With little treatment and multiple causes, Anne Llewellyn gives a guide to the underwriting of fatty liver disease.
If you place your right hand over the area under the ribs on the right side of your body it will just about cover the area of your liver. The liver is the largest gland, and the largest solid organ in the body, and is estimated to have over 500 functions. About 60% of the liver is made up of liver cells called hepatocytes which absorb nutrients and detoxify and remove harmful substances from the blood.
The most important functions of the liver are
• producing energy by breaking down carbohydrates to glucose and storing it as glycogen in the liver and muscles. When energy is required the liver converts its store of glycogen back into glucose ready for the body to use. This can be done extremely rapidly in an emergency.
• removing waste products from the blood which are not excreted by the kidney
• fighting infections, particularly infections arising in the bowel. It does this by mobilising part of your body's defence mechanism called the macrophage system. The liver contains over half of the body's supply of macrophages, known as Kuppfer cells, which literally destroy any bacteria that they come into contact with.
Other important functions are
• processing digested food from the intestine
• controlling levels of fats, amino acids and glucose in the blood
• neutralising and destroying drugs and toxins
• manufacturing bile
• storing iron, vitamins and other essential chemicals
• manufacturing, breaking down and regulating numerous
• making enzymes and proteins which are responsible for most chemical reactions in the body, for example those involved in blood clotting and repair of damaged tissues
There should be little or no fat in a healthy liver. For most people, carrying a little fat in the liver causes no problems, however in some people fat builds up in the hepatocytes. A "fatty liver" until recently was considered rare and relatively harmless. Today it is recognised as one of the most common forms of liver disease and although in the majority of cases fatty liver is benign, for an increasing number of people the effects of having fat in their liver over a long period may lead to inflammation causing swelling and tenderness (hepatitis) and then to scarring (fibrosis), and then scarring and nodules which damage and replace normal liver tissue (cirrhosis), and can be life-threatening.
The main risk factors for fatty liver are alcohol, obesity, hypertension, hyperlipidaemia and diabetes although it can also occur for no apparent reason.
Fatty liver disease is distinguished by whether it is alcohol related or non alcohol related.
Where alcohol is not the cause of fatty liver it is known as Non Alcoholic Fatty Liver Disease (NAFLD). Simple fatty liver, or steatosis, is just a build up of fat to 10% of the liver volume. In itself it does not cause symptoms or serious damage or harm to the liver, however it can be associated with, or cause inflammation of the liver (non-alcoholic steatohepatitis or NASH) which is not a benign condition, since it can lead to cirrhosis of the liver or even liver cancer. NAFLD is the most common liver disease in Western Countries therefore as we would expect the incidence and prevalence of NASH is increasing.
In practical terms NAFLD and alcoholic steatohepatitis are almost the same and clinical and histological features are not reliable in separating alcoholic from nonalcoholic forms of fatty liver disease, with the separation being based largely on an individual's history of alcohol intake. The underwriter has to try and establish the cause since the underlying condition and any associated complications has implications for the acceptance terms and the most likely source of lifestyle information is through a GP report or teleinterviewing.
Patients with steatosis are unlikely to have symptoms although they may feel tired and have pain on the right side of the abdomen, and it is either investigation for this, or routine blood tests, which will be the first indicator there is anything wrong. Liver function tests (LFTs) measure liver enzymes given off during inflammation or when the liver cells are being destroyed and certain abnormalities will trigger further investigations carried out by a hepatologist or gastroenterologist. Other tests will be carried out to rule out other conditions such as viral hepatitis, coeliac disease, haemochromatosis and many other possible differential diagnoses. Diagnostic imaging may be carried out such as an ultrasound scan which will confirm significant amounts of fatty deposits. Finally, a liver biopsy is the only way to confirm a definitive diagnosis of fatty liver and any associated fibrosis.
There is no proven effective treatment for fatty liver disease and where possible treatment is aimed at the cause such as diabetes, hypertension and hyperlipidaemia. Lifestyle modifications (e.g. diet and exercise) to reduce obesity and abstinence from alcohol (as with all liver disease) can have a good result. NASH is often responsive to weight loss, although in practice this is very difficult to achieve and maintain in the long term. Abstinence from alcohol may even reverse steatosis in alcohol related steatosis.
The prognosis is important when considering acceptance terms. Steatosis has a good prognosis with abstinence and gradual weight loss. Steatohepatitis and fibrosis have a worse prognosis and cirrhosis the worst prognosis of all, not because it is fatal but because it is associated with a high risk of liver cancer or liver failure. Unfortunately there is no reliable way to predict these serious latter stages as it is not yet clear why some people go on to develop more serious forms of the disease and others do not. Clearly not abstaining from alcohol or controlling other risk factors will have a poorer prognosis.
When underwriting a client with fatty liver the following information will have to be ascertained, usually from a GP report:
• co-morbidities and the cause of fatty liver
• whether alternative diagnoses been ruled out
• has the diagnosis been confirmed by liver biopsy
• LFT results
• Alcohol consumption
Acceptance terms vary according to the quality of information received by the underwriter. In the best cases where there is full information from the GP with regular follow ups by a gastroenterologist or hepatologist, the diagnosis has been confirmed using a biopsy which shows steatosis only with no fibrosis, there are no co-morbidities and the client is abstaining from alcohol, we can usually accept life cover at standard rates and critical illness and disability benefits with a small rating. Up to moderate NASH confirmed on biopsy can be accepted with a moderate rating. If there is no biopsy terms will depend on alternative diagnoses being ruled out and LFT results. In all cases alcohol use will be assessed cautiously and continued alcohol use in clients with liver disease is almost certain to lead to declinature.6
Anne Llewellyn is underwriting training and development manager at Pru Protect