DOI: 10.1111/jan.

13350

EDITORIAL

Nursing care of patients with chronic liver diseases: Time for

action
1 | INTRODUCTION 1500
1350

Chronic liver diseases are very common worldwide and represent a

major healthcare issue (GBD 2013 Mortality and Causes of Death

Number of articles
Collaborators, 2015). Chronic liver diseases are characterized by 1000
907
inflammation of the liver, which may be secondary to distinct aetio- 734
logical factors, including hepatitis C or B infection, increased alcohol
consumption or non-alcoholic fatty liver disease (NAFLD). Chronic
500
liver inflammation leads to unrelenting fibrosis deposition with for-
mation of scars that progressively disrupt the normal liver architec- 249

ture 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 cirrho-
sis 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 dis-
eases 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, incorpo-
ration 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 dis-
eases, 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
10
0
Cardiovascular Diabetes Dementia Chronic Chronic
diseases obstructive liver
pulmonary diseases
disease
F I G U R E 1 Number of publications from Pubmed search of a
5 year period (March 2013–March 2017) in English language using
the keywords nursing, intervention, and the respective disease
increase the number of nurses caring for patients with liver diseases
in hospitals and primary care.
2 | POSSIBLE ROLES OF NURSING CARE IN
THE MANAGEMENT OF PATIENTS WITH
CHRONIC LIVER DISEASES IN THE
HOSPITAL SETTING
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 hepati-
tis, 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 provid-
ing 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 character-
ized by several complications that may benefit markedly from

498 | © 2017 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/jan J Adv Nurs. 2018;74:498–500.
EDITORIAL
educational and lifestyle interventions that are usually not provided
by treating physicians. Potentially important areas for educational
interventions include dietary habits, exercise, adherence to pre-
scribed 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 glu-
cose 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 hepa-
tologist 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 appro-
priate care to patients with descompensated cirrhosis. Similar to cir-
rhosis, incorporation of nurses into multidisciplinary teams of
management of patients with hepatocellular carcinoma may be of
great value in the care of these patients.
3 | ENGAGEMENT OF PRIMARY CARE
NURSES ON DETECTION AND
MANAGEMENT OF CHRONIC LIVER
DISEASES
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 dura-
tion 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 informa-
tion 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 meta-
bolic 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 infec-
tion 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 particu-
larly illustrative. Identification could be done through assessment of
serum fibrosis scores or transient elastography (EASL, 2016). Serum
| 499
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

s et al.,
without known liver disease (Caballeria et al., 2016; Gine
2016). Whether the assessment of liver fibrosis in high-risk popula-
tions should be done with serum fibrosis scores or transient elastog-
raphy (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.
4 | FUTURE DIRECTIONS
Incorporation of nurses, both in primary and hospital care, is essen-
tial to achieve an effective fight against the epidemics of chronic
liver diseases. However, this incorporation will not be possible with-
out increasing awareness and improving the education and training
of nurses in liver diseases. This should ideally start during the under-
graduate education but must continue through postgraduate educa-
tion 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.
ria Fabrellas1
Nu
Marta Carol1,2
Ferran Torrabadella2
Gloria de Prada2
1
School of Nursing, Faculty of Medicine and Health Sciences,
Universitat de Barcelona, Barcelona, Spain
2
Liver unit, Hospital Clinic, Institut d’investigacions biomediques August
Pi Sunyer (IDIBAPS), Barcelona, Spain
Email: nfabrellas@ub.edu
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500 | EDITORIAL
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