The Worsening Profile of Alcoholic Hepatitis in the United States

Abstract

Background Alcoholic hepatitis (AH) is a major cause of liver-related hospitalization. The profile, treatment patterns, and outcomes of subjects admitted for AH in routine clinical practice are unknown. Also, it is not known whether these are changing over time. This study is thus aimed to identify temporal trends in hospitalization rates, clinical characteristics, treatment patterns, and outcomes of subjects admitted for AH in a routine clinical setting. Methods A retrospective analysis of adults admitted for AH from 2000 to 2011 was performed using an anonymized EMR database of patient-level data from 169 U.S. medical centers. Results (i) Epidemiology: The proportion of baby boomers admitted for AH increased from 2000 to 2011 (26 to 31%, p < 0.0001). (ii) Clinical: The median Model for End-Stage Liver Disease (MELD) score increased over time from 12 to 14 (p = 0.0014) driven mainly by increased international normalized ratio (1.2 to 1.4, p < 0.0001). The median Charlson Comorbidity Index increased from 0 to 1 (p < 0.0001) with increased diabetes, chronic obstructive pulmonary disease, and heart disease. (iii) Complications: The following increased from 2001 to 2011: Gastrointestinal bleed—7 to 10% (p = 0.03); hepatic encephalopathy—7 to 13% (p < 0.0001); hepatorenal syndrome—1.8 to 2.8% (p = 0.0003); sepsis—0 to 6% (p < 0.0001); and pancreatitis—11 to 16% (p = 0.0061). (iv) Treatment patterns and mortality: Eight to 9% of subjects received steroids while pentoxifylline use increased to 2.2%. In those with MELD ≥ 22, mortality remained between 19 and 20% and only steroids modestly improved survival in this subset. Conclusions Severe AH continues to have a high mortality. The severity and comorbidities and complications associated with AH have worsened. Drug therapy remains suboptimal.

Medical Management of Severe Alcoholic Hepatitis: Expert Review from the Clinical Practice Updates Committee of the AGA Institute

“…Two recent studies suggest the number of patients hospitalized in the U.S. with AH increased during the first decade of the 21st century (1, 2). Although in its most severe form, AH has a high short-term mortality rate if untreated, in 2011, only 28% of more than 1,600 patients admitted to U.S. hospitals were treated with glucocorticoids and 17% with pentoxifylline (PTX), suggesting a lack of widespread confidence in the 2 most frequently used therapies for AH (2). Patients with AH are systemically ill with a high risk of nutritional deficiency, infection, acute kidney injury (AKI), and development of multiorgan failure (MOF) syndrome(3).…”

Underestimation of Liver Transplantation for Alcoholic Hepatitis in the National Transplant Database

“…A challenge exists in clinically distinguishing severe AH from acute-on-chronic liver failure in patients with cirrhosis due to alcohol. (4,5) In the United States, liver biopsy to diagnose AH is uncommon, (5,6) and studies have shown that a clinical diagnosis of acute AH is discordant with histology in approximately 25% of patients. (7) In this study, the majority of patients were coded as alcoholic cirrhosis in the UNOS database.…”

Posttransplant Complications Predict Alcohol Relapse in Liver Transplant Recipients

“…Alcohol-related liver disease (ALD) is currently the leading indication for liver transplantation (LT) in the United States, and the number of transplant patients with ALD has rapidly increased. (1,2) Major challenges in LT in patients with ALD include alcohol relapse after LT, which ranges from 8.7% to 42%. (3)(4)(5)(6)(7)(8) Alcohol relapse, especially harmful relapse, could lead to allograft dysfunction or failure due to alcohol toxicity.…”