Alcohol-Related Liver Disease Is Rarely Detected at Early Stages Compared With Liver Diseases of Other Etiologies Worldwide

Abstract

Background & aims: Despite recent advances in treatment of viral hepatitis, liver-related mortality is high, possibly owing to the large burden of advanced alcohol-related liver disease (ALD). We investigated whether patients with ALD are initially seen at later stages of disease development than patients with hepatitis C virus (HCV) infection or other etiologies.

Methods: We performed a cross-sectional study of 3453 consecutive patients with either early or advanced liver disease (1699 patients with early and 1754 with advanced liver disease) seen at 17 tertiary care liver or gastrointestinal units worldwide, from August 2015 through March 2017. We collected anthropometric, etiology, and clinical information, as well as and model for end-stage liver disease scores. We used unconditional logistic regression to estimate the odds ratios for evaluation at late stages of the disease progression.

Results: Of the patients analyzed, 81% had 1 etiology of liver disease and 17% had 2 etiologies of liver disease. Of patients seen at early stages for a single etiology, 31% had HCV infection, 21% had hepatitis B virus infection, and 17% had nonalcoholic fatty liver disease, whereas only 3.8% had ALD. In contrast, 29% of patients seen for advanced disease had ALD. Patients with ALD were more likely to be seen at specialized centers, with advanced-stage disease, compared with patients with HCV-associated liver disease (odds ratio, 14.1; 95% CI, 10.5-18.9; P < .001). Of patients with 2 etiologies of liver disease, excess alcohol use was associated with 50% of cases. These patients had significantly more visits to health care providers, with more advanced disease, compared with patients without excess alcohol use. The mean model for end-stage liver disease score for patients with advanced ALD (score, 16) was higher than for patients with advanced liver disease not associated with excess alcohol use (score, 13) (P < .01).

Conclusions: In a cross-sectional analysis of patients with liver disease worldwide, we found that patients with ALD are seen with more advanced-stage disease than patients with HCV-associated liver disease. Of patients with 2 etiologies of liver disease, excess alcohol use was associated with 50% of cases. Early detection and referral programs are needed for patients with ALD worldwide.

Keywords: Cirrhosis; Mortality; NAFLD.

Copyright © 2019 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1:. Flow Chart of Included Patients and Characteristics of Each Group

*patients with no evidence of cirrhosis (F4), assessed either by liver biopsy or non-invasive tests. Abbreviations: Hepatocellular carcinoma, HCC; International normalized ratio, INR; Institutional review board, IRB.

Figure 2:. Medical Visits at Specialized Centers of Patients with Single Etiology. Panel A: Number of Patients with Medical Visits at Advanced vs. Early Liver Stages. Panel B: Odds Ratio of being seen at Advanced stage.

Panel A: *p<.05.>

Figure 3:. Medical Visits at Specialized Centers of Patients with Double Etiologies. Panel A: Number of Patients with Medical Visits at Advanced vs. Early Liver Stages. Panel B Odds Ratio of being seen at Advanced stage vs. Early Liver Disease stages

Panel A: *p<.05.>

Figure 4:. Heatmap Expression of the Likelihood Receiving a Medical Visited at Advance vs Early Stages Compared to HCV by Continent.

Red color shows those etiologies with the highest likelihood of being seen at advanced vs early stages of liver disease compared to HCV and green color shows the contrary. Abbreviations: DE, double etiologies. Due to their low global frequency Wilson, HFE, Schistosomiasis and triple or quadruple etiologies have been group with the category “other”.