Using social determinants of health to guide liver disease screening

Black people face a higher risk of developing severe liver fibrosis, but a new study suggests personalized care could help mitigate that risk.

Liver fibrosis, or liver scarring, happens when the liver tries to heal itself from persistent injuries from viruses, alcohol consumption or fat buildup. When it goes undetected or untreated, it can result in liver failure and could require a liver transplant.

RUSH transplant hepatology specialist Costica Aloman, MD, one of the study's authors, says what he was seeing in his own practice inspired him to dig deeper.

"We treat a very diverse population at RUSH, and I started to notice that different people had different liver scarring characteristics," Aloman says. "I was very interested in learning more about what the drivers of these differences are."

Aloman and the other authors were interested in learning more about:

• Who experienced liver fibrosis.
• Factors that may be driving its progression.
• If the number of cases had been increasing.

The researchers analyzed data from 47,422 people who took the National Health and Nutrition Examination Survey between 1999 and 2018.

They found the number of liver fibrosis cases had more than doubled in the past two decades. They also found the prevalence of the disease and its causes have changed over time—impacting racial and ethnic groups unevenly. The research is published in the journal JHEP Reports.

Advanced liver fibrosis was more prevalent in Black men and women (non-Hispanic) than it was for white men and women (non-Hispanic). The authors found there are race- and ethnicity-based factors that have a lot to do with who develops the disease.

Black participants had a distinctive set of risk factors compared to the white participants, including:

• Poverty
• Lead exposure
• Cadmium exposure
• Other chemical exposures

Researchers also found that the rates of alcohol drinking nearly doubled among the Black population, which may be an important driver of advanced liver fibrosis among that group.

Diabetes and high blood pressure were not factors for the Black participants. They were, however, symptoms for white patients and people of other races and ethnicities. Smoking and excessive alcohol use were risk factors across the board.

By focusing on those risk factors, the authors say more lives can be saved.

Based on their findings from the analysis, the researchers encourage other medical professionals to take these steps when changing how they screen for and treat liver disease:

• Address risk factors like poverty, smoking, excessive drinking and exposure to environmental toxins for the Black population to achieve better health outcomes.
• Expand liver care services to address the influx of patients being diagnosed.
• Screen patients' routine blood tests during primary care visits to help catch patients who need specialized care from a hepatologist.

Addressing risk factors at RUSH

The recommendations don't follow the traditional path of screening, but Aloman says RUSH isn't a traditional health system.

"At RUSH we serve one of the most diverse populations in the United States, so for me it was some kind of validation," Aloman says. "The results from the study aren't things you can address in traditional ways."

Based on the findings, physicians should be encouraged to include social determinants of health when screening patients for liver disease.