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

Vento, Sandro; Dzudzor, Bartholomew; Cainelli, Francesca; Tachi, Kenneth

doi:10.1016/s2214-109x(18)30344-9

Cited by 48 publications

(49 citation statements)

References 9 publications

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“…Accordingly, we observed high age-standardised death rates in low-income sub-Saharan African regions in 2017, despite a substantial decline since 1990, which is compatible with previous reports. 33 However, we observed lower death rates in higher SDI countries and territories (eg, the lowest rate was in Singapore). These findings are expected because most cirrhosis-related deaths can be avoided in high-income countries through better access to health care and stronger health infrastructure.…”

Section: Discussionmentioning

confidence: 56%

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Sepanlou¹,

Safiri²,

Bisignano³

et al. 2020

The Lancet Gastroenterology & Hepatology

1,086

528

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Background Cirrhosis and other chronic liver diseases (collectively referred to as cirrhosis in this paper) are a major cause of morbidity and mortality globally, although the burden and underlying causes differ across locations and demographic groups. We report on results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 on the burden of cirrhosis and its trends since 1990, by cause, sex, and age, for 195 countries and territories. Methods We used data from vital registrations, vital registration samples, and verbal autopsies to estimate mortality. We modelled prevalence of total, compensated, and decompensated cirrhosis on the basis of hospital and claims data. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost due to premature death and years lived with disability. Estimates are presented as numbers and age-standardised or age-specific rates per 100 000 population, with 95% uncertainty intervals (UIs). All estimates are presented for five causes of cirrhosis: hepatitis B, hepatitis C, alcohol-related liver disease, non-alcoholic steatohepatitis (NASH), and other causes. We compared mortality, prevalence, and DALY estimates with those expected according to the Socio-demographic Index (SDI) as a proxy for the development status of regions and countries. Findings In 2017, cirrhosis caused more than 1•32 million (95% UI 1•27-1•45) deaths (440 000 [416 000-518 000; 33•3%] in females and 883 000 [838 000-967 000; 66•7%] in males) globally, compared with less than 899 000 (829 000-948 000) deaths in 1990. Deaths due to cirrhosis constituted 2•4% (2•3-2•6) of total deaths globally in 2017 compared with 1•9% (1•8-2•0) in 1990. Despite an increase in the number of deaths, the age-standardised death rate decreased from 21•0 (19•2-22•3) per 100 000 population in 1990 to 16•5 (15•8-18•1) per 100 000 population in 2017. Sub-Saharan Africa had the highest age-standardised death rate among GBD super-regions for all years of the study period (32•2 [25•8-38•6] deaths per 100 000 population in 2017), and the high-income super-region had the lowest (10•1 [9•8-10•5] deaths per 100 000 population in 2017). The age-standardised death rate decreased or remained constant from 1990 to 2017 in all GBD regions except eastern Europe and central Asia, where the age-standardised death rate increased, primarily due to increases in alcohol-related liver disease prevalence. At the national level, the age-standardised death rate of cirrhosis was lowest in Singapore in 2017 (3•7 [3•3-4•0] per 100 000 in 2017) and highest in Egypt in all years since 1990 (103•3 [64•4-133•4] per 100 000 in 2017). There were 10•6 million (10•3-10•9) prevalent cases of decompensated cirrhosis and 112 million (107-119) prevalent cases of compensated cirrhosis globally in 2017. There was a significant increase in age-standardised prevalence rate of decompensated cirrhosis between 1990 and 2017. Cirrhosis caused by NASH had a steady age-standardised death rate throughout the study period, whereas the ot...

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Section: Discussionmentioning

confidence: 56%

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Sepanlou¹,

Safiri²,

Bisignano³

et al. 2020

The Lancet Gastroenterology & Hepatology

1,086

528

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“…certified by peer review) (which was not The copyright holder for this preprint this version posted July 3, 2019. . https://doi.org/10.1101/19000968 doi: medRxiv preprint consortium, in which alcohol ranks as the seventh highest cause of DALYs and deaths and worldwide (2), and together with HBV infection is a leading aetiological agent of liver cancer (37).…”

Section: Discussionmentioning

confidence: 99%

“…2.2 (1.7 -3.0) 0.9 (0.6 -1.4) 4.6 (2.3 -9.0) PAR (%) 1,6 3.1% 2.9% -0.2% 1.7% 0.6% 1.5% 3.1% 3.1% -0.2% 8.6% Adj. PAR (%) 5,6 3.3% 2.8% 0.02% 1.4% 0.2% 1.4% 5.7% 2.9% -0.3% 7.6% 1 ALT -Alanine Transminase, AST -Aspartate Transminase, GGT -Gamma-glutamyl transpeptidase, ALP -Alkaline Phosphatase, BR -Total Bilirubin, FIB-4 -fibrosis 4, APRI -AST to Platelet Ratio Index, GPR -GGT to platelet ratio, AST/ALT ratio -Aspartate/ Alanine ratio, RR -relative risk, PAR (%) -population attributable risk percent, 95% CI denotes 95% confidence interval 2 An S-index score of >0.3 is suggestive of liver fibrosis 3 Abnormal LFTs, according to ARR, are defined as test results outside of the following ranges: ALT (Male: 10 -55 U/L, Female: 7 -30 U/L), AST (Male: 10 -40 U/L, Female: 9 -32 U/L), GGT (Male: 8 -61 U/L, Female: 5 -36 U/L), BR (0 -17 mmol/L), ALP (Male: 45 -115 U/L, Female: 30 -100 U/L) 4 Threshold used to predict liver fibrosis: APRI > 0.7. FIB-4 >3.25.…”

Section: Tablesmentioning

confidence: 99%

“…Liver disease causes an estimated 200,000 deaths each year in sub-Saharan Africa (sSA) as a result of liver cirrhosis and hepatocellular carcinoma (1). More than 80% of Africa's burden of liver disease has been attributed to endemic blood borne virus (BBV) infections, such as HIV, hepatitis B (HBV) and hepatitis C (HCV), alcohol, hepatotoxic medications (including traditional and herbal medicines), nonalcoholic fatty liver disease (NAFLD) and exposure to aflatoxins (1)(2)(3). However, the prevalence, distribution and aetiology of liver disease in many parts of Africa have not been well characterised, and the neglect of cirrhosis has recently been highlighted (2).…”

Section: Introductionmentioning

confidence: 99%

“…More than 80% of Africa's burden of liver disease has been attributed to endemic blood borne virus (BBV) infections, such as HIV, hepatitis B (HBV) and hepatitis C (HCV), alcohol, hepatotoxic medications (including traditional and herbal medicines), nonalcoholic fatty liver disease (NAFLD) and exposure to aflatoxins (1)(2)(3). However, the prevalence, distribution and aetiology of liver disease in many parts of Africa have not been well characterised, and the neglect of cirrhosis has recently been highlighted (2). In order to improve screening for liver disease, and to implement appropriate investigations and intervention, we have undertaken a survey of liver function tests (LFTs) together with demographic data for a large rural cohort in South-Western Uganda (4).…”

Section: Introductionmentioning

confidence: 99%

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Liver function tests and fibrosis scores in a rural population in Africa: estimation of the burden of disease and associated risk factors

O’Hara

Mokaya

Hau

et al. 2019

Preprint

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Introduction: Liver disease is a major cause of morbidity and mortality in sub-Saharan Africa. However, its prevalence, distribution and aetiology have not been well characterised. We examined liver function tests (LFTs) and calculated liver fibrosis scores in a rural population in Uganda. Methodology: A cross-sectional survey of LFTs was undertaken in 2011 in a rural population cohort in South-Western Uganda. We classified abnormal LFTs based on reference ranges set in America and in Africa. We derived fibrosis scores (AST to Platelet Ratio Index, fibrosis-4, GGT to platelet ratio, red cell distribution width to platelet ratio, and S-index) to evaluate the potential prevalence of liver disease. We collected information about alcohol intake, and infection with HIV, HBV and HCV, to determine the contribution made by these factors to liver inflammation or fibrosis. Results: Data were available for 8,099 participants (median age 30 years; 56% female). The prevalence of HBV, HCV and HIV infection were 3%, 0.2% and 8%, respectively. The prevalence of abnormal LFTs was higher based on the American reference range compared to the African reference range (e.g. for AST 13% vs 3%, respectively). The prevalence of AST/ALT ratio >2 was 11%, suggestive of alcoholic hepatitis. The highest prevalence of fibrosis was suggested by the GPR score, with 24% of the population falling above the threshold for fibrosis. By multivariate analysis, elevated LFTs and fibrosis scores were most consistently associated with older age, male sex, being under-weight, infection with HIV or HBV, and alcohol consumption. Based on population attributable risk, the highest proportion of elevated fibrosis scores was associated with alcohol use (e.g. 64% of elevated S-index scores). Conclusion: Further work is required to determine normal reference ranges for LFTs in this setting, to evaluate the specificity and sensitivity of fibrosis scores, and to determine aetiology of liver disease.

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The Growing Burden of Disability Related to Nonalcoholic Fatty Liver Disease: Data From the Global Burden of Disease 2007‐2017

et al. 2020

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Chronic liver disease (CLD) is a growing cause of morbidity and mortality worldwide. The burden of CLD varies according to etiology and geographic location. We assessed the global burden of disability from the most important complications of CLD (cirrhosis and liver cancer [LC]) according to the most common etiologies between 2007 and 2017. We obtained years living with disability (YLD), years of life lost (YLL), and disability‐adjusted life‐years (DALYs) data from the Global Burden of Disease 2017 study. Between 2007 and 2017, LC DALYs decreased by 4.52% and cirrhosis DALYs decreased by 10.58%. Nevertheless, in 2017, CLD caused 62.16 million DALYs (33.4% LC and 66.5% cirrhosis), of which 96.8% came from YLL (34.1% LC and 65.9% cirrhosis) and 3.2% from YLD (11.6% LC and 88.4% cirrhosis). In 2017, Asia accounted for 66% of all DALYs globally. Central Asia, Africa regions, Southeast Asia, and Eastern Europe had the highest liver‐related DALYs (≥1,000 per 100,000), whereas the lowest rates (≤500 per 100,000) were seen in high‐income regions, such as Asia Pacific, North America, Western Europe, and Australasia. In 2007, hepatitis B virus caused the majority (47.5%) of liver‐related DALYs, followed by hepatitis C virus (23.7%), alcoholic liver disease (14.2%), and nonalcoholic fatty liver disease/nonalcoholic steatohepatitis (NAFLD/NASH) (6.4%). In 2017, these rates shifted to 45.7%, 24.1%, 4.8%, and 7.1%, respectively. Between 2007 and 2017, cirrhosis‐related DALYs due to NAFLD/NASH increased by 23.4%, whereas the increment was 37.5% for LC‐related DALYs due to NAFLD/NASH. Conclusion: DALYs due to viral hepatitis still account for the largest proportion of CLD‐related DALYs. Although DALYs from all other liver diseases have remained stable in the last decade, DALYs related to NAFLD/NASH are growing. National, regional, and global policies are needed to address the disability burden of NAFLD across the world.

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

Cited by 48 publications

References 9 publications

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

Liver function tests and fibrosis scores in a rural population in Africa: estimation of the burden of disease and associated risk factors

The Growing Burden of Disability Related to Nonalcoholic Fatty Liver Disease: Data From the Global Burden of Disease 2007‐2017

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