Nursing care of patients with chronic liver diseases: Time for action.

Abstract

Chronic liver diseases are very common worldwide and represent a major healthcare issue (GBD 2013 Mortality and Causes of Death Collaborators, 2015). Chronic liver diseases are characterized by inflammation of the liver, which may be secondary to distinct aetiological factors, including hepatitis C or B infection, increased alcohol consumption or non-alcoholic fatty liver disease (NAFLD). Chronic liver inflammation leads to unrelenting fibrosis deposition with formation of scars that progressively disrupt the normal liver architecture and function, eventually leading in some cases to cirrhosis unless the cause of injury is removed (ie, elimination of hepatitis C virus by antiviral drugs) (Schuppan & Afdhal, 2008). Cirrhosis is a progressive disease that causes many complications, has a negative impact on patient health-related quality of life, is a major cause of years of life lost, and hospital readmissions, and ultimately leads to death unless liver transplantation is performed (Schuppan & Afdhal, 2008). In Europe, chronic liver diseases are estimated to affect approximately 25% of the population and cirrhosis is responsible for around 170,000 deaths per year (Blachier, Leleu, Peck-Radosavljevic, Valla, & Roudot-Thoraval, 2012; Younossi et al., 2016). In USA, the prevalence of chronic liver diseases is like that in Europe and cirrhosis is estimated to affect 0.27% of the population and accounts for more than 70,000 deaths each year (Asrani, Larson, Yawn, Therneau, & Kim, 2013; Scaglione et al., 2015). Despite the importance of chronic liver diseases as global health issue, the nursing community has paid little attention to liver diseases compared with other chronic diseases, particularly diabetes, chronic pulmonary diseases, cardiovascular diseases and neurological diseases. Nursing training in hepatology has been remarkably low compared with training in other chronic diseases. Moreover, incorporation of nurses into multidisciplinary teams for hospital care of patients with liver diseases has been very slow in comparison with other chronic conditions, particularly diabetes, cardiovascular diseases, and neurological diseases. Furthermore, nursing role in liver diseases in primary care is not present in most primary care systems. Consequently, nursing research in liver diseases has been markedly lower compared with that in other chronic disorders (Figure 1). The importance of incorporation of nurses to care of patients with chronic liver diseases has been emphasized in the context of Liver Campaign Addressing Liver Diseases in the UK (Williams et al., 2014). One of the 10 key recommendations that the commission asked for strong endorsement and urgent implementation was to improve the education and training of nurses in hepatology and increase the number of nurses caring for patients with liver diseases in hospitals and primary care. For many years the main role of nurses in the care of patients with liver diseases in the hospital setting has been related to viral hepatitis, particularly hepatitis C. Nurses have participated together with hepatologists, pharmacists, psychologists, and social workers in a multidisciplinary approach to care of patients with hepatitis C. Nurses have helped to provide a holistic care to these patients and played a key role in improving adherence to treatments and providing pretreatment education as well as control and evaluation during treatment (Shah & Abu-Amara, 2013). Nursing care of patients with hepatitis C is still important despite the recent introduction of direct antiviral agents that are more effective and safe compared to old interferon-based therapies (Richmond, Sheppard-Law, Mason, & Warner, 2016). An emerging role for nurses with training in hepatology is the care of patients with decompensated cirrhosis. Cirrhosis is characterized by several complications that may benefit markedly from educational and lifestyle interventions that are usually not provided by treating physicians. Potentially important areas for educational interventions include dietary habits, exercise, adherence to prescribed medications, judicious use of laxatives, self-control of heart rate and arterial pressure in patients under beta-blocker treatment, skin care in patients with leg oedema to prevent infections, and glucose control in patients with associated diabetes. This nursing care for patients with cirrhosis requires the implementation of a nursing cirrhosis consultation run by a nurse practitioner with training and experience in patients with cirrhosis and with easy access to a hepatologist for discussion or referral of cases. This nursing care of patients with cirrhosis may help reduce the rate of readmissions to hospital of patients with decompensated cirrhosis, which is very high (Bajaj et al., 2016). Telephone management, although not evaluated in randomized studies, could also be of value in providing an appropriate care to patients with descompensated cirrhosis. Similar to cirrhosis, incorporation of nurses into multidisciplinary teams of management of patients with hepatocellular carcinoma may be of great value in the care of these patients. In the context of the growing epidemics of chronic liver diseases worldwide, particularly NAFLD, primary care may play a crucial role in the identification of patients in early stages. Due to the long duration of liver inflammation, which may run for decades, identification of patients in early stages before cirrhosis develops may allow early interventions that could stop the disease progression or even reverse liver fibrosis. However, there is a remarkable lack of information and awareness about liver diseases in primary care, both among GP and nurses. An effective fight against liver diseases cannot be done without education and training of GPs and nurses working in primary care. In that regard, the commission evaluating liver diseases in the UK, strongly recommended liver diseases to be incorporated in the list of chronic diseases that are actively addressed in primary care, such as arterial hypertension, chronic obstructive pulmonary diseases, and diabetes (Williams et al., 2014). Current knowledge indicates that cirrhosis develops in patients who belong to high-risk populations, including patients with metabolic syndrome, obesity, and type-2 diabetes, patients with increased alcohol consumption (more than 21 drinking units per week in males and more than 14 in females), and patients with high risk of infection with hepatitis B or C virus (iv drug use, blood transfusions prior to 1990s, sexual risk behaviour) (Schuppan & Afdhal, 2008). Primary care nurses should have an active role in the identification of patients with chronic liver diseases and assessment of degree of fibrosis in these high-risk populations. The case of NAFLD is particularly illustrative. Identification could be done through assessment of serum fibrosis scores or transient elastography (EASL, 2016). Serum fibrosis scores, for example, NFS (NAFLD fibrosis score) or FIB-4, are easily calculated through standard laboratory tests and correlate with severity of fibrosis. Their main usefulness consists of ruling out the presence of significant liver fibrosis in patients with risk factors for NAFLD. Transient elastography is a procedure usually performed by trained nurses that measures the stiffness of the liver tissue through the assessment of the velocity of a wave through the liver tissue (Fabrellas et al., 2013). The stiffness correlates with the amount of liver fibrosis. Transient elastography has been available in Europe for more than 10 years and has been mainly used for staging fibrosis in patients with known liver disease, particularly hepatitis C. Recent studies, however, indicate that it is also useful for screening for liver fibrosis in subjects with risk factors of liver disease but without known liver disease (Caballeria et al., 2016; Ginès et al., 2016). Whether the assessment of liver fibrosis in high-risk populations should be done with serum fibrosis scores or transient elastography (or both) is not yet known. Lifestyle interventions in patients with liver fibrosis due to NAFLD are effective in preventing disease progression (EASL, 2016). Primary care nurses may therefore play an important role in modifying lifestyle of patients diagnosed with chronic liver diseases. Incorporation of nurses, both in primary and hospital care, is essential to achieve an effective fight against the epidemics of chronic liver diseases. However, this incorporation will not be possible without increasing awareness and improving the education and training of nurses in liver diseases. This should ideally start during the undergraduate education but must continue through postgraduate education with specific courses performed by national health agencies, national nurses’ associations, scientific societies, and universities. Nursing journals may also play an important role in this education process. Finally, chronic liver diseases should be incorporated into the nursing research agenda.