Epidemiology and Disease Burden of Alcohol Associated Liver Disease
2022; Elsevier BV; Volume: 13; Issue: 1 Linguagem: Inglês
10.1016/j.jceh.2022.09.001
ISSN2213-3453
Autores Tópico(s)Substance Abuse Treatment and Outcomes
ResumoConsumption of alcohol in excess leads to substantial medical, economic, and societal burdens. Approximately 5.3% of all global deaths may be attributed to alcohol consumption. Moreover, the burden of alcohol associated liver disease (ALD) accounts for 5.1% of all disease and injury worldwide. Alcohol use disorder (AUD) affects men more than women globally with significant years of life loss to disability in low, middle and well-developed countries. Precise data on global estimates of alcohol related steatosis, alcohol related hepatitis, and alcohol related cirrhosis have been challenging to obtain. In the United States (US), alcohol related steatosis has been estimated at 4.3% based on NHANES data which has remained stable over 14 years. However, alcohol-related fibrotic liver disease has increased over the same period. In those with AUD, the prevalence of alcohol related hepatitis has been estimated at 10–35%. Globally, the prevalence of alcohol-associated cirrhosis has been estimated at 23.6 million individuals for compensated cirrhosis and 2.46 million for those with decompensated cirrhosis. The contribution of ALD to global mortality and disease burden of liver related deaths is substantial. In 2016 liver disease related to AUD contributed to 50% of the estimated liver disease deaths for age groups 15 years and above. Data from the US report high cost burdens associated with those admitted with alcohol-related liver complications. Finally, the recent COVID-19 pandemic has been associated with marked increase in alcohol consumption worldwide and will likely increase the burden of ALD. Consumption of alcohol in excess leads to substantial medical, economic, and societal burdens. Approximately 5.3% of all global deaths may be attributed to alcohol consumption. Moreover, the burden of alcohol associated liver disease (ALD) accounts for 5.1% of all disease and injury worldwide. Alcohol use disorder (AUD) affects men more than women globally with significant years of life loss to disability in low, middle and well-developed countries. Precise data on global estimates of alcohol related steatosis, alcohol related hepatitis, and alcohol related cirrhosis have been challenging to obtain. In the United States (US), alcohol related steatosis has been estimated at 4.3% based on NHANES data which has remained stable over 14 years. However, alcohol-related fibrotic liver disease has increased over the same period. In those with AUD, the prevalence of alcohol related hepatitis has been estimated at 10–35%. Globally, the prevalence of alcohol-associated cirrhosis has been estimated at 23.6 million individuals for compensated cirrhosis and 2.46 million for those with decompensated cirrhosis. The contribution of ALD to global mortality and disease burden of liver related deaths is substantial. In 2016 liver disease related to AUD contributed to 50% of the estimated liver disease deaths for age groups 15 years and above. Data from the US report high cost burdens associated with those admitted with alcohol-related liver complications. Finally, the recent COVID-19 pandemic has been associated with marked increase in alcohol consumption worldwide and will likely increase the burden of ALD. The consumption of alcohol has been prevalent in different cultures for many centuries. Based on a recent analysis in 2014, the cultural influence has remained an essential correlate of alcohol use and misuse for over 75 years.1Castro FG. Culture and Alcohol Use: Historical and Sociocultural Themes from 75 Years of Alcohol Research.Google Scholar Consumption of alcohol in large quantities can lead to substantial medical, economic, and social burdens on societies in terms of morbidity and mortality. According to reports from WHO in 2016, about 5.3% of all global deaths were attributed to alcohol consumption or approximately 3 million deaths on a global scale.2Park S.H. Kim D.J. Global and regional impacts of alcohol use on public health: emphasis on alcohol policies.Clin Mol Hepatol. 2020 Oct; 26: 652-661Crossref PubMed Scopus (14) Google Scholar The global burden of alcohol-associated liver disease accounts for about 5.1% of disease and injury worldwide, is one of the most frequent causes of death in the world, ranking 30th, and is directly related to the amount of alcohol consumption.3Addolorato G. Abenavoli L. Dallio M. et al.Alcohol associated liver disease 2020: a clinical practice guideline by the Italian Association for the Study of the Liver (AISF).Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver. 2020 Apr; 52: 374-391PubMed Scopus (22) Google Scholar Globally, AUD affects men more than women and is the second most disabling disease and injury condition for men.4Rehm J. The risks associated with alcohol use and alcoholism.Alcohol Res Health. 2011; 34: 135-143PubMed Google Scholar One estimate suggests that AUD may cause 18.4 million years of life lost to disability (YLD) which extrapolates to about 3.5 percent of all YLDs, in low and middle-income countries and 5.7 percent of all YLDs in well-developed countries.4Rehm J. The risks associated with alcohol use and alcoholism.Alcohol Res Health. 2011; 34: 135-143PubMed Google Scholar,5Samokhvalov A.V. Popova S. Room R. Ramonas M. Rehm J. Disability associated with alcohol abuse and dependence.Alcohol Clin Exp Res. 2010 Nov; 34: 1871-1878Crossref PubMed Scopus (92) Google Scholar In this review, we will discuss the evolving nomenclature and standard measurements for AUD, as well providing estimates for disease burden across the spectrum of alcohol-associated liver disease and factors that contribute to progression of alcohol-associated liver disease. Finally, we will address the effects of the recent COVID-19 pandemic on the disease burden of ALD. When estimating the epidemiological burden of alcohol associated liver disease, it is important to understand the different definitions used in association with AUD. Binge drinking, heavy drinking, or any drinking by pregnant women or people younger than 21 is considered excessive drinking. According to NIAAA (National Institute of Alcohol Abuse and Alcoholism) guidelines, binge drinking includes four or more drinks for women and five or more drinks for men on a single occasion or in 2 h. This equates to a drinking pattern that can increase blood alcohol concentration (BAC) to 0.08 percent or 0.08 g of alcohol per deciliter or higher.6Lees B. Meredith L.R. Kirkland A.E. Bryant B.E. Squeglia L.M. Effect of alcohol use on the adolescent brain and behavior.Pharmacol Biochem Behav. 2020 May; 192172906Crossref PubMed Scopus (107) Google Scholar In contrast, heavy drinking is defined as the consumption of more than three drinks on any day or more than seven drinks per week for women and four drinks on any day or more than fourteen drinks per week for men4Rehm J. The risks associated with alcohol use and alcoholism.Alcohol Res Health. 2011; 34: 135-143PubMed Google Scholar Other classifications include the Annual National Survey on Drug Use and Health (NSDUH), conducted by the Substance Abuse and Mental Health Services Administration (SAMHSA), which defines binge drinking as five or more alcoholic drinks for males or four or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least one day in the past month. Though immoderate drinking does not necessarily make a person alcohol dependent, the risk of AUD increases significantly with binge drinking and heavy alcohol use.7Fillmore M.T. Jude R. Defining “binge” drinking as five drinks per occasion or drinking to a .08% BAC: which is more sensitive to risk?.Am J Addict. 2011 Oct; 20: 468-475Crossref PubMed Scopus (79) Google Scholar The Centers for Disease Control (CDC) has provided guidance for the amount alcohol in a standard drink with a standard drink comprising 12 ounces of 5% alcohol by volume (ABV) for beer, 8 ounces of 7% ABV for malt liquor, 5 ounces of 12% ABV for wine, and 1.5 ounces of 40% ABV distilled spirits or alcohol, including gin, rum, vodka, and whiskey. In addition, the CDC estimates that excessive drinking is responsible for approximately 88,000 deaths per year, with a total economic cost burden of 249 billion per year that excludes costs from motor vehicle accidents, violence, injuries, risky sexual behaviors, and chronic conditions such as cancer, hypertension, and heart diseases.8Center of Disease Control and Prevention. Alcohol and Public Health. Available from: https://www.cdc.gov/alcohol/onlinemedia/infographics/excessive-alcohol-use.html [ Accessed Date: 11.29.2021].Google Scholar As we discuss the disease burden of ALD, it is important to note that more than 30 conditions are associated with alcohol consumption, with alcohol being the primary driver in these cases according to WHO International Classification of Diseases, 10th Edition (ICD–10).9WHO. International Statistical Classification of Diseases and Related Health Problems (ICD). Available from: https://www.who.int/standards/classifications/classification-of-diseases [ Accessed Date: 11.29.2021].Google Scholar AUD remains one of the most critical disease illnesses in this group and entails alcohol dependence and alcohol abuse. AUD is associated with considerable disability, being the fourth most disabling disease category in low to middle-income countries and the third most disabling disease category in well-developed countries according to a recent report.10WHO. Global Burden of disease 2004. Available from: https://www.who.int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf [ Accessed Date: 11.29.2021].Google Scholar Based on reports from 2016 National Survey on Drug Use and Health, approximately 136 million US citizens aged 18 and older drink alcohol, with 65.3 million reporting binge drinking in the past month, accounting for half (47%) of the current alcohol users. In addition, 16.3 million also reported heavy drinking in the past month and accounting for 24.9% of individuals who reported binge drinking and 11.9% of individuals with current alcohol use.11SAMHSA. 2016 National survey on drug use and health. Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf [Accessed Date: 12.20.2021].Google Scholar Approximately 35,000 deaths per year are attributable to alcohol-associated cirrhosis, making alcohol-associated liver disease (ALD) one of the two leading indications for liver transplant.11SAMHSA. 2016 National survey on drug use and health. Available from: https://www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2016/NSDUH-FFR1-2016.pdf [Accessed Date: 12.20.2021].Google Scholar,12Udompap P. Kim D. Kim W.R. Current and future burden of chronic nonmalignant liver disease.Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2015 Nov; 13: 2031-2041Abstract Full Text Full Text PDF PubMed Scopus (105) Google ScholarKey pointsDifferent definitions used in association with AUD are important in order to understand the epidemiological burden of alcohol associated liver disease. Approximately, 35,000 deaths per year are attributable to alcohol associated cirrhosis, making ALD as one of the two leading indications for liver transplant. Different definitions used in association with AUD are important in order to understand the epidemiological burden of alcohol associated liver disease. Approximately, 35,000 deaths per year are attributable to alcohol associated cirrhosis, making ALD as one of the two leading indications for liver transplant. In the Western world, AUD represents one of the most common causes of liver damage. The spectrum of liver diseases associated with AUD ranges from simple steatosis, to steatohepatitis, fibrosis, cirrhosis, and cancer.13Frazier T.H. Stocker A.M. Kershner N.A. Marsano L.S. McClain C.J. Treatment of alcoholic liver disease.Ther Adv Gastroenterol. 2011 Jan; 4: 63-81Crossref PubMed Scopus (119) Google Scholar The International Classification of Diseases (ICD-10) recognizes these stages of liver damage, including steatosis, steatohepatitis, and early fibrosis, as being considered reversible, while late stages constituting cirrhosis and liver failure and cancer are considered severe and irreversible (Figure 1).14O'Shea R.S. Dasarathy S. McCullough A.J. Practice guideline committee of the American association for the study of liver diseases, practice parameters committee of the American college of gastroenterology. Alcoholic liver disease.Hepatol Baltim Md. 2010 Jan; 51: 307-328Crossref PubMed Scopus (984) Google Scholar The various stages of ALD and severity are directly related to the amount of alcohol consumed.15Ramstedt M. Per capita alcohol consumption and liver cirrhosis mortality in 14 European countries.Addict Abingdon Engl. 2001 Feb; 96: S19-S33Crossref PubMed Scopus (140) Google Scholar Literature suggests that alcohol consumption of more than 80 g/day in men and 20 g/day in women is associated with liver cirrhosis.16Mellinger J.L. Epidemiology of alcohol use and alcoholic liver disease.Clin Liver Dis. 2019 May 31; 13: 136-139Crossref PubMed Scopus (42) Google Scholar A study from northern Italy examined a total of 6534 subjects, indicating an increased risk of developing either noncirrhotic alcohol-induced liver injury or alcohol-associated cirrhosis in both men and women who consumed at least 30 g of alcohol per day and the risk of ALD substantially increased with increasing alcohol intake.17Bellentani S. Saccoccio G. Costa G. et al.Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group.Gut. 1997 Dec; 41: 845-850Crossref PubMed Scopus (529) Google Scholar Fatty liver (steatosis) is the earliest, most common response of the liver to moderate or large doses (i.e., binge drinking) of alcohol and chronic ethanol consumption. This is attributed to changes in lipid metabolism in the liver with an increase in lipid synthesis and decreased lipid metabolism, causing lipid storage in the hepatocytes. Though fatty liver caused by alcohol consumption was once considered benign, it is now recognized as the leading risk factor for liver disease progression and even cirrhosis.18Osna N.A. Donohue T.M. Kharbanda K.K. Alcoholic liver disease: pathogenesis and current management.Alcohol Res Curr Rev. 2017; 38: 147-161PubMed Google Scholar Dose and duration of alcohol intake remain the primary drivers of alcohol-related steatosis in this case though the exact amount of alcohol intake required for the development of steatosis remains controversial. Based on a study done by Lieber et al., hepatic steatosis may develop after 2–3 weeks of excessive alcohol intake (120–150 g/dl per day), and if alcohol consumption continues, there may be progression to severe inflammation with alcohol-related hepatitis.19Lieber C.S. Jones D.P. Decarli L.M. Effects of prolonged ethanol intake: production of fatty liver despite adequate diets.J Clin Invest. 1965 Jun; 44: 1009-1021Crossref PubMed Scopus (417) Google Scholar,20Liangpunsakul S. Puri P. Shah V.H. et al.Effects of age, sex, body weight, and quantity of alcohol consumption on occurrence and severity of alcoholic hepatitis.Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2016 Dec; 14: 1831-1838.e3Abstract Full Text Full Text PDF PubMed Scopus (39) Google Scholar Alcohol-related hepatitis has been associated with high rates of mortality and morbidity, with severe cases having short term (30 day) mortality rates ranging between 30 and 50 percent.21Basra S. Anand B.S. Definition, epidemiology and magnitude of alcoholic hepatitis.World J Hepatol. 2011 May 27; 3: 108-113Crossref PubMed Scopus (70) Google Scholar,22Palaniyappan N. Subramanian V. Ramappa V. Ryder S.D. Kaye P. Aithal G.P. The utility of scoring systems in predicting early and late mortality in alcoholic hepatitis: whose score is it anyway?.Int J Hepatol. 2012; 2012624675Crossref PubMed Google Scholar Alcohol-related hepatitis is characterized by a constellation of clinical signs and symptoms including fever, elevated bilirubin levels (>2), coagulopathy, and liver-related complications such as ascites, volume overload, hepatic encephalopathy, and GI bleeding. Several prognostic scores have been used to predict short-term mortality in these patients. These include MDF (Maddrey's Discriminant Function), MELD (Model of End-stage Liver Disease), ABIC (Age, Serum bilirubin, INR and serum Creatinine), GAHS (Glasgow Alcoholic Hepatitis Score), and Lillie model. The role of these scoring systems remains limited to determining the long term survival of these patients, as they depend primarily on abstinence from alcohol.22Palaniyappan N. Subramanian V. Ramappa V. Ryder S.D. Kaye P. Aithal G.P. The utility of scoring systems in predicting early and late mortality in alcoholic hepatitis: whose score is it anyway?.Int J Hepatol. 2012; 2012624675Crossref PubMed Google Scholar Excessive and continued alcohol consumption increases the risk of developing alcohol-related cirrhosis.23Menon K.V. Gores G.J. Shah V.H. Pathogenesis, diagnosis, and treatment of alcoholic liver disease.Mayo Clin Proc. 2001 Oct; 76: 1021-1029Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar The exact amount of alcohol consumption for the development of alcohol-related hepatitis and its progression to liver cirrhosis is not yet determined. However, based on prior observational studies, ingestion of more than >20 g of alcohol per day in women and >80 g per day in men is associated with an increased prevalence of liver cirrhosis.17Bellentani S. Saccoccio G. Costa G. et al.Drinking habits as cofactors of risk for alcohol induced liver damage. The Dionysos Study Group.Gut. 1997 Dec; 41: 845-850Crossref PubMed Scopus (529) Google Scholar Signs and symptoms of patients with alcohol-related cirrhosis are similar to other chronic liver diseases and can be further characterized into compensated and decompensated liver cirrhosis. Decompensated liver cirrhosis is associated with complications such as ascites, hepatic encephalopathy (HE), GI bleeding, hepatorenal syndrome (HRS), and death.14O'Shea R.S. Dasarathy S. McCullough A.J. Practice guideline committee of the American association for the study of liver diseases, practice parameters committee of the American college of gastroenterology. Alcoholic liver disease.Hepatol Baltim Md. 2010 Jan; 51: 307-328Crossref PubMed Scopus (984) Google ScholarKey pointsVarious stages and severity of ALD is directly related to amount of alcohol consumed. The International Classification of Diseases (ICD-10) recognizes these stages of liver damage, including steatosis, steatohepatitis, and early fibrosis, as being considered reversible, while late stages constituting cirrhosis and liver failure and cancer are considered severe and irreversible. Various stages and severity of ALD is directly related to amount of alcohol consumed. The International Classification of Diseases (ICD-10) recognizes these stages of liver damage, including steatosis, steatohepatitis, and early fibrosis, as being considered reversible, while late stages constituting cirrhosis and liver failure and cancer are considered severe and irreversible. The prevalence of alcohol related steatosis is challenging to ascertain in the general population as many patients do not seek medical attention due to the asymptomatic nature of the disease.24Han S. Yang Z. Zhang T. Ma J. Chandler K. Liangpunsakul S. Epidemiology of alcohol-associated liver disease.Clin Liver Dis. 2021 Aug; 25: 483-492Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar The estimated prevalence also depends on the diagnostic modality used to screen for steatosis. Methods used to ascertain steatosis include ultrasonography (USG), magnetic resonance imaging (MRI), and liver biopsy. Amongst these, USG is the least expensive and non -invasive method with a sensitivity of 60–90 percent and specificity of 90–95 percent, making it an acceptable choice in the clinical care setting. Magnetic resonance imaging increases the accuracy of detection of alcohol-related steatosis and can help quantify the degree of hepatic steatosis though it is an expensive modality.25Zhang Y.N. Fowler K.J. Hamilton G. et al.Liver fat imaging-a clinical overview of ultrasound, CT, and MR imaging.Br J Radiol. 2018 Sep; 9120170959Google Scholar Liver biopsy remains the gold standard for detection of steatosis; however, its routine use is limited by its invasive nature and related complications, making it a less desirable choice and impractical modality in the clinical setting for steatosis assessment.26Torruellas C. French S.W. Medici V. Diagnosis of alcoholic liver disease.World J Gastroenterol. 2014 Sep 7; 20: 11684-11699Crossref PubMed Scopus (110) Google Scholar The prevalence of alcohol-related steatosis in the US has been estimated using NHANES data derived from questionnaires, abdominal ultrasonography, and laboratory tests. Based on one study, the prevalence of alcohol related-steatosis was around 4.3 percent in the US population among 34, 423 respondents. There was a stable trend over the last 14 year study period from 2001 to 2016; however alcohol-related steatosis associated with stage 2 fibrosis showed an increasing trend from 0.6 to 1.5 percent.27Dang K. Hirode G. Singal A.K. Sundaram V. Wong R.J. Alcoholic liver disease epidemiology in the United States: a retrospective analysis of 3 US databases.Am J Gastroenterol. 2020 Jan; 115: 96-104Crossref PubMed Scopus (57) Google Scholar,28Wong T. Dang K. Ladhani S. Singal A.K. Wong R.J. Prevalence of alcoholic fatty liver disease among adults in the United States, 2001-2016.JAMA. 2019 May 7; 321: 1723-1725Crossref PubMed Scopus (83) Google Scholar Though alcohol-related steatosis has been considered a benign condition, it is now known that there may be progression to advanced fibrosis and cirrhosis, leading to increased morbidity and mortality rates in this patient population. A recent meta-analysis estimated the annual rate of progression of alcohol-related steatosis to cirrhosis at approximately 3 percent, with mortality rate of 6 percent. Interestingly, these patients who progress also tend to have increased mortality from non-hepatic causes when compared with liver-specific mortality rates.29Parker R. Aithal G.P. Becker U. et al.Natural history of histologically proven alcohol-related liver disease: a systematic review.J Hepatol. 2019 Sep; 71: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar Another retrospective study using NHANES data analyzed and compared the prevalence of ALD also over the period of 2001–2016. In this study the overall weighted prevalence of ALD remained stable at 8.8% (95% CI: 7.6–9.9) and 8% (95% CI: 6.5–9.6) in the year 2001–2002 and 2015–2016 respectively (P = 0.102). However, there was an increase in the prevalence of Stage 3 fibrosis in ALD patients from 2.2% (95% CI: 0.4–4.0) to 6.6% (95% CI: 2.0–9.9) over the same period (P = 0.007). Based on the same survey study, the estimated national prevalence of ALD and ALD with stage 3 fibrosis was calculated to be 17.8 million (95% CI: 14.3–21.3) and 1.1 million (95% CI: 0.4–1.8) in the year 2015–2016. The sex specific trends remained stable over the study period, though there was higher prevalence of ALD in men compared to women.27Dang K. Hirode G. Singal A.K. Sundaram V. Wong R.J. Alcoholic liver disease epidemiology in the United States: a retrospective analysis of 3 US databases.Am J Gastroenterol. 2020 Jan; 115: 96-104Crossref PubMed Scopus (57) Google Scholar (Table 1).Key pointsBased on NHANES data from 2001 to 2016, alcohol related steatosis has been stable over the last 14 year study period, while stage 2 fibrosis associated with alcohol related steatosis showed an increasing trend from 0.6 to 1.5 percent.Table 1Estimated Prevalence of Alcoholic Liver Disease (ALD) in US Using NHANES Data Comparing Years 2001–2002 and 2015-2016.29Parker R. Aithal G.P. Becker U. et al.Natural history of histologically proven alcohol-related liver disease: a systematic review.J Hepatol. 2019 Sep; 71: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google ScholarAlcoholic Liver Disease (ALD)Year: 2001–2002Year: 2015–2016Overall weighted Prevalence of ALD8.8% (95% CI: 7.6–9.9)8.1% (95% CI: 6.5–9.6)ALD with Stage ≥3 Fibrosis2.2% (95% CI: 0.4–4.0)6.6% (95% CI: 2.0–9.9)Prevalence of ALD in Men9.7% (95% CI: 7.9–11.4)9.0% (95% CI: 6.2–11.7)Prevalence of ALD in Women8.0% (95% CI: 6.3–9.7)7.2% (95% CI: 5.9–8.5)Prevalence of ALD with Stage ≥3 Fibrosis in Men2.4% (95% CI: 0.01–9.0)7.3% (95% CI: 0.01–15.5)Prevalence of ALD with Stage ≥3 fibrosis in Women2.6% (95% CI: 0.4–4.8)4.6% (95% CI: 0.01–9.2)Abbreviation: ALD, Alcohol-associated liver disease. Open table in a new tab Based on NHANES data from 2001 to 2016, alcohol related steatosis has been stable over the last 14 year study period, while stage 2 fibrosis associated with alcohol related steatosis showed an increasing trend from 0.6 to 1.5 percent. Abbreviation: ALD, Alcohol-associated liver disease. The precise incidence and prevalence of alcohol-related hepatitis are not known with one of the main challenges being asymptomatic patients often remain undiagnosed. According to a study conducted by Naveau et al., the prevalence of alcohol related hepatitis was approximately 20% in a cohort of 1604 patients with AUD with available liver biopsies. Approximately 10–35% of individuals with AUD will have changes consistent with alcohol related hepatitis and an estimate of the prevalence of alcohol-related hepatitis can be extrapolated based on the prevalence of AUD. In the US, the prevalence of AUD has been estimated at 16 million people, or 8% of the general population; hence the number of individuals with AH in the US may approximate up to 5 million individuals.30Naveau S. Giraud V. Borotto E. Aubert A. Capron F. Chaput J.C. Excess weight risk factor for alcoholic liver disease.Hepatol Baltim Md. 1997 Jan; 25: 108-111Crossref PubMed Scopus (557) Google Scholar The National Inpatient Sample (NIS) Database also provides insights into the epidemiology of AH in the US. Based on inpatient data an increase in AH-related hospitalizations has been reported from 2002 (249,884 or 0.66% of total admission in 2002) to 2010 (326,403 or 0.83% of total admissions). There was also an increased rate of readmissions in this patient population given the significant co-morbidities and complications including increased rates of sepsis, acute renal insufficiency, and gastrointestinal bleeding31Jinjuvadia R. Liangpunsakul S. Translational research and evolving alcoholic hepatitis treatment consortium. Trends in alcoholic hepatitis-related hospitalizations, financial burden, and mortality in the United States.J Clin Gastroenterol. 2015 Jul; 49: 506-511Crossref PubMed Scopus (88) Google Scholar (Table 2). Reported readmission rates in these patients range from 20 to 25% at 30 days to 37% at 90 days after discharge. Based on data from National Readmission Database involving 21,572 individuals with alcohol-related hepatitis, the annual cost burden at 30 day and 90 day for AH-related readmissions was approximated at $164 million for 30 day readmissions and $321 million for 90 day readmissions respectively in this cohort.32Adejumo A.C. Cholankeril G. Iqbal U. et al.Readmission rates and associated outcomes for alcoholic hepatitis: a nationwide cohort study.Dig Dis Sci. 2020 Apr; 65: 990-1002Crossref PubMed Scopus (12) Google Scholar In addition, rates of rehospitalizations based on an analysis of over 15,000 commercially insured adults with AH demonstrated more than 50% of survivors were hospitalized within one year and 75% through the second year with total number of readmissions reaching as high as 40,000. The total health care costs were approximated at $2.2 billion over a 5 year period including costs of care associated with liver transplantation.33Thompson J.A. Martinson N. Martinson M. Mortality and costs associated with alcoholic hepatitis: a claims analysis of a commercially insured population.Alcohol Fayettev N. 2018 Sep; 71: 57-63Crossref PubMed Scopus (19) Google Scholar Based on a recent systematic review of 7528 participants, the annual rate of progression of AH to cirrhosis was estimated at 10% with a similar rate of progression to cirrhosis of 8% noted in those with fibrotic liver disease. In addition, there is a significant increase in mortality in patients with alcohol related hepatitis ranging from 5 to 15% annually with the highest rates noted in those with alcohol related hepatitis who required inpatient level of care29Parker R. Aithal G.P. Becker U. et al.Natural history of histologically proven alcohol-related liver disease: a systematic review.J Hepatol. 2019 Sep; 71: 586-593Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar (see Table 3).Key pointsBased on NIS data base analysis, there has been an increase in the rate of readmissions in patients with alcohol related hepatitis due to higher rates of complications such as sepsis, acute renal insufficiency, and gastrointestinal bleeding in this patient population. In addition, there is a significant increase in mortality in patients with alcohol related hepatitis ranging from 5 to 15% annually with the highest rates noted in those with alcohol related hepatitis who required inpatient level of care.Table 2Trends in Alcoholic Hepatitis Related Hospitalizations, Financial Burden and Mortality Rates in USA Using NIS Data Base Analysis (2002–2010).33Thompson J.A. Martinson N. Martinson M. Mortality and costs associated with alcoholic hepatitis: a claims analysis of a commercially insured population.Alcohol Fayettev N. 2018 Sep; 71: 57-63Crossref PubMed Scopus (19) Google Scholar20022
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