Khat-related liver disease in sub-Saharan Africa: neglected, yet important
Authors: Stian Magnus Staurung Orlien, Nega Belay Berhe, Marsha Yvonne Morgan, Asgeir Johannessen
Journal: The Lancet Global Health (2019)

In their Comment, Sandro Vento and colleagues (October, 2018)1Vento S Dzudzor B Cainelli F Tachi K Liver cirrhosis in sub-Saharan Africa: neglected, yet important.Lancet Glob Health. 2018; 6: e1060-e1061Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar highlight cirrhosis as an important but neglected health issue in sub-Saharan Africa. We endorse their call for greater public awareness of this emerging health issue, for governmental commitment to facilitate pertinent preventative efforts in public health, and for better diagnostic and treatment options. However, we were surprised that they did not mention what is, without a doubt, one of the most important emerging causes of chronic liver disease in this region, namely the recreational use of khat (Catha edulis). The importance of this association has been clearly highlighted in several publications,2Chapman MH Kajihara M Borges G et al.Severe, acute liver injury and khat leaves.N Engl J Med. 2010; 362: 1642-1644Crossref PubMed Scopus (58) Google Scholar, 3Mahamoud HD Muse SM Roberts LR Fischer PR Torbenson MS Fader T Khat chewing and cirrhosis in Somaliland: case series.Afr J Prim Health Care Fam Med. 2016; 8: a1124Crossref Scopus (8) Google Scholar, 4Orlien SMS Ismael NY Ahmed TA et al.Unexplained chronic liver disease in Ethiopia: a cross-sectional study.BMC Gastroenterol. 2018; 18: 27Crossref PubMed Scopus (13) Google Scholar, 5Orlien SMS Sandven I Berhe NB et al.Khat chewing increases the risk for developing chronic liver disease: a hospital-based case-control study.Hepatology. 2018; 68: 248-257Crossref PubMed Scopus (11) Google Scholar including a case–control study undertaken in eastern Ethiopia,5Orlien SMS Sandven I Berhe NB et al.Khat chewing increases the risk for developing chronic liver disease: a hospital-based case-control study.Hepatology. 2018; 68: 248-257Crossref PubMed Scopus (11) Google Scholar which found a significant association between chewing khat and the risk for developing chronic liver disease, particularly in men. This risk was strong (adjusted odds ratio 5·67, 95% CI 1·85–17·37) and dose-dependent, suggesting a causal relationship.5Orlien SMS Sandven I Berhe NB et al.Khat chewing increases the risk for developing chronic liver disease: a hospital-based case-control study.Hepatology. 2018; 68: 248-257Crossref PubMed Scopus (11) Google Scholar Vento and colleagues omitted this and other compelling evidence for the hepatotoxic effects of khat and misquoted a publication,4Orlien SMS Ismael NY Ahmed TA et al.Unexplained chronic liver disease in Ethiopia: a cross-sectional study.BMC Gastroenterol. 2018; 18: 27Crossref PubMed Scopus (13) Google Scholar which found that khat might be an independent risk factor for the development of chronic liver disease in Ethiopia, by saying that “traditional herbal medicine could also contribute” to the risk of developing liver disease. Khat is not a herbal medicine but, in sub-Saharan Africa, a widely available, extensively used, and socially acceptable recreational drug. The necessity and importance of increased awareness, better screening, and improved and extended treatment for viral hepatitis in sub-Saharan Africa is indisputable. However, since khat is a major contributor to the development of chronic liver disease in this region, not recognising this association means that its importance for public health will continue to be ignored. Further, given its legal status, social acceptability, and its widespread use, it will be extremely difficult to radically reduce the burden of liver disease in this part of the world if preventive measures for dealing with khat chewing are not implemented. Tackling this problem will be complex and will require a multidisciplinary approach with considerable input from health and addiction services and from political and religious leaders, both in local communities, as well as at the governmental level. A first but essential step is to recognise the existence of khat-related liver disease and to place it firmly on the agenda at future stakeholder meetings. This way, opportunities will arise for the concerted action needed to deal with khat-related liver disease and to alleviate the burden it imposes on sub-Saharan communities. We declare no competing interests. Liver cirrhosis in sub-Saharan Africa: neglected, yet importantClinical efforts and research on liver diseases have been scarce in sub-Saharan Africa. The first Conference on Liver Disease in Africa (Nairobi, Sept 13–15, 2018), gathering all stakeholders from the continent, is a welcome step towards greater attention to the problem, and the important issue of liver cirrhosis. Full-Text PDF Open AccessKhat-related liver disease in sub-Saharan Africa: neglected, yet important – Authors' replyWe thank Stian Orlien and colleagues for raising attention to the issue of khat use as a recreational drug in sub-Saharan Africa in response to our Comment.1 Although we mentioned the fact that traditional herbal medicine could contribute to the burden of cirrhosis in this region, as the use of khat is associated with a substantial increase in liver fibrosis,2 we do not think that the available evidence shows that khat is a major contributor to chronic liver disease. Khat is used in parts of east Africa, including Djibouti, Ethiopia, Somalia, Somaliland, Kenya, Sudan, Uganda, and Madagascar. Full-Text PDF Open Access