Pandemic's Impact on Liver Disease in the Spotlight at Liver Meeting

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Alcohol-associated liver disease mortality soared during the COVID-19 pandemic, researchers reported as part of a set of studies slated for presentation at the American Association for the Study of Liver Diseases (AASLD) meeting.

Deaths from both alcohol-related liver disease and non-alcoholic fatty liver disease (NAFLD) showed "alarming" upward trends from 2010 to 2021, with surges during the pandemic, reported Yee Hui Yeo, MD, of Cedars-Sinai Medical Center in Los Angeles.

For NAFLD, mortality rates rose almost twofold more in people ages 25-44 (annual percentage increase 28.4%) during the pandemic than what was seen in 45- to 64-year-olds (7.4%) or older individuals (12%), Yeo reported at a press conference in advance of presentation at the Liver Disease meeting, which kicks off Friday in Washington, D.C.

Non-Hispanic American Indian and Alaskan Native groups had the most pronounced increase in alcohol-related liver disease-related mortality rates.

The data came from the CDC's National Vital Statistics System dataset, "which includes more than 99% of the population of all the deceased in the United States annually," Yeo said.

From these data, researchers were able to accurately identify the patients who died from the "big four" chronic liver diseases -- alcohol liver disease, NAFLD, hepatitis B, and hepatitis C -- and then used statistical analysis to examine trends in causes of death.

Between 2010 and 2021, there were approximately 340,000 patients who died from alcohol-related liver disease, followed by 200,000 from hepatitis C, 58,000 from NAFLD, and 20,000 from hepatitis B, he explained.

"The trend for these four diseases varied significantly," Yeo said. As curative treatment for hepatitis C emerged in late 2013 to early 2014, the increase in hepatitis C infection-related deaths from 2010 to 2014 turned into "a significant decrease from 2014 to 2019."

"However during the pandemic we saw that this decrease became a non-significant change, which means that our progress for the past 5 or 6 years has already stopped during the pandemic," Yeo added.

Despite showing slightly lower mortality rates over the past 10 years, hepatitis B-related deaths did not change much during the pandemic.

Alcoholic-Hepatitis During the Pandemic

Another, albeit smaller, study presented at the press conference also showed a surge in cases of alcohol-related hepatitis during the pandemic.

After examining electronic medical records data from 2019 to 2021, only 131 admissions for alcohol-related hepatitis were observed in 2019, compared with 215 such admissions in 2021 -- a 64% increase in total cases, reported Aalam Sohal, MD, of the University of California San Francisco-Fresno.

"This increase, which is in and out of three hospital systems in Fresno, California, might reflect a larger national problem," Sohal said.

Alcohol-related hepatitis has been significantly linked to morbidity, mortality, and healthcare costs. Hospital admissions during the pandemic for this disorder stayed far above pre-pandemic levels.

What Sohal called "more disturbing" trends were that women accounted for 24% of alcohol-related hepatitis in 2019 but 67% in 2021 -- a 179% increase in total cases -- and that patients under age 40 jumped from 30% of cases in 2019 to 71% in 2021 (a 136% increase).

Alcohol-related hepatitis readmissions also increased by 4.5-fold from 2019 to 2021, Sohal reported.

Adding Weight Management to NAFLD Care

A multidisciplinary care program for NAFLD boosted referrals for bariatric surgery by 25 times the national average, according to Ysabel Ilagan-Ying, MD, of the Yale University School of Medicine in New Haven, Connecticut.

Among more than 1,000 patients referred to Yale's Fatty Liver Disease Program, in which hepatologists work in tandem with nutritionists and other specialists in medical weight management, 25.1% of those eligible for bariatric surgery were referred for it. The national average is less than 1%, Ilagan-Ying noted.

"It takes a village to fight obesity," said Ilagan-Ying. "We all recognize that obesity is a growing problem."

Fat stored in the liver can develop into fatty liver disease, she noted. "With prolonged inflammation and scarring from having a fatty liver, patients can progress to cirrhosis and liver cancer, which is why fatty liver disease is now emerging as the leading reason why people need liver transplants in America."

Losing at least 10% of total body weight is the treatment for fatty liver disease, which can be accomplished by highly effective bariatric surgical procedures, such as sleeve gastrectomy.

After studying over 1,000 patients referred to the program from October 2015 through May 2022, 965 had fatty liver disease. Of those, 58% had a mood or anxiety disorder and 46% had diabetes. Based on insurance criteria, 62% of patients were eligible for bariatric surgery.

While more than half of the patients experienced weight loss by 12 months, by the end of follow-up "all patients who underwent bariatric surgery achieved their predicted final BMI," Ilagan-Ying said. "Those who underwent surgery lost 20% of their body weight."

Post-surgical complications were minimal. Not surprisingly, decreased nutritional absorption was the most common complication.

Other Research

In a fourth study presented at the briefing, Black and Latino individuals were significantly under-represented in clinical trials that evaluated cirrhosis in the U.S.

These groups represented only 7% of enrollment in phase III clinical trials for cirrhosis, according to Paige McLean Diaz, MD, of the Massachusetts General Hospital in Boston.

Race and ethnicity were also under-reported, being included in just 9% of trials (12 of 133).

"It's clear that barriers to clinical trial enrollment of racial and ethnic minority patients need to be systematically investigated to improve representation," McLean Diaz said.

Other research highlighted at the press conference as data to watch at the meeting included a study looking at a low-carbohydrate, high-fat diet to reduce lipids in NAFLD patients with type 2 diabetes; data on NAFLD and the risk of cardiovascular disease in inflammatory bowel disease; and trends in life lost to cirrhosis before and after the pandemic.