Alcoholic cirrhosis in Denmark - population-based incidence, prevalence, and hospitalization rates between 1988 and 2005: a descriptive cohort study. BMC Gastroenterol. 2008;8:3. [PMID: 18261240 PMCID: PMC2275281 DOI: 10.1186/1471-230x-8-3]

Cause-specific mortality in patients with alcohol-related liver disease in Denmark: a population-based study

BACKGROUND

Increased knowledge of the causes of death will be essential to prevent premature death in alcohol-related liver disease. We examined cause-specific mortality, including death due to specific cancers, in the 15 years after diagnosis of alcohol-related liver disease.

METHODS

We used nationwide health registries to identify patients (aged ≥18 years) with a first diagnosis of alcohol-related liver disease between Jan 1, 2002, and Dec 31, 2017, in Denmark and followed up patients for their underlying cause of death up to Dec 31, 2019. We estimated the cause-specific mortality and investigated whether the cause-specific mortality differed by sex, age (<50, 50-59, and ≥60 years), alcohol-related liver disease severity at diagnosis (decompensated cirrhosis, compensated cirrhosis, alcoholic hepatitis, and steatosis or unspecified liver disease), and presence of diabetes.

FINDINGS

The study included 23 385 patients with incident alcohol-related liver disease. Patients had a median age of 58 years (IQR 51-65), 15 819 (68%) were men and 7566 (32%) were women, and 15 358 (66%) had cirrhosis. During 111 532 person-years of follow-up, 15 692 (67%) patients died. Liver disease was the leading cause of death. In the first 5 years after alcohol-related liver disease diagnosis, liver disease caused almost half of all deaths, and the 5-year risk of death due to liver disease was 25·8% (95% CI 25·3-26·4). Beyond 5 years, causes other than liver disease combined became more common; of these extrahepatic causes, cancer, cardiovascular disease, and alcohol use disorder were the most common. Hepatocellular carcinoma was the dominant cause of cancer death (10-year risk of 2·5%, 95% CI 2·3-2·7), followed by lung cancer (1·9%, 1·7-2·1). The 10-year risk of death due to liver disease (around 30%) was similar for patients in all age groups and independent of sex and diabetes but was three times higher for those with decompensated cirrhosis (46·7%, 44·8-48·4) than steatosis or unspecified liver disease (16·2%, 15·3-17·2).

INTERPRETATION

Patients diagnosed with alcohol-related liver disease were at high risk of dying from liver disease many years after diagnosis, irrespective of age and sex. Death due to specific cancers, including hepatocellular carcinoma, each contributed minimally to the total mortality in patients with alcohol-related liver disease.

FUNDING

TrygFonden and the Novo Nordisk Foundation.

Prevalence of Statin Use and Predictors of Statin Initiation Among Patients with Alcohol-Related Cirrhosis - A Danish Nationwide Cohort Study

Purpose

Statins reportedly increase the survival of patients with cirrhosis due to alcohol-related liver disease (ALD cirrhosis), but this association might be confounded by socioeconomic status. We examined the prevalence of statin use and socioeconomic and demographic predictors of statin initiation and discontinuation among patients with ALD cirrhosis.

Patients and Methods

Using Danish nationwide healthcare registries, we examined statin use among patients diagnosed with ALD cirrhosis in 1997-2018. We computed the prevalence of statin use and incidence of statin initiation and discontinuation, and we used multivariable Cox regression to identify predictors of statin initiation and discontinuation.

Results

We identified 28,260 patients with ALD cirrhosis in 1997-2018. During this period, the prevalence of statin use rose sharply, reaching 19.0% in late 2018. Among patients diagnosed with ALD cirrhosis after 2010, 16.9% were using statins when they were diagnosed with cirrhosis. Among the patients who did not use statins initially, those with lower educational attainment were more likely to begin taking them than those with higher attainment. Also, cohabiting patients were more likely to begin than patients who lived alone, and employed patients were more likely to begin compared to patients outside the labour force. Among current statin users, unemployment predicted statin discontinuation.

Conclusion

The use of statins has become increasingly prevalent among Danish patients with ALD cirrhosis, reaching 19.0% in 2018. Employment, cohabitation, and a short education predicted statin initiation after ALD cirrhosis diagnosis, and unemployment predicted statin discontinuation. Overall, statin use was not a marker of a high socioeconomic status.

Systematic review: development of a consensus code set to identify cirrhosis in electronic health records

BACKGROUND

Electronic health records (EHRs) collate longitudinal data that can be used to facilitate large-scale research in patients with cirrhosis. However, there is no consensus code set to define the presence of cirrhosis in EHR. This systematic review aims to evaluate the validity of diagnostic coding in cirrhosis and to synthesise a comprehensive set of ICD-10 codes for future EHR research.

METHOD

MEDLINE and EMBASE databases were searched for studies that used EHR to identify cirrhosis and cirrhosis-related complications. Validated code sets were summarised, and the performance characteristics were extracted. Citation analysis was done to inform development of a consensus code set. This was then validated in a cohort of patients.

RESULTS

One thousand six hundred twenty-six records were screened, and 18 studies were identified. The positive predictive value (PPV) was the most frequently reported statistical estimate and was ≥80% in 17/18 studies. Citation analyses showed continued variation in those used in contemporary research practice. Nine codes were identified as those most frequently used in the literature and these formed the consensus code set. This was validated in diverse patient populations from Europe and North America and showed high PPV (83%-89%) and greater sensitivity for the identification of cirrhosis than the most often used code set in the recent literature.

CONCLUSION

There is variation in code sets used to identify cirrhosis in contemporary research practice. A consensus set has been developed and validated, showing improved performance, and is proposed to align EHR study designs in cirrhosis to facilitate international collaboration and comparisons.

NAFLD and Alcohol-Associated Liver Disease Will Be Responsible for Almost All New Diagnoses of Cirrhosis in Canada by 2040

BACKGROUND AND AIMS

Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040.

APPROACH AND RESULTS

This is a retrospective cohort study in Ontario, Canada, using population-based administrative health care data. Individuals with incident cirrhosis (2000-2017) were identified, and etiology was defined as HCV, HBV, NAFLD, alcohol-associated liver disease (ALD), or autoimmune liver disease/other using validated case definitions. Annual age/sex-adjusted cirrhosis incidence rate per 100,000 person-years was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. In total, 159,549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI, 1.6-2.4; P < 0.001). The largest increases were for HCV (AAPC, 4.1%/year; 95% CI, 2.6-5.7; P < 0.001) and NAFLD (AAPC, 3.3%/year; 95% CI, 2.6-4.1%; P < 0.001). ALD and HCV cirrhosis in those born >1980 increased by 11.6%/year (95% CI, 9.3-13.9; P < 0.001) and 9.5%/year (95% CI, 6.2-13.0; P < 0.001), respectively. However, by 2040, cirrhosis incidence is projected to continue to increase, driven mostly by NAFLD, especially in postmenopausal women, and ALD in individuals born >1980.

CONCLUSIONS

Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.

Risk and Outcome of Venous and Arterial Thrombosis in Patients With Cirrhosis: A Danish Nation-wide Cohort Study

BACKGROUND AND AIMS

Cirrhosis affects hemostasis, but its effects across the spectrum of thromboses remain poorly understood. We examined risks and outcomes of venous and arterial thrombosis.

APPROACH AND RESULTS

We used nation-wide Danish health care registries to identify outpatients with cirrhosis and a sex- and age-matched comparison cohort without cirrhosis from the general population. Patients with cirrhosis and comparators were followed until they had a venous thromboembolism (VTE), acute myocardial infarction (AMI), or ischemic stroke (IS) or died. We computed absolute risks and HRs of thrombosis and compared outcomes after thrombosis. We included 5,854 patients with cirrhosis (median Model for End-Stage Liver Disease score, 9; interquartile range, 7-13), and their risk of any of the thrombotic events was 0.8% after 1 year and 6.3% after 10 years. They were more likely than the 23,870 matched comparators to have a VTE (adjusted hazard ratio [aHR], 2.0; 95% CI, 1.5-2.6) or IS (aHR, 1.7; 95% CI, 1.3-2.3), but not AMI (aHR, 0.7; 95% CI, 0.5-0.9). Among patients with cirrhosis, decompensation increased the risk of AMI, but not the other thromboses. Following thrombosis, patients with cirrhosis had higher 90-day mortality than comparators (after VTE: 17% vs. 7%; after AMI: 27% vs. 5%; after IS: 10% vs. 7%) and were less likely to receive antithrombotic treatment.

CONCLUSIONS

Patients with cirrhosis had an increased risk of VTE and IS, but not AMI. Among patients with cirrhosis, decompensation increased the risk of AMI, exclusively. Mortality after thrombosis was higher in patients with cirrhosis than in other patients. These findings are relevant for decisions about antithrombotic prophylaxis in patients with cirrhosis.

Socioeconomic inequalities in the incidence of alcohol-related liver disease: A nationwide Danish study

Background

There is socio-economic inequality in total alcohol-related harm, but knowledge of inequality in the incidence of specific alcohol-related diseases would be beneficial for prevention. Registry-based studies with nationwide coverage may reveal the full burden of socioeconomic inequality compared to what can be captured in questionnaire-based studies. We examined the incidence of alcohol-related liver disease (ALD) according to socioeconomic status and age.

Methods

We used national registries to identify patients with an incident diagnosis of ALD and their socioeconomic status in 2009-2018 in Denmark. We computed ALD incidence rates by socioeconomic status (education and employment status) and age-group (30-39, 40-49, 50-59, 60-69 years) and quantified the inequalities as the absolute and relative difference in incidence rates between low and high socioeconomic status.

Findings

Of 17,473 patients with newly diagnosed ALD, 78% of whom had cirrhosis, 86% had a low or medium-low educational level and only 20% were employed. ALD patients were less likely to be employed in the 10 years prior to diagnosis than controls. The incidence rate of ALD correlated inversely with educational level, from 181 (95% CI, 167-197) to 910 (95% CI, 764-1086) per million person-years from the highest to the lowest educational level. By employment status, the incidence rate per million person-years was 211 (95% CI, 189-236) for employed and 3449 (95% CI, 2785-4271) for unemployed. Incidence rates increased gradually with age leading to larger inequalities in absolute numbers for older age-groups. Although ALD was rare in the younger age-groups, the relative differences in incidence rates between high and low socioeconomic status were large for these ages. The pattern of socioeconomic inequality in ALD incidence was similar for men and women.

Interpretation

This study showed substantial socioeconomic inequalities in ALD incidence for people aged 30-69 years.

Funding

The study was supported by grants from the Novo Nordisk Foundation (NNF18OC0054612) and the Research Fund of Bispebjerg Hospital.

A Search for Undiagnosed Charcot-Marie-Tooth Disease Among Patients Registered with Unspecified Polyneuropathy in the Danish National Patient Registry

Purpose

In a recent study based on data from the Danish National Patients Registry (DNPR), we reported the prevalence of Charcot-Marie-Tooth disease (CMT) in Denmark to be 22.5 per 100.000. This prevalence is most likely a minimum estimate, as many cases of CMT may be misdiagnosed or remain undiagnosed due to the heterogeneous nature of the disorder. The aim of this study was to investigate the possible number of undiagnosed CMT cases among patients registered with unspecified polyneuropathy (UP) diagnoses in the DNPR.

Patients and Methods

From the DNPR we extracted data on all patients given an UP diagnosis in the period 1977 to 2012. We selected all patients diagnosed with a primary UP diagnosis before age 40 at a department of neurology, neurophysiology, clinical genetics or pediatrics, and excluded all patients with a specified polyneuropathy diagnosis or with diagnostic codes related to alcohol and diabetes mellitus. To assess the proportion of possible CMT patients, we performed medical record review in a random sample of patients diagnosed in the Central Denmark Region. To further investigate the possible overlap between UP and CMT in the DNPR, we performed a series of searches for ICD-8 and ICD-10 codes related to CMT.

Results

Between 1977 and 2012, 30.903 patients were diagnosed with UP without also being diagnosed with CMT. A total of 940 patients fulfilled the selection criteria. We found that 21.5% (95% CI 13.1%–32.2%) of the cases in the random sample fulfilled our criteria for CMT. This estimate increases the prevalence of CMT in Denmark with 3.6 per 100,000 (95% CI 2.4%–5.5%).

Conclusion

This study illustrates how hitherto undiagnosed CMT patients may be identified in the DNPR and further reports the number of possible CMT cases. Our results support the hypothesis that the true prevalence of CMT is higher than recently reported.

Decreasing Incidence of Alcohol-Related Liver Disease in Denmark: A 25-Year Nationwide Study

Purpose

Alcohol consumption has decreased in Denmark in recent years. We aimed to illustrate and investigate the developments in the incidence, hospital care, and mortality of alcohol-related liver disease (ALD) in Denmark during the last 25 years.

Patients and Methods

Through nationwide healthcare registries, we identified all Danish patients with incident ALD in 1994–2018. We computed standardized incidence rates by sex, age, and geography, age-specific incidence rates by birth cohort, and standardized prevalence. We enumerated inpatient admissions, days of admission, outpatient visits, and emergency room visits. Lastly, we estimated relative risks of mortality, standardized mortality rates, and the proportion of deaths caused by ALD.

Results

The standardized incidence rate decreased from its peak at 357 per 1,000,000 in 2009 to 240 per 1,000,000 in 2018, and the decrease was evident for both sexes and all age groups below 70 years. The standardized prevalence was stable around 0.22% from 2011 onwards. There was an almost fivefold geographic variation in standardized incidence by municipalities, and age-specific incidence rates decreased sequentially with each 5-year birth cohort after 1960. The number of inpatient admissions, days of admission, and emergency room visits decreased during the study period, while the number of outpatient visits was stable. For patients diagnosed in 2014–2018 compared to 1994–1998, the relative risk of 1-year mortality was 0.83 (95% confidence interval: 0.78–0.87), and the standardized mortality along with the proportion of deaths caused by ALD decreased during the study period.

Conclusion

The incidence of ALD decreased from 357 to 240 per 1,000,000 over the last 10 years in Denmark. During the same period, the prevalence remained stable around 0.22% and mortality decreased. Additionally, the burden of ALD on hospital care decreased significantly between 1994 and 2018. We anticipate a further decrease in the incidence of ALD in the future.

Risk of hepatocellular carcinoma in Danish outpatients with alcohol-related cirrhosis

BACKGROUND AND AIMS

Accurate estimates of hepatocellular carcinoma (HCC) risk in patients with cirrhosis are important to guide surveillance strategies. We described HCC risk among outpatients with alcohol-related cirrhosis and contrasted the risk of death from HCC with the risk of death from variceal bleeding or trauma.

METHODS

This was a nationwide, registry-based historical cohort study between 2006 and 2018. We included all Danish outpatients with a hospital diagnosis of alcohol-related cirrhosis, except those with cancer, those with chronic viral hepatitis or autoimmune liver disease, and those older than 80 years. We followed them through 2018 and described the cumulative risk of HCC and the cumulative risk of death from HCC, variceal bleeding, or trauma.

RESULTS

Of the 4,553 patients included, 181 developed HCC and 2,274 died. The cumulative risk of HCC was 0.9% (95% CI 0.7-1.3) after 1 year, 3.6% (95% CI 3.0-4.2) after 5 years, and 6.0% (95% CI 5.1-7.0) after 10 years, or approximately 0.7% per year. Male sex, older age, and decompensated cirrhosis predicted a higher HCC risk. After 10 years, 6.9% of deaths in the cohort could be attributed to HCC, whereas 6.5% could be attributed to variceal bleeding, and 5.0% to trauma.

CONCLUSIONS

In 2006-2018, Danish outpatients with alcohol-related cirrhosis had an HCC risk of 0.7% per year, and they were nearly as likely to die from variceal bleeding or from trauma as from HCC. The implications are that many potentially harmful examinations are required for every HCC found through surveillance, so interventions targeting the prevention of other causes of death might be more cost-effective.

LAY SUMMARY

We described the risk of hepatocellular carcinoma (HCC, the most common form of liver cancer originating in the liver) in Danish outpatients with cirrhosis due to harmful alcohol consumption. Accurate data on that risk are important for patient counselling and decisions about screening for HCC. The risk was about 0.7% per year, which is lower than might be expected and suggests that many potentially harmful screening examinations are required for every HCC found through surveillance.

Nicotinamide Adenine Dinucleotide Metabolome Is Functionally Depressed in Patients Undergoing Liver Transplantation for Alcohol-Related Liver Disease

Nicotinamide adenine dinucleotide (NAD⁺) and related coenzymes play critical roles in liver function. Although hepatic alcohol metabolism depresses NAD⁺, current understanding of the NAD⁺ metabolome in alcohol‐related liver disease (ArLD) is based on animal models. We used human liver samples to quantify the NAD⁺ metabolome in ArLD with samples obtained at the time of liver transplantation or resection at University Hospitals Birmingham National Health Service Foundation Trust. The severity of steatohepatitis in liver from patients with ArLD was assessed with standard liver function tests and histology. NAD‐targeted quantitative metabolomic analysis of liver tissue was performed by liquid chromatography–tandem mass spectrometry. Seventy‐two human liver specimens were analyzed, including 43 with ArLD. The NAD⁺ metabolome differed significantly between different types of liver disease (two‐way analysis of variance [ANOVA], P = 0.001). ArLD liver tissue showed markedly depressed concentrations of NAD⁺ (432 μM vs. 616 μM in normal liver) and precursor molecules nicotinic acid and nicotinamide riboside. There was a significant overall difference in the NAD⁺ metabolome between ArLD samples with and without steatohepatitis (two‐way ANOVA, P = 0.018). After correcting for multiple comparisons, a significant difference for individual components of the metabolome was observed for the concentration of NAD⁺ (mean, 462 μM vs. 322 μM; P < 0.01 in nonsevere vs. severe alcoholic steatohepatitis, respectively). NAD⁺ concentration was inversely related to serum bilirubin concentration (r² = −0.127; P = 0.04) and positively correlated with myeloperoxidase activity (r² = 0.31; P = 0.003). The concentration of NAD⁺ and its precursor molecules are significantly reduced in ArLD and are associated with disease activity. Conclusion: Liver samples from people with ArLD show depressed NAD⁺ and precursor levels as well as depressed myeloperoxidase activity.

Atorvastatin for prevention of disease progression and hospitalisation in liver cirrhosis: protocol for a randomised, double-blind, placebo-controlled trial

INTRODUCTION

Patients with liver cirrhosis are often diagnosed late and once complications are present, the 2-year survival is 50%. Increasing evidence supports systemic inflammation and metabolic dysfunction in the hepatic stellate cell as key drivers of progression of cirrhosis. However, there is no registered medication, that targets inflammation and cellular dysfunction in the liver.

METHODS AND ANALYSIS

In a randomised double-blind and placebo-controlled trial with atorvastatin for liver cirrhosis, we aim to investigate clinical endpoints of survival, hospitalisations and safety, but also exploratory endpoints of genomics and protein functions in the liver.

ETHICS AND DISSEMINATION

There is no registered medication that actively prevents development of complications or systemic inflammation in liver cirrhosis. All patients continue regular clinical management during the trial period. Atorvastatin has been on the market for several years with a safety profile that is acceptable even in patients with liver disease. A beneficial effect of atorvastatin on clinical outcomes in cirrhosis will provide cheap and effective causal treatment for chronic liver disease. The trial is registered by the Danish Data Protection Agency (P-2019-635) and approved by the Danish Medicines Agency (EudraCT 2019-001806-40) and the Scientific Ethics Committee of the Capital Region of Denmark (H-19030643) before initiation. Reporting of the trial will follow the Consolidated Standards of Reporting Trials guidelines for reporting of randomised clinical trials.

TRIAL REGISTRATION NUMBER

The trial is registered in clinicaltrials.gov (NCT04072601) and in clinicaltrialsregister.eu (EudraCT 2019-001806-40) (Pre-results).

Mortality Associated with Hepatobiliary Disease in Portugal between 2006 and 2012

INTRODUCTION

Hepatobiliary disease is becoming a major public health problem, and recent data suggest that the burden of liver disease is higher than previously thought. Our aim was to quantify the mortality from hepatobiliary disease in Portugal and to compare this with the mortality related o other causes over a 7-year period (2006-2012).

MATERIALS AND METHODS

A statistical analysis of mortality data according to cause, sex, age, and region from the National Statistics Institute in Portugal was carried out. The data related to 14 causes of death, the most frequent of which were alcoholic liver disease (ALD) (International Classification of Diseases code K70), unspecified cirrhosis of liver (UCL) (K74.6), hepatocellular carcinoma (HCC) (C22.0), unspecified malignant neoplasm of liver (C22.9), and cholangiocarcinoma (C22.1).

RESULTS

Between 2006 and 2012, 18,279 deaths (24.5/100,000) from hepatobiliary disease were registered in Portugal, constituting the 8th leading cause of death. The main causes of death from hepatobiliary disease were ALD (7.1/100,000), UCL (5.5/100,000), and HCC (4.3/100,000), with a male predominance (72%). ALD was the main aetiology in younger age groups (40-65 years), while primary neoplasms of the liver and the intrahepatic bile ducts were predominant in the elderly (>80 years). The mortality related to HCC increased by 66% between 2006 and 2012.

CONCLUSION

These data outline the burden of hepatobiliary disease in Portugal (8th cause of death) and highlight a potential impact on economic productivity.

Hospital contacts with alcohol problems prior to liver cirrhosis or pancreatitis diagnosis

AIM

To evaluate prior hospital contacts with alcohol problems in patients with alcoholic liver cirrhosis and pancreatitis.

METHODS

This was a register-based study of all patients diagnosed with alcoholic liver cirrhosis or pancreatitis during 2008-2012 in Denmark. Hospital contacts with alcohol problems (intoxication, harmful use, or dependence) in the 10-year period preceding the diagnosis of alcoholic liver cirrhosis and pancreatitis were identified.

RESULTS

In the 10 years prior to diagnosis, 40% of the 7719 alcoholic liver cirrhosis patients and 40% of the 1811 alcoholic pancreatitis patients had at least one prior hospital contact with alcohol problems. Every sixth patient (15%-16%) had more than five contacts. A similar pattern of prior hospital contacts was observed for alcoholic liver cirrhosis and pancreatitis. Around 30% were diagnosed with alcohol dependence and 10% with less severe alcohol diagnoses. For the majority, admission to somatic wards was the most common type of hospital care with alcohol problems. Most had their first contact with alcohol problems more than five years prior to diagnosis.

CONCLUSION

There may be opportunities to reach some of the patients who later develop alcoholic liver cirrhosis or pancreatitis with preventive interventions in the hospital setting.

Liver cirrhosis in England-an observational study: are we measuring its burden occurrence correctly?

OBJECTIVES

Mortality due to liver disease (of which cirrhosis is the end stage) is increasing more than any other chronic condition in the UK. This study aims to demonstrate that (1) exclusive reliance on mortality rates may not reveal the true burden of liver cirrhosis, and (2) diverse use of diagnostic coding may produce misleading estimates.

DESIGN

Observational study.

SETTING

The Office for National Statistics death registry was interrogated to investigate liver cirrhosis mortality trends in England and Wales from 1968 to 2011.

MAIN OUTCOME

Standardised mortality trends according to three different definitions of liver cirrhosis based on the specificity of diagnostic codes were calculated: 1 (chronic liver diseases), 2 (alcoholic and unspecified cirrhosis only) and 3 (cirrhosis as end-stage liver disease). The mortality trends were compared with incidence rates established in a previous population-based study (based on definition 3), from 1998 to 2009, to investigate discrepancies between these two measures.

RESULTS

Over the study period, the overall standardised liver cirrhosis mortality rates were 8.8, 5,1 and 5.4 per 100 000 person-years for definitions 1, 2 and 3, respectively. The mortality rates for definition 3 in 1998 and 2009 were 6.2 and 5.9 per 100 000 person-years, respectively; while the equivalent incidence rates were at least threefold and sixfold higher: 23.4 and 35.9 per 100 000 person-years, respectively. This discrepancy between incidence and mortality rates was also at least threefold in men and women separately and across age groups.

CONCLUSION

Mortality rates underestimated the incidence of liver cirrhosis by at least threefold between 1998 and 2009 and varied with differing definitions of disease. Mortality data should not be used exclusively as an indicator for the occurrence of liver cirrhosis in the population. Routinely collected healthcare data are available to measure occurrence of this disease. Careful consideration should be taken when selecting diagnostic codes for cirrhosis.

Time-trends in incidence and prognosis of hepatocellular carcinoma in Denmark: A nationwide register-based cohort study

BACKGROUND & AIMS

There are no recent data on incidence or survival of hepatocellular carcinoma (HCC) in Denmark. We examined current HCC epidemiology.

METHODS

We used data from nationwide registries to identify all Danish citizens diagnosed with HCC in 1994-2016. We computed annual standardized incidence rates for the entire 1994-2016 period, and we compared survival for patients diagnosed in 2004-2014; data on HCC stage were available for that period alone and coded according to the TNM classification.

RESULTS

The incidence rate for 1994-2016 was 3.7 (95% CI 3.6-3.8) per 100 000 population per year. It was stable around 3.0 in 1994-2007, climbed steadily to 5.7 in 2008-2011, and remained high in 2012-2016. The proportion of non-cirrhotic patients with HCC was 21%, with a slightly decreasing time trend. Median survival time rose from 2.7 months in 2004-2006 to 7.7 months in 2013-2014, but only patients with early HCC (stage I or II HCC or a "probably early HCC") saw improvements after 2007 (confounder-adjusted mortality hazard ratio for 2013-2014 vs 2007-2009=0.67, 95% 0.50-0.90). The proportion of patients with early HCC rose from 17% in 2004-2006 to 30% in 2013-2014.

CONCLUSIONS

HCC incidence increased between 2007 and 2011. Concurrently, the HCC stage at diagnosis and patient survival improved. The likely reasons for the changes include easier access to HCC workup, changing diagnostic criteria for HCC, increased prevalence of risk factors for HCC, and improved treatment of patients with HCC.

Risk for alcoholic liver cirrhosis after an initial hospital contact with alcohol problems: A nationwide prospective cohort study

Alcoholic liver cirrhosis is usually preceded by many years of heavy drinking, in which cessation in drinking could prevent the disease. Alcohol problems are not consistently managed in hospital patients. We followed all Danish patients with an initial hospital contact with alcohol problems (intoxication, harmful use, or dependence) during 1998-2002 for alcoholic liver cirrhosis development (n = 36,044). In this registry-based cohort, we identified predictors of the absolute risk for alcoholic liver cirrhosis. Incidence rate ratios (IRRs) were estimated as the incidence rate of alcoholic liver cirrhosis in these patients relative to the general population. Age and alcohol diagnosis were significant predictors of alcoholic liver cirrhosis risk in men and women, whereas civil status, education, and type of hospital care were not. In men, the 15-year absolute risk was 0.7% (95% confidence interval [CI], 0.4, 0.8) for 20-29 years, 5.5% (95% CI, 4.9, 6.2) for 30-39 years, 9.8% (95% CI, 9.0, 11) for 40-49 years, 8.9% (95% CI, 8.1, 9.8) for 50-59 years, 6.2% (95% CI, 5.1, 7.2) for 60-69 years, and 2.5% (95% CI, 1.7, 3.3) for 70-84 years. According to alcohol diagnosis in men, the 15-year absolute risk was 2.6% (95% CI, 2.3, 2.9) for intoxication, 7.7% (95% CI, 6.4, 7.9) for harmful use, and 8.8% (95% CI, 8.2, 9.4) for dependence. The IRR for alcoholic liver cirrhosis in the cohort relative to the general population was 11 (95% CI, 10, 12) in men and 18 (95% CI, 15, 21) in women.

CONCLUSION

Hospital patients with alcohol problems had a much greater risk for alcoholic liver cirrhosis compared to the general population. The risk was particularly increased for patients 40-59 years and for patients diagnosed with harmful use or dependence. (Hepatology 2017;65:929-937).

Alcoholic Liver Disease in Asia, Europe, and North America

Alcoholic liver diseases comprise a spectrum of clinical disorders and changes in liver tissue that can be detected by pathology analysis. These range from steatosis to more severe signs and symptoms of liver disease associated with inflammation, such as those observed in patients with alcoholic hepatitis or cirrhosis. Although the relationship between alcohol consumption and liver disease is well established, severe alcohol-related morbidities develop in only a minority of people who consume alcohol in excess. Inter-individual differences in susceptibility to the toxic effects of alcohol have been studied extensively-they include pattern of alcohol consumption, sex, environmental factors (such as diet), and genetic factors, which vary widely among different parts of the world. Alcoholic liver disease is becoming more common in many parts of Asia, but is decreasing in Western Europe. Treatment approaches, including availability of medications, models of care, and approach to transplantation, differ among regions.

Decreasing Mortality Among Danish Alcoholic Cirrhosis Patients: A Nationwide Cohort Study

OBJECTIVES

Clinical management of certain cirrhosis complications has improved over the last two decades. In this study we aimed to examine whether mortality among Danish alcoholic cirrhosis patients has decreased during this period.

METHODS

In this historical cohort study we used nationwide hospital data to identify Danish alcoholic cirrhosis patients diagnosed in 1996-1998, 1999-2001, 2002-2004, 2005-2007, 2008-2010, and 2011-2013. We used Cox regression to examine time trends in mortality after cirrhosis diagnosis, adjusting for confounding by age, gender, and prevalence of variceal bleeding, ascites, hepatorenal syndrome, alcoholic hepatitis, infection, hepatocellular carcinoma, comorbidity, and in-patient status at the time of cirrhosis diagnosis.

RESULTS

We included 22,734 patients (69% men). The adjusted mortality hazard ratio (HR) for patients diagnosed in each period compared with those diagnosed in 1996-1998 was 0.99 (95% confidence interval (CI): 0.92-1.06) in 1999-2001, 1.00 (95% CI: 0.94-1.08) in 2002-2004, 0.97 (95% CI: 0.90-1.04) in 2005-2007, 0.94 (95% CI: 0.88-1.01) in 2008-2010, and finally 0.84 (95% CI: 0.79-0.90) in 2011-2013.

CONCLUSIONS

In recent years, mortality among Danish alcoholic cirrhosis patients has decreased.

The Danish National Patient Registry: a review of content, data quality, and research potential

Background

The Danish National Patient Registry (DNPR) is one of the world’s oldest nationwide hospital registries and is used extensively for research. Many studies have validated algorithms for identifying health events in the DNPR, but the reports are fragmented and no overview exists.

Objectives

To review the content, data quality, and research potential of the DNPR.

Methods

We examined the setting, history, aims, content, and classification systems of the DNPR. We searched PubMed and the Danish Medical Journal to create a bibliography of validation studies. We included also studies that were referenced in retrieved papers or known to us beforehand. Methodological considerations related to DNPR data were reviewed.

Results

During 1977–2012, the DNPR registered 8,085,603 persons, accounting for 7,268,857 inpatient, 5,953,405 outpatient, and 5,097,300 emergency department contacts. The DNPR provides nationwide longitudinal registration of detailed administrative and clinical data. It has recorded information on all patients discharged from Danish nonpsychiatric hospitals since 1977 and on psychiatric inpatients and emergency department and outpatient specialty clinic contacts since 1995. For each patient contact, one primary and optional secondary diagnoses are recorded according to the International Classification of Diseases. The DNPR provides a data source to identify diseases, examinations, certain in-hospital medical treatments, and surgical procedures. Long-term temporal trends in hospitalization and treatment rates can be studied. The positive predictive values of diseases and treatments vary widely (<15%–100%). The DNPR data are linkable at the patient level with data from other Danish administrative registries, clinical registries, randomized controlled trials, population surveys, and epidemiologic field studies – enabling researchers to reconstruct individual life and health trajectories for an entire population.

Conclusion

The DNPR is a valuable tool for epidemiological research. However, both its strengths and limitations must be considered when interpreting research results, and continuous validation of its clinical data is essential.

Ten years of hospital admissions for liver cirrhosis in Portugal

BACKGROUND AND AIMS

More data on epidemiology of liver diseases in Europe are needed. We aimed to characterize hospital admissions for liver cirrhosis in Portugal during the past decade.

PATIENTS AND METHODS

We analyzed all hospital admissions for cirrhosis in Portugal Mainland between 2003 and 2012 registered in the national Diagnosis-Related Group database. Cirrhosis was classified according to etiology considering alcohol, hepatitis B, and hepatitis C.

RESULTS

Between 2003 and 2012, there were 63,910 admissions for cirrhosis in Portugal Mainland; 74.4% involved male patients. Etiologies of admitted cirrhosis were as follows: 76.0% alcoholic, 1.1% hepatitis B, 1.4% hepatitis B plus alcohol, 3.6% hepatitis C, and 4.0% hepatitis C plus alcohol. There was a significant decline (P<0.001) in admissions for alcoholic cirrhosis, whereas hospitalizations for cirrhosis caused by hepatitis C or hepatitis C plus alcohol increased by almost 50% (P<0.001). Patients admitted with alcoholic plus hepatitis B or C cirrhosis were significantly younger than those with either alcoholic or viral cirrhosis (53.1 vs. 59.4 years, respectively, P<0.001). Hospitalization rates for cirrhosis were 124.4/100,000 in men and 32.6/100,000 in women. Hepatocellular carcinoma and fluid retention were more common in viral cirrhosis, whereas encephalopathy and variceal bleeding were more frequent in alcoholic cirrhosis. Hepatorenal syndrome was the strongest predictor of mortality among cirrhosis complications (odds ratio 12.97; 95% confidence interval 11.95-14.09). In-hospital mortality was 15.2%.

CONCLUSION

Despite the decline in admissions for alcoholic cirrhosis and the increase in those related to hepatitis C, the observed burden of hospitalized liver cirrhosis in Portugal was essentially attributable to alcoholic liver disease.

Alcoholic Cirrhosis Increases Risk for Autoimmune Diseases: A Nationwide Registry-Based Cohort Study

BACKGROUND & AIMS

Alcoholic cirrhosis is associated with hyperactivation and dysregulation of the immune system. In addition to its ability to increase risk for infections, it also may increase the risk for autoimmune diseases. We studied the incidence of autoimmune diseases among patients with alcoholic cirrhosis vs controls in Denmark.

METHODS

We collected data from nationwide health care registries to identify and follow up all citizens of Denmark diagnosed with alcoholic cirrhosis from 1977 through 2010. Each patient was matched with 5 random individuals from the population (controls) of the same sex and age. The incidence rates of various autoimmune diseases were compared between patients with cirrhosis and controls and adjusted for the number of hospitalizations in the previous year (a marker for the frequency of clinical examination).

RESULTS

Of the 24,679 patients diagnosed with alcoholic cirrhosis, 532 developed an autoimmune disease, yielding an overall increased adjusted incidence rate ratio (aIRR) of 1.36 (95% confidence interval [CI], 1.24-1.50). The strongest associations were with Addison's disease (aIRR, 2.47; 95% CI, 1.04-5.85), inflammatory bowel disease (aIRR, 1.56; 95% CI, 1.26-1.92), celiac disease (aIRR, 5.12; 95% CI, 2.58-10.16), pernicious anemia (aIRR, 2.35; 95% CI, 1.50-3.68), and psoriasis (aIRR, 4.06; 95% CI, 3.32-4.97). There was no increase in the incidence rate for rheumatoid arthritis (aIRR, 0.89; 95% CI, 0.69-1.15); the incidence rate for polymyalgia rheumatica decreased in patients with alcoholic cirrhosis compared with controls (aIRR, 0.47; 95% CI, 0.33-0.67).

CONCLUSIONS

Based on a nationwide cohort study of patients in Denmark, alcoholic cirrhosis is a risk factor for several autoimmune diseases.

Scandinavian epidemiological research in gastroenterology and hepatology

In the last decades, a large number of epidemiological studies in gastroenterology and hepatology have originated from the Scandinavian countries. With the help of large health databases, with good validity and other registries related to patient outcomes, researchers from the Scandinavian countries have been able to make some very important contributions to the field. These countries, Sweden, Norway, Finland, Denmark and Iceland, have all universal access to health care and have shown to be ideal for epidemiological research. Population-based studies have been frequent and follow-up studies have been able to describe the temporal trends and changes in phenotypes. Our ability in Scandinavia to follow up defined groups of patients over time has been crucial to learn the natural history of many gastrointestinal and liver diseases and often in a population-based setting. Patient-related outcomes measures will probably gain increasing importance in the future, but Scandinavian gastroenterologists and surgeons are likely to have a better infrastructure for such endeavors compared to most other populations. Thus, there is a bright future for international competitive research within the field of gastrointestinal and liver diseases in Scandinavia.

Alcohol drinking pattern and risk of alcoholic liver cirrhosis: a prospective cohort study

BACKGROUND & AIMS

Alcohol is the main contributing factor of alcoholic cirrhosis, but less is known about the significance of drinking pattern.

METHODS

We investigated the risk of alcoholic cirrhosis among 55,917 participants (aged 50-64 years) in the Danish Cancer, Diet, and Health study (1993-2011). Baseline information on alcohol intake, drinking pattern, and confounders was obtained from a questionnaire. Follow-up information came from national registers. We calculated hazard ratios (HRs) for alcoholic cirrhosis in relation to drinking frequency, lifetime alcohol amount, and beverage type.

RESULTS

We observed 257 and 85 incident cases of alcoholic cirrhosis among men and women, respectively, none among lifetime abstainers. In men, HR for alcoholic cirrhosis among daily drinkers was 3.65 (95% CI: 2.39; 5.55) compared to drinking 2-4 days/week. Alcohol amount in recent age periods (40-49 and 50-59 years) was associated with an increased risk, whereas the amount in 20-29 and 30-39 years was not. In men drinking 14-28 drinks/week, HR was 7.47 (95% CI: 1.68; 33.12), 3.12 (95% CI: 1.53; 6.39), and 1.69 (95% CI: 0.79; 3.65) in drinkers of little (<1% of weekly amount), some (1-15%), and mostly wine (50-100%), compared to drinking <14 drinks/week. In general, results were similar for women.

CONCLUSIONS

In men, daily drinking was associated with an increased risk of alcoholic cirrhosis. Recent alcohol consumption rather than earlier in life was associated with risk of alcoholic cirrhosis. Compared to beer and liquor, wine might be associated with a lower risk of alcoholic cirrhosis.

Urinary aquaporin-2 excretion before and after transjugular intrahepatic portosystemic shunt insertion for refractory ascites

OBJECTIVE

The role of renal aquaporin-2 (AQP2) water channel turnover in patients with liver cirrhosis, portal hypertension and water retention remains unclear. Transjugular intrahepatic portosystemic shunt (TIPS) insertion reduces portal hypertension, improves water excretion and lowers plasma vasopressin. The aim of this study was to establish whether TIPS insertion decreases urinary AQP2 excretion (uAQP2) in parallel with improved water excretion.

MATERIAL AND METHODS

Fourteen cirrhosis patients with refractory ascites were studied before TIPS insertion and 4 and 12 weeks after insertion. A 24-h urine collection was followed by an oral water load (20 ml/kg body weight) with a 4-h blood and urine sampling.

RESULTS

TIPS reduced the portal pressure gradient from a median 18(4) (25-75% InterQuartile-range) to 7(2) mmHg, p < 0.05 and the need for diuretics (p < 0.05). TIPS increased plasma sodium from 136(6) mmol/l to 139(4), (p < 0.05) and diuresis from 1650(1043) ml/24 h to 2230(560) (p < 0.05), although the 24-h urinary sodium excretion did not change. There was no change in the baseline uAQP2 before 274(249) ng/(mmol creatinine/24 h) and 12 weeks after TIPS 242(201). There were no systematic changes in uAQP2, plasma vasopressin or other vasoactive substances during the water loads, before or after TIPS.

CONCLUSION

The effective amelioration of portal hypertension improved the patient's water excretion and plasma sodium, but there was no change in renal AQP2 trafficking or vasopressin. These findings do not support a primary role for renal AQP2 water channels in portal hypertensive water retention.

The burden of alcoholism in fifteen years of cirrhosis hospital admissions in Portugal

BACKGROUND & AIMS

Deploying a longitudinal perspective, we observe how cirrhosis caused mortality rates in Portugal are converging with the levels reported in the European Union (15 countries). However, we still lack analysis of the burden of alcoholic cirrhosis in terms of hospital admissions and associated mortality. As Portugal may be considered a paradigmatic case in Europe, our aim was to characterize the evolution of hospital admissions for alcoholic cirrhosis between 1993 and 2008 and draw conclusions for other countries.

METHODS

Retrospective analysis of the hepatic cirrhosis admissions in 97 Portuguese state hospitals was carried out based on the National Registry.

RESULTS

We report a convergence in terms of mortality rates resulting from cirrhosis between Portugal and European Union (a differential of 6.7 deaths per 100 000 habitants in 1994 to 0.4 in 2008). We accounted for 81 543 hospital admissions for cirrhosis: 84% for alcoholic cirrhosis and 16% for non-alcoholic cirrhosis. Hospital admissions have increased 29% in men and with no increase in women. In the male, alcoholic cirrhosis patient group aged between 40 and 54, the rise in hospital admissions was more pronounced with an increase of around 45%. These patients underwent longer lengths of stay and reported higher mortality rates and passing away 20 years earlier than the average national expectancy of life.

CONCLUSIONS

These data draw attention to the burden of alcohol consumption not only in Portugal but also in other countries and its impacts on hospital systems and on policy making.

Focus on alcoholic liver disease: from nosography to treatment

Abusive alcohol intake currently ranks as a major cause of liver disease, and is associated with significant mortality worldwide. Alcoholic liver disease (ALD) generically defines liver abnormalities ranging from liver steatosis to the end-stages of disease such as liver cirrhosis. Information regarding the precise incidence and prevalence of ALD is still limited by a lack of large population-based studies and by the absence of large systematic reviews of all epidemiological data available. However, existing collected data show an overall increase in the number of alcohol abusers and alcohol-related liver disease. The burden exerted on medical systems worldwide is significant, with hospitalization and management costs rising constantly over the years. A great number of all cirrhosis-related deaths in Europe and a significant percentage worldwide are associated with alcohol consumption. The main possible risk factors for ALD are the amount and duration of alcohol abuse, patterns of drinking and the type of alcoholic beverage consumed. However, ALD does not progress to cirrhosis in all patients, therefore a series of additional factors are implicated. Even though insufficiently studied, genetic factors are generally regarded as highly important, and the presence of comorbidities and dietary habits seem to play a role in disease onset and progression. This lack of clear pathophysiological data further translates in the absence of definite treatment for ALD and shall prove challenging in the coming years. In this article, we aimed to briefly review epidemiologic data on the burden of ALD, risk factors, clinical and nosographic as well as therapeutic aspects of this disease. Without attempting to be exhaustive, this short topic highlight emphasizes each point and may serve as a general guidance tool in the complicated literature related to ALD.

The burden of liver disease in Europe: a review of available epidemiological data

To survey the burden of liver disease in Europe and its causes 260 epidemiological studies published in the last five years were reviewed. The incidence and prevalence of cirrhosis and primary liver cancer are key to understand the burden of liver disease. They represent the end-stage of liver pathology and thus are indicative of the associated mortality. About 0.1% of Hungarian males will die of cirrhosis every year compared with 0.001% of Greek females. WHO estimate that liver cancer is responsible for around 47,000 deaths per year in the EU. Harmful alcohol consumption, viral hepatitis B and C and metabolic syndromes related to overweight and obesity are the leading causes of cirrhosis and primary liver cancer in Europe. Chronic hepatitis B affects 0.5-0.7% of the European population. In the last decade the prevalence of chronic hepatitis C was 0.13-3.26%. It is of great concern that about 90% of people in Europe infected by viral hepatitis are unaware of their status. Available data suggest the prevalence rate of NAFLD is 2-44% in the general European population (including obese children) and 42.6-69.5% in people with type 2 diabetes. Each of these four major causes of liver disease is amenable to prevention and treatment, reducing the burden of liver disease in Europe and saving lives. Further surveys are urgently needed to implement cost-effective prevention programmes and novel treatments to tackle this problem.

Incidence, etiology and mortality of cirrhosis: a population-based cohort study

OBJECTIVE

Knowledge on the prognosis among patients with cirrhosis is mainly based on clinical trials with selected patient groups as well as population-based register studies with suboptimal diagnostic reliability. The aim of the study was to describe incidence, etiology, and mortality of well-validated cirrhotic cases in a population-based cohort at Funen (population 470,000) between 1996 and 2006.

MATERIALS AND METHODS

A population-based cohort study with case identification from discharge diagnosis followed by manual validation of patient records with inclusion of cases that fulfilled predefined diagnostic criteria.

RESULTS

4010 possible cases were identified. 1369 patients were included, 67% males, mean age 56.4 years, 75% had cirrhotic complications at entry. Mean follow-up was 3.6 years with a total of 4976 years of follow-up. The incidence was 33/100,000 person-years (95% confidence interval CI 28-40). Stratified for age and sex, the incidence was twice as high for men compared with women in all age groups. The five-year mortality was 62% (95% CI 59-65). A multivariate analysis showed a high mortality associated with male gender (HR 1.24, 95% CI 1.08-1.42), ages above 70 years (HR 2.01 95% CI 1.65-2.47) compared with ages 50-59 years, complications present at diagnosis (HR 1.28, 95% CI 1.09-1.50) and etiology of alcoholic disease or cryptogenic cirrhosis (HR 2.38, 95% CI 1.22-4.67 and 2.26, 95% CI 1.13-4.53).

CONCLUSIONS

Incidence of cirrhosis is higher among men than among women. High age, male gender, alcoholic cirrhosis, cryptogenic cirrhosis, and complications at the time of diagnosis increased mortality.

Liver stiffness and 30-day mortality in a cohort of patients admitted to hospital

BACKGROUND

Transient elastography (TE) is a new noninvasive method to assess the degree of liver fibrosis by measuring liver stiffness. The objective of this study was to determine whether increased liver stiffness in patients admitted to medical wards was associated with increased 30-day mortality.

MATERIALS AND METHODS

A prospective cohort study at the medical admissions ward at Odense University Hospital, Denmark, covering a population of 300 000 inhabitants. Consecutive patients ≥ 18 years of age were examined by TE (Fibroscan) at admission. Outcome measure was 30-day mortality.

RESULTS

Among 568 patients admitted during 24 days, 289 (50·8%) were included in the study, 212 (73·4%) with valid TE measurement. Increased liver stiffness (TE value > 8 kPa) was found in 22·6% (48/212). This was independently associated with cirrhosis of the liver (P < 0·001) and congestive heart failure (CHF) (P < 0·001). The estimated prevalence of cirrhosis was 7% (95% CI 4-11%). The 30-day mortality among patients with TE value > 8 kPa was 20·8% (10/48, 95%CI 10·5-35·0%) compared to patients with TE value ≤ 8 kPa 3·7% (6/164, 95%CI 1·3-7·8%) (P < 0·001), and TE value > 8 kPa was an independent predictor of death.

CONCLUSIONS

Elevated TE value at admission is associated with increased mortality, cirrhosis of the liver and CHF. This information may potentially be used to improve the outcome of high-risk patients admitted to hospital.

The epidemiological pattern of chronic liver diseases in a community undergoing voluntary screening for hepatitis B and C

BACKGROUND

Vallecamonica-Sebino is a community in Northern Italy (99,776 inhabitants) with one of the highest mortality rates for primary liver cancer and cirrhosis in Italy, and voluntary screening for HCV and HBV is widespread. The aim of this study was to estimate the prevalence of chronic liver diseases and their aetiology in the area.

METHODS

We used the following sources of data, linked at an individual level: (1) hospital discharge data; (2) local Viral Hepatitis Services; (3) tests for anti-HCV antibodies and HBsAg from local laboratories; (4) Local Health Authority registry of chronic liver disease patients; (5) drug prescriptions for HBV and HCV treatment; (6) archives of Alcohol Units.

RESULTS

3.5% of the residents had chronic liver disease, mainly chronic hepatitis (61.6%), followed by cirrhosis (14.0%) and alcoholic liver disease (11.2%). HCV was the main cause of chronic liver disease in females (46.3%) and males (29.8%), followed by alcohol abuse in males (22.9%) and HBV (10.9% males and 9.2% females). Prevalence of anti-HCV positivity was 3.2%, and increased with age to 8.8% in subjects aged 65 years and over.

CONCLUSION

This study shows that an epidemiologic pattern of the prevalence of chronic liver diseases and their aetiology can be obtained using routinely collected data.

Survival of patients with primary liver cancer in central and northern Denmark, 1998-2009

Objective

Primary liver cancer (PLC) is a serious disease with high mortality. During the last decade, improvements in the diagnostic procedures and treatment of PLC may have improved survival. However, few updated longitudinal studies examined this issue. In a population-based setting, we studied changes in the prognoses over time.

Methods

Between 1998 and 2009, we identified all patients with PLC in the central and northern Denmark regions, with a combined population of 1.8 million. We determined age- and period-stratified survival, and computed mortality rate ratios (MRRs) with 95% confidence intervals (CIs), using Cox proportional hazard regression to assess changes over time, while controlling for age and gender. We conducted the analyses for PLC overall and separately for hepatocellular carcinoma (HCC) and cholangiocarcinoma, respectively.

Results

We included 1064 patients with PLC. Their median age was 69 years (range 17–94 years). The number of patients diagnosed with PLC in the period 2007–2009 was approximately 40% higher than the number in 1998–2000. One-year survival increased from 16% in 1998–2000 to 28% in 2007–2009, corresponding to an adjusted 1-year MRR of 0.65 (95% CI: 0.54–0.79). In patients aged <60 years, we found the most pronounced increase in 1-year survival, from 14% to 49% in women and from 19% to 41% in men. The 3- and 5-year survival in the entire cohort increased from 5% to a predicted 11% and from 2% to a predicted 7% during our study period, respectively. Accordingly, the expected 3- and 5-year adjusted MRRs were 0.68 (95% CI: 0.57–0.82) and 0.68 (95% CI: 0.57–0.81), respectively. One-, 3-, and 5-year survival improved during the study period for both HCC and cholangiocarcinoma.

Conclusion

PLC survival remains poor in the Danish population, although we observed an increase over the period 1998–2009, particularly in young people.

Existing data sources for clinical epidemiology: the Danish National Pathology Registry and Data Bank

Diagnostic histological and cytological specimens are routinely stored in pathology department archives. These biobanks are a valuable research resource for many diseases, particularly if they can be linked to high quality population-based health registries, allowing large retrospective epidemiological studies to be carried out. Such studies are of significant importance, for example in the search for novel prognostic and predictive biomarkers in the era of personalized medicine. Denmark has a wealth of highly-regarded population-based registries that are ideally suited to conduct this type of epidemiological research. We describe two recent additions to these databases: the Danish National Pathology Registry (DNPR) and its underlying national online registration database, the Danish Pathology Data Bank (DPDB). The DNPR and the DPDB contain detailed nationwide records of all pathology specimens analyzed in Denmark since 1997, and an incomplete but nonetheless valuable record of specimens from some pathology departments dating back to the 1970s. The data are of high quality and completeness and are sufficient to allow precise and efficient localization of the specimens. We describe the relatively uncomplicated procedures required to use these pathology databases in clinical research and to gain access to the archived specimens.

Clinical course of alcoholic liver cirrhosis: a Danish population-based cohort study

The clinical course of alcoholic cirrhosis, a condition with a high mortality, has not been well described. We examined prevalence, risk, chronology, and mortality associated with three complications of cirrhosis: ascites, variceal bleeding, and hepatic encephalopathy. We followed a population-based cohort of 466 Danish patients diagnosed with alcoholic cirrhosis in 1993-2005, starting from the date of hospital diagnosis and ending in August 2006. Data were extracted from medical charts during the follow-up period. Risk and mortality associated with complications were calculated using competing-risks methods. At diagnosis of alcoholic cirrhosis, 24% of patients had no complications, 55% had ascites alone, 6% had variceal bleeding alone, 4% had ascites and variceal bleeding, and 11% had hepatic encephalopathy. One-year mortality was 17% among patients with no initial complications, 20% following variceal bleeding alone, 29% following ascites alone, 49% following ascites and variceal bleeding (from the onset of the later of the two complications), and 64% following hepatic encephalopathy. Five-year mortality ranged from 58% to 85%. The risk of complications was about 25% after 1 year and 50% after 5 years for all patients without hepatic encephalopathy. The complications under study did not develop in any predictable sequence. Although patients initially without complications usually developed ascites first (12% within 1 year), many developed either variceal bleeding first (6% within 1 year) or hepatic encephalopathy first (4% within 1 year). Subsequent complications occurred in an unpredictable order among patients with ascites or variceal bleeding.

CONCLUSION

Patients with alcoholic cirrhosis had a high prevalence of complications at the time of cirrhosis diagnosis. The presence and type of complications at diagnosis were predictors of mortality, but not of the risk of subsequent complications.

Hospitalization rates before and after adult-to-adult living donor or deceased donor liver transplantation

OBJECTIVE

To compare rates of hospitalization before and after adult-to-adult living donor liver transplant (LDLT) and deceased donor liver transplant (DDLT).

SUMMARY BACKGROUND DATA

LDLT recipients have been reported to have lower mortality but a higher complication rate than DDLT recipients. The higher complication rate may be associated with greater consumption of inpatient hospital resources and a higher burden of disease for LDLT recipients.

METHODS

Data from the 9-center Adult-to-Adult Living Donor Liver Transplantation retrospective cohort study were analyzed to determine pretransplant, transplant, and posttransplant hospitalizations among LDLT candidates (potential living donor was evaluated) who received LDLT or DDLT. Hospital days and admission rates for LDLT and DDLT patients were calculated per patient-year at risk, starting from the date of initial potential donor history and physical examination. Rates were compared using overdispersed Poisson regression models.

RESULTS

Among 806 candidates, 384 received LDLT and 215 received DDLT. In addition to the 599 transplants, there were 1913 recipient hospitalizations (485 pretransplant; 1428 posttransplant). Mean DDLT recipient pretransplant, transplant, and posttransplant lengths of stay were 5.8 +/- 6.3, 27.0 +/- 32.6, and 9.0 +/- 14.1 days, respectively, and for LDLT were 4.1 +/- 3.7, 21.4 +/- 24.3, and 7.8 +/- 11.4 days, respectively. Compared with DDLT, LDLT recipients had significantly lower adjusted pretransplant hospital day and admission rates, but significantly higher posttransplant rates. Significantly higher LDLT admission rates were observed for biliary tract morbidity throughout the second posttransplant year. Overall hospitalization rates starting from the point of potential donor evaluation were significantly higher for eventual recipients of LDLT.

CONCLUSIONS

LDLT recipients, despite lower acuity of disease, have higher hospitalization requirements when compared with DDLT recipients. Continuing efforts are warranted to reduce the incidence of complications requiring post-LDLT inpatient admission, with particular emphasis on biliary tract issues.

Incidence and prevalence of cirrhosis in the United Kingdom, 1992-2001: a general population-based study

BACKGROUND/AIMS

To determine the incidence and prevalence of cirrhosis in the United Kingdom.

METHODS

We identified patients aged 25 or over with cirrhosis, oesophageal varices or portal hypertension from the UK General Practice Research Database between 1992 and 2001. We measured incidence rates by sex, year and aetiology, incidence rate ratios and estimated prevalence figures.

RESULTS

Three thousand three hundred and sixty cases of cirrhosis were identified. Crude incidence was 14.55 per 100,000 person years increasing from 12.05 to 16.99 per 100,000 person years from 1992 to 2001. Incidence was over 50% higher in men compared with women (adjusted incidence rate ratio 1.52 (95%CI [1.42-1.63])). A statistically significant increase in incidence of both alcoholic cirrhosis and non-alcohol-related cirrhosis was seen in men and women. Prevalence of cirrhosis was an estimated 76.3 per 100,000 population aged over 25 in mid-2001.

CONCLUSIONS

There was a 45% increase in the incidence of cirrhosis during the decade 1992-2001 in the UK and a 68% increase in prevalence. Cirrhosis occurred more commonly and at younger ages in men than women. Cirrhosis represents a growing burden of morbidity and mortality in the UK, with an estimated 30,000 people living with cirrhosis and at least 7000 new cases being diagnosed each year.

Comorbidity and survival of Danish cirrhosis patients: a nationwide population-based cohort study

Patients with liver cirrhosis have a high mortality, not just from cirrhosis-related causes, but also from other causes. This observation indicates that many patients with cirrhosis have other chronic diseases, yet the prognostic impact of comorbidities has not been examined. Using data from a nationwide Danish population-based hospital registry, we identified patients who were diagnosed with cirrhosis between 1995 and 2006 and computed their burden of comorbidity using the Charlson comorbidity index. We compared survival between comorbidity groups, adjusting for alcoholism, sex, age, and calendar period. We also examined the risks of cirrhosis-related and non-cirrhosis-related death using data from death certificates and identified a matched comparison cohort without cirrhosis from the Danish population. We included 14,976 cirrhosis patients, 38% of whom had one or more comorbidities. The overall 1-year survival probability was 65.5%; the 10-year survival probability was 21.5%. Compared with patients with a Charlson comorbidity index of 0, the mortality rate was increased 1.17-fold in patients with an index of 1 [95% confidence interval (CI), 1.11-1.23], 1.51-fold in patients with an index of 2 (95% CI, 1.42-1.62), and two-fold in patients with an index of 3 or higher (95% CI, 1.85-2.15). In the first year of follow-up, but not later, comorbidity increased the risk of cirrhosis-related death, and this was consistent with an apparent synergy between the cirrhosis and comorbidity effects on mortality in the same period.

CONCLUSION

Our findings demonstrate that comorbidity is an important prognostic factor for patients with cirrhosis. Successful treatment of comorbid diseases in the first year after diagnosis may substantially reduce the mortality rate.