Your Liver - Q1 2021

Q1 / 2021

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Your Liver

Full campaign on www.healthawareness.co.uk

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“Despite being highly preventable, liver disease is a silent killer.”

Pamela Healy, Chief Executive, British Liver Trust

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Online at healthawareness.co.uk

“Chronic fatigue and problems with concentration are long-term features of life with PBC.”

“Just 13% of patients diagnosed with liver cancer survive for five or more years.”

Collette Thain MBE, CEO, PBC Foundation

Natalie Day, Chief Executive Officer, the Foundation for Liver Research Dr Shilpa Chokshi, Acting Director and Chief Scientific Officer, the Institute of Hepatology, London

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IN THIS ISSUE

04 New research is helping us better understand liver disease.

It’s time to sound the alarm on late diagnosis of liver disease Late diagnosis of liver disease is causing a crisis across the UK, denying many patients the chance of getting the best possible treatment. Evidence shows the earlier a patient is diagnosed, the greater their chance of survival.

Natalie Day, Chief Executive Officer, the Foundation for Liver Research Dr Shilpa Chokshi, Acting Director and Chief Scientific Officer, the Institute of Hepatology, London

06 Entire generations could be saved.

Dr Su Wang, President, World Hepatitis Alliance

06 NASH is a “hidden epidemic” as there are often no symptoms in the early stages.

Vanessa Hebditch, Director of Policy and Communications, British Liver Trust

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WRITTEN BY

Pamela Healy Chief Executive, British Liver Trust

T

hree quarters of people are currently diagnosed with liver disease in an emergency setting and by this time it is often too late for effective treatment.

Despite being highly preventable, liver disease is a silent killer and there are usually no symptoms in the early stages.

Lack of awareness of the seriousness and prevalence of the disease, together with the stigma that often surrounds i,t means that it is consistently overlooked and underfunded.

Prevention of liver disease Ninety per cent of liver disease is preventable and if liver damage is detected at an early stage, a patient can make lifestyle changes that can stop the progression or even reverse the damage.

However, GPs lack effective tools to find those at risk and make an early diagnosis.

At the British Liver Trust, we know that there are areas of the UK which have excellent pathways in place – we need to see these pockets of good practice rolled out across the UK. We are also calling for liver disease to be part of the routine NHS (over 40’s) health checks.

Prioritising liver health Liver disease usually has no symptoms in the early stages so the best defence for any of us is to take steps to keep our livers healthy.

The liver is a remarkable organ, performing hundreds of vital functions including the removal of waste

While the liver works hard and can take a lot of abuse, it is like an elastic band – it can only stretch so far before it breaks.​ products and storing nutrients. Despite this, most people underestimate the importance of looking after it.

While the liver works hard and can take a lot of abuse, it is like an elastic band – it can only stretch so far before it breaks.​ Three simple steps to improve your liver health:

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Drink within recommended limits and have three consecutive days off alcohol every week.

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Eat a healthy diet and take plenty of exercise.

Know the risk factors for viral hepatitis and get tested or vaccinated if at-risk.

To address the late diagnosis of liver disease, the British Liver Trust has launched a new campaign called ‘Sound the Alarm on liver disease’ to demand faster diagnosis.

You can find out if you’re at risk by visiting our screener here: www.britishlivertrust. org.uk/screener

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Boost in fight against liver disease A new non-invasive approach to identifying levels of liver fat could deliver an important boost in the fight against liver disease.

E INTERVIEW WITH

Renaud Maloberti Chief Commercial Officer (CCO), ENDRA Life Sciences (Nasdaq: NDRA)

WRITTEN BY:

Mark Nicholls

Paid for by ENDRA Life Sciences

arly diagnosis is key to helping combat liver disease.

Changes in lifestyle can prevent the condition becoming serious and developing into NAFLD (non-alcoholic fatty liver disease) or NASH (non-alcoholic steatohepatitis).

However, early monitoring of the liver for excess fat is not always straightforward and the acknowledged gold standard approach of MRI-PDFF (proton density fat fraction) scan is costly, while the alternative of biopsies are uncomfortable and invasive for the patient.

Because of the nature of liver problems, diagnosis can often come too late for effective interventions to be implemented without resorting to more drastic and invasive treatments.

The scale of the problem is significant, according to Renaud Maloberti, Chief Commercial Officer of ENDRA Life Sciences, who says NAFLD affects well over one billion people worldwide.

“If not diagnosed and treated it can progress to liver inflammation (a.k.a NASH), cirrhosis, liver cancer and conditions that can ultimately lead to a patient requiring a liver transplant.

Liver disease is also closely associated with diabetes and cardiovascular disease,” he adds.

Non-invasive liver assessment ENDRA has developed a unique solution to help advance liver disease diagnosis with its TAEUS® product offering rapid, non-invasive, pointof-care liver disease assessment.

TAEUS stands for Thermo Acoustic Enhanced Ultrasound and is a unique technology using a hybrid combination of radio frequency and ultrasound to characterise tissue.

The TAEUS probe, when placed on the patient’s skin for 1.2 seconds, provides a numerical reading to assess the amount of liver fat. Physicians can characterise tissue and non-invasively evaluate NAFLD. “Liver disease is growing rapidly, due our lifestyles and a host of other causes, including diabetes,” continues Mr Maloberti. “It’s a progressive, often asymptomatic disease, which can lead to much more expensive care issues from a healthcare system standpoint – like a liver transplant.”

How stigma can delay liver disease diagnosis Reducing stigma associated with liver disease is crucial in helping tackle the condition, according to leading experts in the field.

S INTERVIEW WITH Prof. Maria Buti Chair of EASL Policy and Public Health Committee, EASL

INTERVIEW WITH Prof. Jeffrey Lazarus Member of EASL Policy and Public Health Committee Member, EASL WRITTEN BY: Mark Nicholls

tigma surrounding liver disease is hampering the fight against the condition. Experts in the field are concerned that patients are often hesitant in seeking help because of negative connotations associated with it.

Professor Jeffrey Lazarus explains that this stigma arises out of an association of liver disease with alcohol use or drug abuse, or in the case of NAFLD (non-alcoholic fatty liver disease), with obesity.

The reluctance to seek medical help because of stigma is delaying diagnosis and, in turn, leading to poorer outcomes, he adds.

In addition, hepatitis B in Europe has a higher prevalence among people from sub-Saharan Africa, resulting in stigmatisation of migrant communities.

Advocating early diagnosis But Professor Lazarus, who is ViceChair of the European Association for the Study of Liver’s (EASL) International Liver Foundation,

stressed that liver disease affects the wider population and is not limited to specific sections of society.

Another concern is discrimination from healthcare professionals, such as withholding liver disease treatment from those who inject drugs.

“When that stigmatising or discriminatory behaviour is in a healthcare setting, it is a double whammy,” he says. “People do not come back for appointments, but if we detect liver disease early, we can treat it. But if it is later, it may be too late to deliver effective treatment; it could become cancer, or end-stage liver cirrhosis.”

With most people who have liver disease not showing symptoms, EASL advises those who may be at risk to have liver tests. And here, primary care plays a central role.

Professor Maria Buti, Chair of the EASL Policy and Public Health Committee, says an important step would be increase awareness and improve the diagnosis of liver disease among primary care physicians.

Lifestyle changes Early assessment can either rule out NAFLD or allow for lower cost interventions such as lifestyle changes or, in the near future, targeted drug therapies.

“Clinical literature indicates that anybody with more than 5%-6% liver fat, needs to be monitored,” he continues.

“Since there is no convenient way to monitor NAFLD, people tend to find the problem when the disease is already in the more advanced stages.”

With a rich pipeline of drugs in development to fight liver disease, he believes simple, point-of-care diagnostics will be essential to screen-in patients and monitor the effectiveness of those therapies for patients.

ENDRA’s new TAEUS product has CE certification in Europe. TAEUS has not yet been approved for sale in the US. Clinical evaluation at six sites in the United States and Europe are comparing its performance with MRI-PDFF in 75-100 patients at each location, with the aim of deploying it clinically in 2021.

For more information visit: ENDRAinc.com

The reluctance to seek medical help because of stigma is delaying diagnosis and, in turn, leading to poorer outcomes.

The impact of the pandemic She also notes that the COVID-19 pandemic has had a major impact on liver disease and particularly on hepatitis elimination plans, with less screening activity, and fewer diagnoses as laboratories focus on coronavirus.

As well as healthcare services being overwhelmed, harm reduction and addiction centres have closed or been working on reduced hours.

With liver disease a major cause of mortality in the working-age population in Europe, her concern is that this perfect storm of events will translate into more cases of liver-related conditions such as viral hepatitis, NAFLD/NASH and alcohol-related liver disease.

EASL believes awareness of liver disease needs to be raised among the public and that healthcare professionals should be more aware of the need for de-stigmatising behaviours.

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Research is showing the way forward for liver disease

PBC: health care begins with self-care

The human body is built to repair itself and the most astonishing example of this is the liver, which is the only solid organ to regenerate. New research is helping us better understand liver disease.

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he liver is an organ designed to meet the daily challenges of keeping us healthy. Yet increasingly, as is evident from the astonishing 400% rise in rates of liver disease in the UK over the last 40 years, we are pushing it beyond the limits of tolerance.

WRITTEN BY

Natalie Day Chief Executive Officer, the Foundation for Liver Research

WRITTEN BY

Dr Shilpa Chokshi Acting Director and Chief Scientific Officer, the Institute of Hepatology, London

Unlocking the reasons for different clinical outcomes Alcohol is one of the most well-known challenges testing the liver. Addressing the underlying psychological addiction and achieving abstinence remain the main treatments for alcoholic liver disease (ALD).

There are no targeted treatment options for the underlying physical disease. Interestingly, not all people who drink at harmful levels develop liver disease. Understanding the precise mechanisms that confer protection in some individuals might be key to unlocking the development of effective and targeted therapies for others.

The World Health Organization (WHO) identifies alcohol as the third largest risk factor for ill-health in developed countries, behind tobacco and high blood pressure.

Historically there has been very limited investment in research despite the significant global heath burden.

Stigma associated with alcohol abuse is one possible reason.

Yet diabetes and obesity, both closely related to lifestyle choices and behaviours, have received considerably more research attention and resources.

Research-led solutions Another reason is the lack of good experimental models mimicking the development of disease. The complexity of alcohol related liver injury, in terms of early damage and processes leading to fibrosis and cirrhosis, cannot be replicated in isolated cells, cell lines and small animal models.

This research problem has hampered the development of prognostic and diagnostic biomarkers. Pre-clinical testing of therapeutic targets developed with these models has shown they do not reliably translate into effective treatments in humans.

References: Palma, E., Doornebal, E. & Chokshi, S. Precision-cut liver slices: a versatile tool to advance liver research.

Hepatol Int 13, 51–57 (2019). https://doi.org/10.1007/ s12072-018-9913-7 Chokshi, S. Alcoholic liver disease: why research is vital. Health and Social Care News. November 19, 2018. https://www.openaccessgovernment.org/ alcoholic-liver-disease-research-vital/32373/

A game-changing technique A new research technique may represent an answer. The human precision cut liver slice model takes ultrathin liver slices (around 00−250 µm thick) which more accurately simulate the intracellular mechanisms and complex architecture of the liver.

Used in research in ALD, it is enabling examination of the hepatotoxic response to alcohol and when slices are cultured in combination with immune cells, allows recreation of interactions between the immune system and the normal/diseased liver. This is potentially game-changing, as many patients who develop alcohol-related cirrhosis die of bacterial infections which overwhelm their impaired immune systems.

This is just one example of innovative, research-led thinking transforming how we treat patients with liver disease. It is research that opens the way to better patient survival.

People with PBC can take an active role in their diagnosis and in managing their condition.

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iving with a progressive condition like primary biliary cholangitis (PBC) - which has no known cause or cure - takes some getting used to, says Collette Thain MBE. Collette set up the PBC Foundation specifically to support people like herself with this autoimmune condition.

“Our aim is to help people through this journey,” she says.

INTERVIEW WITH Collette Thain MBE CEO, PBC Foundation

WRITTEN BY

Ailsa Colquhoun

The journey to diagnosis Like Collette, people often start their journey with PBC with multiple trips to the GP for non-specific symptoms such as heavy limbs and fatigue. A liver function test is a key diagnostic tool, but Collette says that all too often patients - 90% of whom are women find themselves labelled as suffering something ‘psychological’. “But why should a GP assume that?” she asks. “Why are women not pushing back with questions such as: ‘Why do you think my symptoms are ‘emotional’? Or ‘why do you not think a blood test is justified?’ Patients need to start seeing themselves as a joint partner with the GP.”

Chronic fatigue and problems with concentration are long-term features of life with PBC and for some people this can force significant lifestyle changes such as giving up work, or particular activities.

Making lifestyle changes Chronic fatigue and problems with concentration are longterm features of life with PBC and for some people this can force significant lifestyle changes such as giving up work, or particular activities.

The Foundation supports people through those changes: to reduce the isolation they may feel; to give them the opportunity to share their experiences and to help people maximise their quality of life through self-management.

A number of factors make a real difference in living with PBC: exercise, fun and laughter, eating healthier and reducing processed food, music, relaxation and mindfulness, to name a few. So many patients benefit from active selfmanagement, irrespective of their PBC journey. “PBC is real, the symptoms are real, the struggle is real, but we can help ourselves”, says Collette, “Our health care really does begin with self-care.”

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Treating liver cancer by guiding immune cells to the right place

Hepatocellular cancer (HCC), the most common form of primary liver cancer, is a major global challenge. Cases around the world, including in the UK, are set to rise dramatically in the coming years.1

H WRITTEN BY Dr Shishir Shetty Cancer Research UK Advanced Clinician Scientist and Honorary Consultant Hepatologist, Reader in Liver Tumour Immunology, Centre for Liver and Gastrointestinal Research, University of Birmingham and NIHR Birmingham BRC

CC is difficult to diagnose at an early stage because it seldom causes any symptoms and the current screening methods remain ineffective. A recent breakthrough has been the approval of immunotherapy to treat HCC.2 Immunotherapy is the ability to harness the patient’s own immune system to prevent the spread of HCC. Advancements in immunotherapy In order for immunotherapy to be successful, it is critical that immune cells can get to the right place at the right time. Our research in the Centre for Liver and Gastrointestinal Research (CLGR) at the University of Birmingham is focussed on understanding how HCC tumours can hide from the immune system.

Immune cells travel along our blood vessels and we study cancer blood vessels to find new treatments that will guide immune cells to the optimal location. The CLGR partners with world class scientific research

teams and is strongly supported by the Cancer Research UK Birmingham Centre to translate the global impact of our research. Our work is boosted by a £1.4 million grant from Cancer Research UK. This funding builds on the strong partnership between the CLGR and the University Hospitals Birmingham (UHB) NHS trust.

Using donations to advance disease research UHB has a supraregional centre for liver disease with one of the largest surgical and liver transplant units in the world. It provides a range of expertise and treatment for patients with HCC. The donation of blood and tissue samples that my team receives from our patients is vital in helping understand why HCC develops in the liver and how we can prevent the cancer from growing. We use these samples to develop experimental models which will help us understand how blood vessels could guide tumour-killing immune cells into the

Just an itch?

Don’t PBC so sure The symptoms of primary biliary cholangitis/cirrhosis (PBC) may not immediately make you think of liver disease – but early diagnosis could just save your life.

Y Professor Stephen Ryder Consultant in liver diseases at Nottingham University Hospitals NHS Trust and Medical Advisor to the British Liver Trust

Written by: Alisa Colquhoun

ou might think it’s just an itch, but if it happens regularly, seems to ‘move’ around your body and doesn’t come with a rash, you might want to get tested for primary biliary cholangitis/ cirrhosis (PBC), says Dr Stephen Ryder, Consultant Physician in Hepatology and Gastroenterology.

Connecting the symptoms to liver PBC is an easily treatable disease of the liver but, because symptoms do not obviously suggest a liver problem, it often goes undiagnosed and for too long. This can result in severe liver problems requiring a transplant, or even liver failure, resulting in death.

Dr Ryder says: “We can see people who have suffered for years, when for most people treatment can restore a normal life both in terms of quality and years.”

In a healthy individual, bile is produced inside the liver to help digest fats and remove waste products from

the body. This liquid then passes out of the liver through small tubes called bile ducts.

However, in PBC the body’s immune system mistakenly attacks the bile ducts, which become damaged.

This causes bile to build up in the liver, ultimately leading to further liver damage. The tell-tale itching associated with PBC is a result of excess bile seeping into the blood stream, triggering nerve endings into a response that the body interprets as an itch.

Other symptoms can include significant daily fatigue, dry eyes and mouth, poor sleep, pain or discomfort in the upper right side of the tummy and dizziness when standing up.

Who’s at risk?

As with other autoimmune diseases, PBC is more commonly seen in people with a family history of them. It’s 10 times more common in women,

In order for immunotherapy to be successful, it is critical that immune cells can get to the right place at the right time. microenvironment of HCC. Setting up these models will help us to find new therapies and boost the effectiveness of current treatments.

The advent of immunotherapy for patients with HCC brings hope. With continuing research in this field, our team aims to greatly improve the outlook in HCC and bring about a cure for more patients in the future.

References: 1. https://www.cancerresearchuk.org/health-professional/ cancer-statistics/statistics-by-cancer-type/liver-cancer/ incidence#heading-Three 2. https://www.nice.org.uk/guidance/ta666 Read more at birmingham.ac.uk/ research/liver/index.aspx

We can see people who have suffered for years, when for most people treatment can restore a normal life both in terms of quality and years.

particularly in those aged 40-50 years old. However, diagnoses are increasing, says Dr Ryder, in line with better testing and the general increase in autoimmune conditions, which also include type 1 diabetes and thyroid problems. Currently, PBC affects around one in 3,000-4,000 people.

Treatment for PBC generally involves life-long treatment with tablets, but these produce mostly manageable side effects, reassures Dr Ryder. He says: “Yes, taking tablets comes at a cost, but it is far better to get onto treatment early for the best chance of regaining a normal life.

My advice to people who are worried is to go and see their GP as early as possible. A test could save your life.”

For more information visit pbcfoundation.org.uk britishlivertrust.org.uk

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Protecting the next generation from liver cancer Every day, babies are born around the world and become infected with the hepatitis B virus. It can happen during childbirth if the mother has hepatitis B and a high viral load.

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A ticking time bomb We need to stop this. We should be testing all pregnant women for hepatitis B and vaccinating all babies. If we did that, we would stop the passing on of this ticking bomb and entire generations could be saved.

The interventions to prevent motherto-child transmission of hepatitis B are not new; the hepatitis B birth dose vaccine has been around for years and is available for pennies, but only 43% of babies receive it globally. Medications for treating a pregnant woman’s high viral load have been generic for years, but treatment is not always offered.

As a mother living with hepatitis B, I see this as an urgent crisis. My four children received the birth dose and are hepatitis B free and I am eternally grateful. But I am gravely concerned that this is not accessible to everyone.

Mothers everywhere are struggling to get services, and they worry about passing on the infection.

I can only imagine the guilt they feel if their children are infected, and how they are plagued with worry over the life-changing impact on their child’s health and life opportunities.

The tragedy is that it was preventable through simple and affordable interventions.

It’s time to speak up It is time for parents and family members to speak up. Mothers and babies deserve these simple tools to combat hepatitis B. The NOhep movement is the campaign for hepatitis elimination. Prevention of mother-tochild transmission of hepatitis B is a critical piece of elimination. It is within our reach, but we must not wait.

We call on everyone to demand that governments, policy makers, health systems and international donors prioritise the health of mothers and babies.

Please help amplify our call and join us at www.nohep.org

WRITTEN BY

Dr Su Wang President World Hepatitis Alliance

© R AS I B H A D R A M A N I

nfection at birth can lead to lifelong chronic hepatitis B, the leading cause of liver cancer in the world. Daily, more than 2,400 people succumb to this tragic outcome of hepatitis B.

NASH – the forgotten liver disease epidemic For many people as soon as you say “liver disease” the first thing that they think about is alcohol. But there is another form of liver disease, related to obesity and type 2 diabetes.

N WRITTEN BY

Vanessa Hebditch Director of Policy and Communications, British Liver Trust

on-alcohol related fatty liver disease (NAFLD) is when fat builds up in the liver. It usually occurs when people are overweight or obese. Type 2 diabetes is also a risk factor. Early stage NAFLD does not cause any harm but approximately 20% of people develop NASH (Non-Alcoholic SteatoHepatitis), a more serious form of the disease when the liver starts to scar.

Greater awareness of fatty liver disease NASH is a “hidden epidemic” as there are often no symptoms in the early stages. It could affect as many as one in eight adults in the UK and is soon to be the primary reason for liver transplantation.

Professor Stephen Ryder, a leading hepatologist and medical advisor to the British Liver Trust says “Studies suggest that the UK prevalence of NASH - the more serious form of fatty liver disease will present a huge burden on the NHS in years to come – with an increasing number of people requiring care for cirrhosis or needing liver transplants.

Greater awareness of the risk factors of fatty liver disease is crucial.”

Better access to diagnostic tools “We also need patients to have much better access to non-invasive diagnostic tools to help to catch people earlier in

Studies suggest that the UK prevalence of NASH - the more serious form of fatty liver disease will present a huge burden on the NHS in years to come their disease, so they can make lifestyle changes or seek other treatments that will help them to prevent further damage and improve the health of their liver.”

People are more likely to develop NASH if they are overweight or live with type 2 diabetes.

Doctors treating patients with type 2 diabetes already have a lot to check on — eyes, kidneys, heart risks — but the British Liver Trust recommends that they should also not neglect the liver.

If you are diagnosed with NAFLD or NASH, losing weight and eating a healthy diet is also the first line of treatment. Professor Stephen Ryder explains, “There is good evidence that losing 10% of body weight can control and, in some cases, reverse the condition.”

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Why taking early action can prevent liver damage from alcohol You may only notice symptoms of alcohol-related liver damage when you are on the path to liver failure. Taking stock of your drinking can prevent serious self-inflicted harm.

INTERVIEW WITH

Dr Varuna Aluvihare Drinkaware Trustee and leading Hepatology Specialist

WRITTEN BY

Tony Greenway

Paid for by Drinkaware

How you can be damaging your liver and not realise it Too much alcohol may cause cell damage which can lead to inflammation and scarring of the liver, reducing its function and increasing risk of cancer.

Symptoms of alcohol-related liver damage can include jaundice, swelling of the belly, legs or ankles, easy bruising, fatigue, weakness, loss of appetite, and bleeding; yet these may not appear until the later stages of liver disease.

“You can abuse your liver for a long time without noticing the damage it’s sustaining,” notes Dr Aluvihare.

Perhaps this is why many of us don’t feel the need to cut back on drinking and give our livers a break. Or perhaps some of us think that if we simply stop drinking (one day, we promise, we’ll get around to it) we can reverse any alcoholinduced liver damage. “The liver has a well-known ability to regenerate, so it’s true that if you intervene early enough it can recover completely, or almost completely,” confirms Dr Aluvihare.

“The trouble is, by the time you see a liver specialist, your liver might be

©DGLIMAGES

W

e don’t think enough about liver health, insists Dr Varuna Aluvihare, leading Hepatology Specialist. Yet we should because when a person’s liver fails, their whole body starts to shut down.

“The liver is a workhorse,” explains Dr Aluvihare, pointing out that it’s an organ with many different and vital functions, which include converting food into energy, filtering toxins from the blood and fighting infection and disease, and produces many important proteins. “It’s only when it stops functioning properly that patients suddenly understand just how vital it is.”

What many of us don’t realise is that we are doing irreparable damage to our livers through too much consumption of alcohol. In fact, alcohol-related liver disease is on the rise, accounting for over a third of liver disease deaths.

Unfortunately, because of increased drinking in the lockdown, Dr Aluvihare — who is a Trustee of independent alcohol education charity Drinkaware — is concerned that could lead to more alcohol-related harm matierialising over the next few years.

working at only 10% or 15% of its normal function and may have reached the point of no return.”

While it’s unlikely that damage can be reversed at this stage, it may be possible to prevent the liver failing entirely by giving up alcohol, eating healthily and exercising. “A person with cirrhosis can still lead a pretty good life with specialist medical care,” says Dr Aluvihare. “But if they carry on harming themselves with alcohol, the likelihood is that they will progress to liver failure stage — and then they run the risk of serious harm.”

Why sensible alcohol consumption is so important Dr Aluvihare has simple advice for anyone worried about the effect that alcohol is having on their liver: follow the low risk drinking guidelines set by the UK Chief Medical Officers’ — i.e. no more than 14 units per week, for both men and women. “Also, how you consume alcohol is important,”

Alcohol-related liver disease is on the rise, accounting for over a third of liver disease deaths. he says. “It’s not healthy to have six alcohol-free days and then binge drink 14 units in one go. Your liver has a saturation point.”

Your GP can give you a simple blood test to identify if your liver is laying down fat, which is one of the first signs of alcohol damage. “Fat is increasingly prevalent in our population,” says Dr Aluvihare. “Fat-induced liver disease mimics alcohol-induced liver disease, so if you are overweight and you drink harmfully, then you more than double the health risk to your liver. So, keep physically active, eat well — and stop harming yourself with alcohol.”

Speak to your GP for help and advice on whether you should make any changes in your drinking.

Other support tools are available through the Drinkaware website drinkaware.co.uk

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The liver is an organ designed to meet the daily challenges of keeping us healthy but increasingly, as is evident from the astonishing 400% rise in rates of liver disease in the UK over the last 40 years, we are pushing it beyond the limits of tolerance. ~ Natalie Day, Chief Executive Officer, the Foundation for Liver Research

©NENSURIA

~ Dr Shilpa Chokshi, Acting Director and Chief Scientific Officer, the Institute of Hepatology, London