Millennials, fatty liver predicted to feed cirrhosis diagnoses by 2040
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By 2040, researchers predict 75% of cirrhosis cases in North America will be due to nonalcoholic fatty liver disease with a nearly 350% increase in women born after 1980, according to a presenter at the Digital International Liver Conference.
“The burden of cirrhosis has increased substantially in Canada over the past 2 decades, driven by both [hepatitis C virus] and NAFLD,” Jennifer Flemming, MD, of Queen’s University in Kingston, Canada, said during her presentation. “We did note concerning trends for alcohol-related disease and HCV-related cirrhosis in younger cohorts, and this is expected to continue to contribute to cirrhosis disease burden to the year 2040. Therefore, addressing chronic liver diseases in North America will require multidisciplinary efforts to prevent and manage not only NAFLD, but also alcohol-related liver disease and HCV in younger generations.”
Flemming presented a retrospective population-based cohort study using provincial health care data from Ontario, Canada from 2000 to 2017. Adults with incident cirrhosis were identified using a validated case definition and sorted by birth cohort. Cirrhosis etiology was assigned to one of five categories: hepatitis B (HBV), hepatitis C (HCV), NAFLD, alcohol-related liver disease (ALD) or Other.
From 2000 to 2017, Flemming showed that there was an overall increase in NAFLD cirrhosis of 3.3% (95% CI, 2.6-4.1) and that women in the 1946 to 1964 age group had the largest increase of 8.6% per year (95% CI, 6.1-11.2). With this increase in mind, Flemming’s group predicted that there would be a 24% overall increase of NAFLD-associated cirrhosis by 2040 and that women in the 1965 to 1980 cohort — thought to be the postmenopausal age group by 2040 — would see a 346% increase.
“By 2040, 75% of all new diagnoses of cirrhosis are anticipated to be secondary to NAFLD, with the highest increases anticipated in menopausal females,” Flemming said.
In alcohol-related cirrhosis, Flemming showed an overall decline of 1.2% (95% CI, –1.9 to –0.5). She explained that although the rate remained stable in the 1946 to 1964 birth cohort, older age groups contributed most to the decline. This trend, though, reversed in the younger generations, she said with those born after 1980 showing an 11.6% increase (95% CI, 9.3-13.9). By 2040, Flemming predicted an overall increase in alcohol-related cirrhosis by 15%, with men born after 1980 increasing by 423% and women by 320%.
Although NAFLD would still contribute to 67% of the cases of cirrhosis by 2040 in the cohort born after 1980, Flemming predicted alcohol would be the root cause for 25% of the cases.
HCV-related cirrhosis increased by 4.1% from 2000 to 2017 (95% CI, 2.6-5.7), with the greatest increase in the 1946 to 1964 birth cohort, although Flemming noted this is starting to decline. Similarly to the alcohol-related cirrhosis, the worrying trends upward were seen in those born after 1980. Men born after 1980 showed a 10.3% increase (95% CI, 6-14.9). Because of the more recent trend for baby boomer cirrhosis due to HCV, Flemming predicted an overall decline of 46% in this disease etiology by 2040. But in those born after 1980, she predicted cirrhosis in men to increase by 158% and women by 46%.
Cirrhosis due to HBV declined in all birth cohorts for an overall stable incidence, Flemming said. With that trend, she predicted a decline of 224% by 2040. Similarly, autoimmune cirrhosis remained stable and should decline by 50%, she said.
“Overall, we suspect that 75% of all new diagnoses of cirrhosis will be secondary to NAFLD,” Flemming said. “However, this will be differential based on year of birth. For instance, when you look at individuals born after 1980, there will be a much higher proportion who will develop alcohol-related cirrhosis.”
Perspective
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Jamile’ Wakim-Fleming, MD, FACG, FAASLD
Alcoholic liver disease, opioid use and, consequently, hepatitis C and NAFLD are still affecting the younger generations and they make up the leading risk factors for cirrhosis and its complications. When these problems begin in childhood, it is likely that they will continue into adulthood; an obese child, for example, may grow to become an obese adult.
In a retrospective population-based cohort study, Flemming and colleagues observed an increase in NAFLD-related cirrhosis by 3.3% from 2000 until 2017, by 4.1% in HCV related cirrhosis and by 11.8% in alcohol related cirrhosis in people born after 1980.
With these increases in mind, the reasearchers predicted that by 2040, overall NAFLD-associated cirrhosis would increase by 24%, adding up to 75% of all new diagnosis of cirrhosis related to NAFLD in 2040. Additionally, women born between 1965 and 1980 would see an increase of 346%. Overall predicted cirrhosis related to HCV would see a decline by 46%, but an increase in men born after 1980 by 158% and in women of the same age by 48%. The same conclusion may be drawn regarding alcohol related cirrhosis. The predicted change would be an overall decline by a modest 1.2%, mostly attributed to the older age groups. However, there would be an increase by 423% in men and 320% in women born after 1980.
These trends are not very surprising, but the numbers are. These staggering numbers merit serious consideration and continuous emphasis on education, new therapies and preparedness to what may become an exponential loss of lives, severe morbidity and health-related costs to future generations.
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Flemming J, et al. AS061. Presented at: Digital International Liver Congress, August 27-29.
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