organs, especially the liver, and can lead to fibrosis progression and cirrhosis. In a study of 224 HH patients, 61% of subjects who consumed more than 60 g of alcohol per day had severe fibrosis or cirrhosis, compared to 7% of subjects who consumed less than 60 g per day [60]. Similar findings have been found in other studies [61, 62, 63]. The role of low to moderate alcohol consumption as a risk factor for fibrosis progression in HH remains to be studied.

Liver Transplantation
ALD is one of the leading indications for liver transplantation (LTX), and cases listed for LTX due to ALD have increased by 45% between 2004 and 2013 in the USA [17]. Although no formal recommendation on alcohol consumption exist for non-ALD cases either from AASLD or EASL after LTX, [64, 65] a careful approach is often advocated. Indeed, around 60% of non-ALD cases continue to consume alcohol after LTX, although often in small amounts [66]. Excessive drinking after LTX, independent of the primary indication, is associated with increased mortality [67] and graft loss [68].

Methodological ConsiderationsSeveral difficulties exist when trying to investigate the risk of alcohol consumption on disease progression or severity in concomitant liver disease. First, most studies investigating alcohol consumption have done so by using methodological designs including patients with manifest liver disease, including cirrhosis or HCC. This could induce misclassification bias of persons who has had a high lifetime consumption of alcohol but are currently abstaining due to symptoms, so-called “sick quitters” [69].

Also, patients under evaluation for any liver disease might be reluctant to disclose their true alcohol habits, or might unknowingly under-report these, leading to misclassification or recall bias. Indeed, in a recent study of 120 NAFLD patients who all reported drinking less than 14 units of alcohol per week, 11% of the sample had high levels of phosphatidyl ethanol (PEth) [28•], a validated marker for recent alcohol consumption [70, 71, 72], suggesting a higher than reported consumption of alcohol. This indicates that some patients with NAFLD could actually be classified as ALD patients. The use of validated biomarkers such as PEth could be one way to differentiate between NAFLD and ALD.

Second, different confounding factors could possibly explain the association between both detrimental and beneficial effects of alcohol and severity of liver disease. These include among others physical activity, smoking, dietary factors such as coffee and antioxidants, drinking patterns, and type of alcohol consumed, why such factors should ideally be accounted for in future studies.

Finally, genetic differences including mutations in the PNPLA3 [73, 74] and TM6SF2 genes [75, 76] are associated with increased risk of adverse outcomes in ALD and could influence the risk of disease progression that alcohol consumption might assert on any concurrent liver disease.

Conclusions
In summary, alcohol consumption of more than 30 g per day in men and 20 g per day in women is associated with fibrosis progression, development of cirrhosis and hepatocellular carcinoma, and mortality in most liver diseases. Large, well-designed studies on the risk, or benefit, of low to moderate alcohol consumption in the setting of concurrent liver disease are missing but are eagerly awaited. An individual approach should be made by clinicians advising patients with known or suspected liver diseases.