Clinical Practice GuidelinesEASL Clinical Practice Guidelines: Management of alcohol-related liver disease
Section snippets
Guideline development process
A panel of clinicians with an interest in liver disease and alcoholic liver disease (ALD), approved by the European Association for the Study of the Liver (EASL) Governing Board, wrote and discussed this Clinical Practice Guidelines (CPG) document between November 2016 and March 2017. The guidelines were independently peer reviewed, and all contributors to the CPG disclosed their conflicts of interest by means of a disclosure form provided by the EASL Office prior to work commencing. The EASL
Methods
These guidelines have been produced using evidence published before 1 October, 2017. Where possible, the level of evidence and recommendation are cited (Table 1). The evidence and recommendations in these guidelines have been graded using methods adapted from the grading of recommendations assessment development and evaluation (GRADE system). The strength of recommendations thus reflects the quality of underlying evidence. The GRADE system offers two grades of recommendation: strong or weak (
Terminology
The term alcoholic is stigmatising and undermines patient dignity and self-esteem. For this reason, these guidelines will use the following terms (Box 1):
Alcohol-related morbidity and mortality
According to the World Health Organization’s (WHO) 2014 report on noncommunicable diseases, harmful use of alcohol causes approximately 3.3 million deaths every year, corresponding to 5.9% of all deaths. Furthermore, 139 million disability-adjusted life years, or 5.1% of the global burden of disease and injury, were attributable to alcohol consumption. The proportion of global deaths attributable to alcohol differs based on gender, with 7.6% of deaths among males and 4.0% of deaths among
Terminology and definitions
The publication of the DSM-V has been an important step forward to overcome the arbitrary differentiation between alcohol abuse and dependence, through the creation of the overarching concept of alcohol use disorder (AUD).30 This new concept is not only useful because it unifies the disorder, but also because it introduces a partially dimensional perspective into what has been traditionally called alcoholism. The categorical distinction between who is and who is not an alcoholic is not
Screening and clinical diagnosis of ALD
Diagnosis of ALD is usually suspected upon documentation of regular alcohol consumption of >20 g/d in females and >30 g/d in males together with the presence of clinical and/or biological abnormalities suggestive of liver injury. As a high proportion of patients with histological features of ALD do not express any clinical symptoms or laboratory abnormalities, asymptomatic patients consuming a critical amount of alcohol should undergo appropriate screening investigations.78 As previously
Definition and diagnosis
Alcoholic hepatitis is a distinct clinical syndrome characterised by the recent onset of jaundice with or without other signs of liver decompensation (i.e. ascites and/or encephalopathy) in patients with ongoing alcohol abuse.176 It is not uncommon for patients to have ceased alcohol consumption days or weeks before the onset of symptoms. Underlying this clinical syndrome is steatohepatitis, a disease defined histologically by steatosis, hepatocyte ballooning, and an inflammatory infiltrate
Alcohol-related fibrosis
Excessive alcohol consumption may induce a wide spectrum of lesions that include pure alcoholic steatosis, steatohepatitis, progressive liver fibrosis, cirrhosis and HCC.231 Above a daily consumption of 30 g/day, or a weekly consumption above seven units in women and 14 units in men,232 the risk of developing ALD is increased.233 At a daily intake of 100 g/day the relative risk reaches 26.234 Pure hepatic steatosis, often asymptomatic and overlooked, is almost constant in individuals consuming
Trends in liver transplantation of ALD
Liver transplantation (LT) is the most effective therapeutic option for patients with end-stage liver disease, with post-transplant patient and graft survival of around 80–85% at one year. Liver outcomes after LT in patients with AUD have improved, with graft and patient survival similar to those seen after transplantation for other aetiologies.[311], [312] Although only a minority of patients with AUD meet the rigorous criteria required of LT candidates, the number of transplantations done for
Conflict of interest
Mark Thursz reports grant support from Vital therapies; consultant/advisory roles for Gilead, AbbVie, CN-Bio and MSD; sponsored lectures for Gilead, BMS and AbbVie. Antoni Gual reports grant support from Lundbeck, consultant/advisory roles for D&A Pharma and Lundbeck; sponsored lectures for D&A Pharma and Lundbeck. Christophe Moreno reports grant support from Gilead; consultant/advisory roles for Gilead and Promethera; performance of Gilead sponsored clinical trial in alcoholic hepatitis.
Acknowledgements
We would like to thank the reviewers of this Clinical Practice Guideline for their time and critical reviewing: EASL Governing Board, Ewan Forrest, Fabio Caputo and Vijay Shah.
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