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Epidemiology of Alcoholic Liver Disease

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Clinical Epidemiology of Chronic Liver Diseases

Abstract

Alcohol abuse is recognized as a major determinant of public health outcomes. The use of alcohol accounted for 5.9% of all deaths worldwide in 2012. Only in the twentieth century has alcohol been found to be a direct hepatotoxin. A dose dependent relationship has been described in many studies across many countries between the consumption of alcohol and the development of alcoholic liver disease.

There is not a clear consumption threshold for development of liver disease, which spans a spectrum from steatosis to steatohepatitis to fibrosis to cirrhosis. Other factors for development of cirrhosis include type of alcohol, pattern of drinking, gender, age, ethnicity, obesity, viral hepatitis, genetics, smoking, coffee, and hepatic iron overload.

Worldwide data from 2010 indicate greater than 1 million deaths (2% of all deaths) and 31 million disability adjusted life years (DALYs) lost were related to liver cirrhosis and alcohol contributed to 493,300 of those deaths (47.9%). Often alcoholic liver disease affects a relatively more productive middle-aged cohort relative to other liver diseases and this effect poses unique societal and economic costs.

Regional variations in consumption and public policy have provided outcomes worthy of study and understanding the epidemiology of alcoholic liver disease is important to this end. In countries where the per capita consumption of alcohol decreases, there appears to be an associated drop in the burden of disease. Avoidance of alcohol remains the best treatment of alcoholic liver disease and the burden of this lethal disease is preventable.

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Acknowledgments

The work is supported by faculty development grant funding to AKS from the American College of Gastroenterology.

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA

    C. Taylor Richardson & Ashwani K. Singal

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  1. C. Taylor Richardson
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  2. Ashwani K. Singal
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Correspondence to Ashwani K. Singal .

Editor information

Editors and Affiliations

  1. Division of Gastroenterology and Hepatology, Alameda Health System Highland Hospital, Oakland, CA, USA

    Robert J. Wong

  2. Robert G. Gish Consultants LLC, Hepatitis B Foundation, Stanford Health Care, San Diego, CA, USA

    Robert G. Gish

Summary Table of Landmark Literature

Summary Table of Landmark Literature

Study title and authors

Study design

Summary results

Main limitations

Bellentani S, et al. Journal of Hepatology. 1994; 20:1442–1449

Italian cohort study assessing the prevalence of liver disease and attributable risks

• Above the 30 g/day threshold, the incidence of alcoholic liver disease and of cirrhosis increases linearly with increasing alcohol intake

• Limited study population and unclear if results can be generalized to other populations

Corrao G, et al. Addiction Biology. 1998; 3:413–422

Descriptive study that assesses cirrhosis mortality trends in seven Eastern Europe countries relative to Europe as a whole

• In Europe the cirrhosis mortality rates were explained by their relationship with per capita alcohol consumption with a specific lag time

• Descriptive, epidemiologic study that does not address natural history of cirrhosis

• Does not account for other factors like viral hepatitis?

Ramstedt M, et al. Addiction. 2001; 96:S19–34

Analysis of yearly changes in gender and age specific mortality rates from 1990 to 1995 in 14 European countries in relation to corresponding yearly changes in per capita alcohol consumption

• There exists a positive and statistically significant effect in changes of per capita consumption on changes in cirrhosis mortality, particularly in northern Europe

• Mortality data based on ICD codes

• Per capita consumption data based on alcohol sales

Roizen R, et al. BMJ. 1999; 319:666–669

Trend analysis using data on US cirrhosis mortality and per capita alcohol consumption

• A relationship exists between per capita consumption of distilled spirits and mortality from cirrhosis in the United States

• Relationship between consumption and mortality does not establish a causal relationship

Kerr W, et al. Addiction. 2000; 95:339–346

Pooled cross-sectional time series analysis to compare beverage specific per capita consumption and cirrhosis mortality in multiple countries

• Associations between mortality and consumption were found for total alcohol and for distilled spirits specifically

• Use of spirits may affect mortality more than wine and beer

• Multiple potential confounder factors exist (i.e. those who drink spirits may be more prone to binging, heavier drinking)

• Does not establish a causal relationship

Rehm J, et al. Journal of Hepatology. 2013; 59:160–168

Review of global mortality and consumption data to calculate and report the global burden of alcoholic liver disease

• In 2010 alcohol attributable liver disease was responsible for 493,300 deaths and 14,544,000 DALYs

• Reliability of global data on consumption

• The role of past consumption to the current burden of disease for a disease like cirrhosis

Naveau S, et al. Hepatology. 1997; 25:108–111

French cohort study to assess whether being overweight was a risk factor for the development of alcoholic liver disease

• In patients with alcohol abuse, being overweight for at least ten years was independently correlated with developing cirrhosis, acute alcoholic hepatitis, and steatosis

• Does not establish a causal relationship

Carrrao G, et al. Hepatology 1998; 27:914–919

Data used from two case control studies in Italy to assess the joint effect of alcohol and hepatitis C infection on the development of cirrhosis

• The interaction between lifetime daily alcohol intake and the presence of the hepatitis c virus was additive for low volume consumers, but multiplicative in high volume consumers suggesting a synergistic effect

• Small study size

• Self-reported alcohol use.

• Small presence of heavy drinkers who had hepatitis C in the control (non-cirrhosis) group

Singal AK. Eur J Gastroenterol Hepatol. 2012; 24:1178–1184

Data from the US Nationwide Inpatient Sample dataset (1998–2007) reviewed to identify patients with alcoholic hepatitis and factors associated with hepatitis C positivity and mortality

• Hepatitis C infection is an independent predictor of mortality in patients with alcoholic hepatitis

• Does not establish a mechanism for the impact of hepatitis C in patients with alcoholic hepatitis

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Taylor Richardson, C., Singal, A.K. (2019). Epidemiology of Alcoholic Liver Disease. In: Wong, R., Gish, R. (eds) Clinical Epidemiology of Chronic Liver Diseases. Springer, Cham. https://doi.org/10.1007/978-3-319-94355-8_7

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