Unexplained chronic liver disease in Ethiopia: a cross-sectional study

Abstract

BackgroundHepatitis B virus (HBV) infection is assumed to be the major cause of chronic liver disease (CLD) in sub-Saharan Africa. The contribution of other aetiological causes of CLD is less well documented and hence opportunities to modulate other potential risk factors are being lost. The aims of this study were to explore the aetiological spectrum of CLD in eastern Ethiopia and to identify plausible underlying risk factors for its development.MethodsA cross-sectional study was undertaken between April 2015 and April 2016 in two public hospitals in Harar, eastern Ethiopia. The study population comprised of consenting adults with clinical and radiological evidence of chronic liver disease. The baseline evaluation included: (i) a semi-structured interview designed to obtain information about the ingestion of alcohol, herbal medicines and local recreational drugs such as khat (Catha edulis); (ii) clinical examination; (iii) extensive laboratory testing; and, (iv) abdominal ultrasonography.ResultsOne-hundred-and-fifty patients with CLD (men 72.0%; median age 30 [interquartile range 25–40] years) were included. CLD was attributed to chronic HBV infection in 55 (36.7%) individuals; other aetiological agents were identified in a further 12 (8.0%). No aetiological factors were identified in the remaining 83 (55.3%) patients. The overall prevalence of daily khat use was 78.0%, while alcohol abuse, defined as > 20 g/day in women and > 30 g/day in men, was rare (2.0%). Histological features of toxic liver injury were observed in a subset of patients with unexplained liver injury who underwent liver biopsy.ConclusionThe aetiology of CLD in eastern Ethiopia is largely unexplained. The widespread use of khat in the region, together with histopathological findings indicating toxic liver injury, suggests an association which warrants further investigation.

Liver function tests and fibrosis scores in a rural population in Africa: a cross-sectional study to estimate the burden of disease and associated risk factors

“…38 45 Khat chewing (a popular recreational drug in some settings) was recently found to be a major cause of unexplained liver disease in east Ethiopia. 45 Aflatoxin exposure is associated with liver cirrhosis and is among the major causes of hepatocellular carcinoma globally, with most cases reported from sSA. Within a previous study of the GPC,>90% of individuals had evidence of exposure.…”

Khat chewing increases the risk for developing chronic liver disease

“…A post hoc sensitivity analysis was performed excluding all cases of CLD with an identifiable etiology after a comprehensive panel of tests, which included parasitology and serological testing for viral, autoimmune, and genetic liver diseases . Controls did not undergo the same comprehensive panel of tests or abdominal ultrasound, but all had serum ALT activities <40 U/L and were screened for the risk factors assumed a priori to be the most relevant ( viz .…”

“…Khat chewing is also associated with a number of somatic health sequelae, including myocardial infarction, systemic hypertension, upper gastrointestinal cancers, cognitive impairment, and impaired fetal growth . Khat has also been implicated in the development of both acute hepatitis and chronic liver disease (CLD) in several case series. Chapman et al reported on 6 patients of Somali origin, living in the United Kingdom, in whom khat abuse was implicated in the development of fulminant hepatic failure .…”

“…Decompensated CLD is one of the most frequent reasons for admission to medical wards in eastern Ethiopia; in >50% of the cases the liver disease is “unexplained.” Khat chewing is widespread throughout the country but more especially in the eastern regions where khat cultivation predominantly takes place . The number of people chewing khat has increased rapidly in recent years with the habit gaining popularity in all segments of the community; hence, the overall prevalence of khat chewing in Ethiopia is estimated at 15.3% but with wide regional variations .…”

Liver cirrhosis in sub-Saharan Africa: neglected, yet important

“…1 The understudied nonalcoholic fatty liver disease probably has a role in these latter cases, considering the increase in obesity in sub-Saharan Africa, and traditional herbal medicine could also contribute, because its use is associated with a substantial increase in liver fibrosis. 2,3 Treatment of liver cirrhosis is inaccessible in most parts of sub-Saharan Africa, given the huge shortage of hepatologists and gastroenterologists, interventional radiologists, hepatobiliary surgeons, and pathologists. Liver transplants are uncommon and done only in South Africa, and the costs are prohibitive for the governments of almost all sub-Saharan countries.…”