Gastroenterology

Gastroenterology

Volume 149, Issue 6, November 2015, Pages 1471-1482.e5
Gastroenterology

Original Research
Full Report: Clinical—Liver
Trends in Burden of Cirrhosis and Hepatocellular Carcinoma by Underlying Liver Disease in US Veterans, 2001–2013

https://doi.org/10.1053/j.gastro.2015.07.056Get rights and content

Background & Aims

Cirrhosis and hepatocellular carcinoma (HCC) are predicted to increase in the United States but the accuracy of prior forecasts and the contributions from various liver disease etiologies remain unclear. We aimed to determine the burden of cirrhosis and HCC according to underlying cause from 2001 to 2013.

Methods

We developed a national retrospective cohort of Veterans Affairs (VA) patients with the diagnosis of cirrhosis (n = 129,998) or HCC (n = 21,326) from 2001 to 2013. We used laboratory results, International Classification of Diseases, ninth edition (ICD-9) codes, and body mass index to identify underlying etiologies.

Results

In 2013, VA provided care to 5,720,614 individuals, of whom 60,553 (1.06%) had cirrhosis and 7,670 (0.13%) had HCC. Hepatitis C virus (HCV) was present in an increasing proportion of cirrhosis and HCC between 2001 and 2013, reaching 48% of cirrhosis cases and deaths and 67% of HCC cases and deaths by 2013. Cirrhosis prevalence nearly doubled from 2001 to 2013 (664 to 1058 per 100,000 enrollees), driven by HCV and nonalcoholic fatty liver disease (NAFLD). Cirrhosis incidence ranged from 159 to 193 per 100,000 patient-years. Deaths in patients with cirrhosis increased from 83 to 126 per 100,000 patient-years, largely driven by HCV. HCC incidence was 2.5-fold increased from 17 to 45 per 100,000 patient-years. HCC mortality tripled from 13 to 37 per 100,000 patient-years, driven overwhelmingly by HCV, with much smaller contributions from NAFLD and alcoholic liver disease.

Conclusions

Cirrhosis prevalence and mortality and HCC incidence and mortality increased from 2001 to 2013, driven by HCV, with a smaller contribution from NAFLD. If current trends continue, cirrhosis prevalence will peak in 2021. Health care systems will need to accommodate rising numbers of patients with cirrhosis and HCC.

Section snippets

Data Source: Veterans Affairs Corporate Data Warehouse

The VA health care system is composed of 154 medical centers and 875 ambulatory care and community-based outpatient clinics throughout the United States. It is the largest integrated health care provider in the country and uses electronic medical records almost exclusively. In 2013, 5,720,614 veterans received VA health care.10 We extracted electronic data for all patients in VA care from October 1, 1999 until July 21, 2014, using the VA Corporate Data Warehouse, a national, continually updated

Characteristics of Patients With Cirrhosis or HCC in 2013

Of 5,720,614 patients in VA care in 2013, 60,553 patients (1.06%) had cirrhosis and 7,670 (0.13%) had HCC. Among patients with cirrhosis, 28,811 (48%) had HCV infection (60.9% of whom also had a chronic alcohol-related diagnosis), 18,404 (30%) had ALD, 9027 (15%) had NAFLD, 1299 (2.1%) had HBV infection, and 1737 (2.9%) had cryptogenic cirrhosis, while <1% had hemochromatosis, PSC, PBC, or AIH (Table 1). The average age was 62.4 years; 77% were white, 18% were black, and 8.7% were Hispanic. The

Discussion

The national prevalence and mortality of cirrhosis in VA health care users increased approximately 2-fold and 1.5-fold, respectively, between 2001 and 2013, whereas the incidence and mortality of HCC increased nearly 3-fold. If current trends continue, our data suggest that the prevalence of cirrhosis will peak in 2021. In contrast, the incidence of HCC continues to increase, confirming worrisome predictions of rapid growth put forward by work conducted in the mid-2000s.7

These trends were

Acknowledgements

The authors thank Dr Anna S. F. Lok for many valuable contributions to our analyses and manuscript preparation and the HIV, Hepatitis, and Public Health Pathogens Program of the Office of Public Health, Department of Veterans Affairs, for its commitment to treating hepatitis C virus and other liver diseases in veterans. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs.

References (36)

  • A. Wasley et al.

    Surveillance for acute viral hepatitis—United States, 2006

    MMWR Surveill Summ

    (2008)
  • G.L. Davis et al.

    Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression

    Gastroenterology

    (2010)
  • S.F. Altekruse et al.

    Changing hepatocellular carcinoma incidence and liver cancer mortality rates in the United States

    Am J Gastroenterol

    (2014)
  • B. Njei et al.

    Emerging trends in hepatocellular carcinoma incidence and mortality

    Hepatology

    (2015)
  • National Center for Veterans Analysis and Statistics. Number of veteran patients by healthcare priority group: FY 2000...
  • http://vaww.vinci.med.va.gov/vincicentral/overview.aspx. Last accessed...
  • J.R. Kramer et al.

    The validity of viral hepatitis and chronic liver disease diagnoses in Veterans Affairs administrative databases

    Aliment Pharmacol Ther

    (2008)
  • G.N. Ioannou et al.

    Incidence and predictors of hepatocellular carcinoma in patients with cirrhosis

    Clin Gastroenterol Hepatol

    (2007)
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    This article has an accompanying continuing medical education activity on page e17. Learning Objective: Upon completion of this exam, successful learners will be able to (1) describe trends and predictions related to the prevalence, incidence, and etiology of cirrhosis in US Veterans; (2) describe trends and predictions related to the prevalence, incidence, and etiology of hepatocellular carcinoma in US Veterans; (3) Identify factors associated with HCV-related cirrhosis.

    Conflicts of interest The authors have no conflicts of interest to disclose.

    Funding This study was supported by Merit Review grant I01CX000320, Clinical Science Research and Development, Office of Research and Development, Veterans Affairs (G.N.I.) and by the HIV, Hepatitis, and Public Health Pathogens Program of the Office of Public Health, Department of Veterans Affairs (L.A.B.). The sponsors had no role in study design or collection, analysis or interpretation of the data.

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