Mortality due to cirrhosis and liver cancer in the United States, 1999-2016: observational study

Abstract

ObjectiveTo describe liver disease related mortality in the United States during 1999-2016 by age group, sex, race, cause of liver disease, and geographic region.DesignObservational cohort study.SettingDeath certificate data from the Vital Statistics Cooperative, and population data from the US Census Bureau compiled by the Center for Disease Control and Prevention’s Wide-ranging Online Data for Epidemiologic Research (1999-2016).ParticipantsUS residents.Main outcome measureDeaths from cirrhosis and hepatocellular carcinoma, with trends evaluated using joinpoint regression.ResultsFrom 1999 to 2016 in the US annual deaths from cirrhosis increased by 65%, to 34 174, while annual deaths from hepatocellular carcinoma doubled to 11 073. Only one subgroup—Asians and Pacific Islanders—experienced an improvement in mortality from hepatocellular carcinoma: the death rate decreased by 2.7% (95% confidence interval 2.2% to 3.3%, P<0.001) per year. Annual increases in cirrhosis related mortality were most pronounced for Native Americans (designated as “American Indians” in the census database) (4.0%, 2.2% to 5.7%, P=0.002). The age adjusted death rate due to hepatocellular carcinoma increased annually by 2.1% (1.9% to 2.3%, P<0.001); deaths due to cirrhosis began increasing in 2009 through 2016 by 3.4% (3.1% to 3.8%, P<0.001). During 2009-16 people aged 25-34 years experienced the highest average annual increase in cirrhosis related mortality (10.5%, 8.9% to 12.2%, P<0.001), driven entirely by alcohol related liver disease. During this period, mortality due to peritonitis and sepsis in the setting of cirrhosis increased substantially, with respective annual increases of 6.1% (3.9% to 8.2%) and 7.1% (6.1% to 8.4%). Only one state, Maryland, showed improvements in mortality (−1.2%, −1.7% to −0.7% per year), while many, concentrated in the south and west, observed disproportionate annual increases: Kentucky 6.8% (5.1% to 8.5%), New Mexico 6.0% (4.1% to 7.9%), Arkansas 5.7% (3.9% to 7.6%), Indiana 5.0% (3.8% to 6.1%), and Alabama 5.0% (3.2% to 6.8%). No state showed improvements in hepatocellular carcinoma related mortality, while Arizona (5.1%, 3.7% to 6.5%) and Kansas (4.3%, 2.8% to 5.8%) experienced the most severe annual increases.ConclusionsMortality due to cirrhosis has been increasing in the US since 2009. Driven by deaths due to alcoholic cirrhosis, people aged 25-34 have experienced the greatest relative increase in mortality. White Americans, Native Americans, and Hispanic Americans experienced the greatest increase in deaths from cirrhosis. Mortality due to cirrhosis is improving in Maryland but worst in Kentucky, New Mexico, and Arkansas. The rapid increase in death rates among young people due to alcohol highlight new challenges for optimal care of patients with preventable liver disease.

Diagnosis and Treatment of Alcohol‐Associated Liver Diseases: 2019 Practice Guidance From the American Association for the Study of Liver Diseases

“…Alcohol‐associated liver disease includes a variety of clinical disorders: steatosis, ASH, AH of varying degrees of severity, AC, and AC complicated by hepatocellular carcinoma (HCC). ALD comprises a substantial portion of the overall cirrhosis burden, both in the United States and worldwide, and is responsible for rising rates of liver‐related mortality in the United States, especially among younger patients . In the United States, mortality due to all ALD was estimated at 5.5 per 100,000 in 2012; the relative contribution of ALD to all cirrhosis mortality is predicted to increase as the proportion of deaths due to hepatitis C virus (HCV) cirrhosis declines .…”

“…In the United States, mortality due to all ALD was estimated at 5.5 per 100,000 in 2012; the relative contribution of ALD to all cirrhosis mortality is predicted to increase as the proportion of deaths due to hepatitis C virus (HCV) cirrhosis declines . More recently, AC mortality was shown to have increased from 2008 to 2016, particularly among patients ages 25‐34 years old . Cirrhotic and noncirrhotic ALD prevalence has been estimated at approximately 2% in the general US population, whereas AC in the US Veterans' population was estimated at 327 per 100,000 enrollees .…”

Diabetes Is Associated With Increased Risk of Hepatocellular Carcinoma in Patients With Cirrhosis From Nonalcoholic Fatty Liver Disease

“…Incidence and mortality rates of hepatocellular carcinoma (HCC) have been increasing in the United States . Whereas chronic hepatitis C virus (HCV) infection has been the leading cause of HCC in the United States for the past several decades, successful treatment of chronic hepatitis C with highly potent direct antiviral treatment is decreasing the disease burden of HCV and thus decreasing the number of HCV‐associated HCC .…”

The Quality and Outcomes of Care Provided to Patients with Cirrhosis by Advanced Practice Providers

“…Cirrhosis is common, affecting up to 5 million Americans, and its prevalence is increasing . It is characterized by poor quality of life and life‐limiting complications such as variceal hemorrhage, ascites, hepatic encephalopathy (HE), and hepatocellular carcinoma (HCC) .…”