Abnormal LFTs in migrant populations

Dr Doug Macdonald

Consultant Hepatologist

Royal Free Hospital

Migrants in London

www.migrationobservatory.ox.ac.uk

Migrants in London

Migrants in London

Common liver diseases in migrant populations

• Viral Hepatitis

• Alcoholic liver disease

• Non-alcoholic steatohepatitis (NASH)

Diagnostic and treatment challenges specific to migrant populations

Macedonian

Bulgarian

Scottish

English

Indian

Burmese

Summary of Pathway • Isolated hyperbilirubinaemia – Gilbert’s. Exclude haemolysis

• Jaundice with other abnormal LFTs (Bilirubin>40) – urgent referral

• ALT>300 – urgent discussion and referral

• Cholestatic LFTs (raised GGT, ALP) or “hepatitic” picture (ALT<300) request

USS and liver “panel” then refer if abnormalities detected: HBsAg HCV Ab Autoantibodies Ferritin/ TF saturation Caeruloplasmin Immunoglobulins α1-antitrypsin • If normal screen for alcohol excess give lifestyle advice and monitor LFTs

• If fatty liver on USS is the only abnormality – see NAFLD pathway

Liver disease with normal LFTs

Alazawi W et al. Br J Gen Pract 2014;64:e694-e702

Alazawi W et al. Br J Gen Pract 2014;64:e694-e702

Prevalence of NAFLD, ALD, HBV and HCV in different ethnic groups within the

general population.

NAFLD Pathway

Summary of NAFLD Pathway

• Use the FIB4 test to identify patients at high risk of advanced fibrosis

( Age x AST ) / ( Platelets x √ALT )

• Non-invasive tests (e.g. ELF) for patients with intermediate FIB4 score

• High FIB4/positive non-invasive test should be referred to hepatology

• Low FIB4/negative non-invasive fibrosis test managed in primary care: • Treat metabolic syndrome components (hypercholesterolaemia,

diabetes, hypertension) • Lifestyle modification – diet , exercise, alcohol • Aim 10% weight loss • Annual LFTs and reassess fibrosis risk if LFTs remain abnormal

Weight loss– a level playing field?

• 3 components: • Reduced calorie diet • Increased physical activity • Maintenance strategy (e.g. group monitoring)

• Tailored delivery by trained interventionalist (physical trainer, dietician,

psychologist) produces better weight loss than advice alone

• BUT – Short-term weight loss (6 months) almost always followed by slow regain of initial weight over 1-2 years

• No evidence for weight loss programmes tailored to ethnic or cultural minorities

Weight loss– a level playing field?

Gill JM, Celis-Morales CA, Ghouri N. Physical activity, ethnicity and cardio-metabolic health: does one size fit all? Atherosclerosis. 2014 Feb;232(2):319-33.

Alazawi W et al. Br J Gen Pract 2014;64:e694-e702

Alcohol

ALD in the EU

WHO status report on alcohol and health in 35 European countries 2013

Alcohol in Migrant Populations

Pattern Ethnic Group

Low rates of drinking but high consumption in drinkers

Pakistani men, mixed ethnicity men

High rates of drinking and high consumption

White ethnicities (Irish, Scottish, Polish, English), Sikh Men,

Low rates of drinking and low consumption in drinkers

Chinese, Bangladeshi, Hindu

Rising rates and consumption Indian women and Irish women of high socioeconomic status

Ethnicity and alcohol: A review of the UK literature. Middlesex University 2010

Alcohol in Migrant Populations

• Rates and pattern of consumption in country of birth is a poor indicator

of alcohol consumption in the UK • Migrants adopt local consumption patterns

• 2nd generation not distinguishable from general population • Alcohol use associated with migration itself- social isolation, anxiety and

depression

Ethnicity and alcohol: A review of the UK literature. Middlesex University 2010

Alcohol – screening and treating

A QOF for alcohol consumption screening and brief intervention? - Currently under development by NICE , but only in patients with

hypertension SIPS study: 3 cluster randomised controlled trials of brief interventions in primary care, emergency departments and probation services. Brief lifestyle counselling tool, patient information leaflet, Brief advice tool. Follow-up at 6 months and 12 months (AUDIT questionnaire)

SIPS study in Primary Care

Screening and treating the migrant population

EACH - Ethnic Alcohol Counselling Hounslow Eastern Europe Advice Centre – AA meetings for Polish-speaking attendees Tailored patient information leaflets?

Marian Bogusz,“Stop Drinking! Come With Us and Build a Better Tomorrow”, 1952.

Jacek Cwikla, Untitled, 1984.

American Journal of Public Health | November 2010, Vol 100, No. 11

Alazawi W et al. Br J Gen Pract 2014;64:e694-e702

Hepatitis B

Primary Care Management of Viral Hepatitis B Guidance This guidance has been been developed in collaboration with local specialists in Camden and Islington This is to assist GPs in decision making and is not intended to replace clinical judgment

Newly Diagnosed Hepatitis BsAg positive patient

Perform following tests in primary care:

• FBC, INR • LFT (inc AST and ALT) & AFP • HBeAg, HBeAb, HBV DNA viral load • Hepatitis C, Hepatitis D • HIV (offer) • Ultrasound Liver scan

See next page for guidance regarding secondary care pathway

Refer to secondary care Document co-morbidities. Special attention to psychiatric, cardiovascular and immune

Attach all blood and US scan results

Offer testing and immunization of the household

Offer lifestyle advice regarding alcohol, obesity and hepatitis B Test for Hepatitis A and offer vaccination if not immune

Consider Urgent referral if • US demonstrates HCC • ALT> 300 • Evidence of

decompensated liver disease i.e. ascites/ encephalopathy, jaundice

~350 million worldwide

>8%

2-8%

<2%

Adapted from Centre for Disease Control, USA

Hepatitis B

Hepatitis B in Migrants

Late presentation (HCC, decompensated cirrhosis) Ethnicity confers additional HCC risk. 6 monthly AFP and USS: - Cirrhosis - Asian men >40 - Asian women >50 - African > 20 Do our responsibilities for contact tracing end at the border?

Alazawi W et al. Br J Gen Pract 2014;64:e694-e702

Hepatitis C

>10%

2.5-10%

1-2.5%

<1%

~150 million worldwide

Adapted from Centre for Disease Control, USA

Hepatitis C

Primary Care Management of Viral Hepatitis C Guidance This guidance has been been developed in collaboration with local specialists in Camden and Islington This is to assist GP’s in decision making and is not intended to replace clinical judgment

Newly Diagnosed Hepatitis C antibody patient

Perform following tests in primary care including: • FBC, INR

• AFP, LFT’s (inc AST and ALT), TFT’s • HCV RNA viral load, HCV

Genotype • HIV (offer), HAV, HBV, HDV • Ultrasound Liver scan

See next page for guidance regarding secondary care

pathway

Refer to secondary care Document co-morbidities. Special attention to psychiatric, cardiovascular

and immune Attach all results

Offer hepatitis A testing and vaccination

Offer lifestyle advice regarding alcohol, obesity and hepatitis C

Consider Urgent referral if • US demonstrates HCC • ALT> 300 • Evidence of

decompensated liver disease i.e. ascites/ encephalopathy, jaundice

HCV antibody positive patient discharged post treatment (RNA negative)

Annual Review for Chronic Liver Disease • FBC, LFT’s, AFP

If rising LFT’s, follow abnormal LFT pathway and ensure relevant blood

tests done (do not need repeat genotype)

Abnormal Tests

Hepatitis C in Migrants

Under-diagnosis

Under-treatment

Poor response to treatment

Not being tested at the point of care

Genotype 3 now the most difficult to treat, especially when cirrhotic

Unequal access to care, lack of awareness of new treatments, Poor information management by Secondary care.

Summary

The study of migrant populations is inherently reductionist and often conflates ethnicity, genetics, country of origin and even religion. An awareness of prevalence in country of origin is useful for targeted screening, particularly for viral hepatitis, but this must encompass patients with normal LFTs Certain migrant populations are at greater risk of NASH and a lack of response to lifestyle interventions does not necessarily indicate non-compliance. Studies of drinking patterns in migrant populations are of questionable utility, but interventions for ALD may be more effective if tailored to the target population There is an urgent issue with unequal access to diagnosis and treatment of HCV