Burden Of Cirrhosis Research Articles

The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017

SummaryBackgroundCirrhosis and other chronic liver diseases (collectively referred to as cirrhosis in this paper) are a major cause of morbidity and mortality globally, although the burden and underlying causes differ across locations and demographic groups. We report on results from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017 on the burden of cirrhosis and its trends since 1990, by cause, sex, and age, for 195 countries and territories.MethodsWe used data from vital registrations, vital registration samples, and verbal autopsies to estimate mortality. We modelled prevalence of total, compensated, and decompensated cirrhosis on the basis of hospital and claims data. Disability-adjusted life-years (DALYs) were calculated as the sum of years of life lost due to premature death and years lived with disability. Estimates are presented as numbers and age-standardised or age-specific rates per 100 000 population, with 95% uncertainty intervals (UIs). All estimates are presented for five causes of cirrhosis: hepatitis B, hepatitis C, alcohol-related liver disease, non-alcoholic steatohepatitis (NASH), and other causes. We compared mortality, prevalence, and DALY estimates with those expected according to the Socio-demographic Index (SDI) as a proxy for the development status of regions and countries.FindingsIn 2017, cirrhosis caused more than 1·32 million (95% UI 1·27–1·45) deaths (440 000 [416 000–518 000; 33·3%] in females and 883 000 [838 000–967 000; 66·7%] in males) globally, compared with less than 899 000 (829 000–948 000) deaths in 1990. Deaths due to cirrhosis constituted 2·4% (2·3–2·6) of total deaths globally in 2017 compared with 1·9% (1·8–2·0) in 1990. Despite an increase in the number of deaths, the age-standardised death rate decreased from 21·0 (19·2–22·3) per 100 000 population in 1990 to 16·5 (15·8–18·1) per 100 000 population in 2017. Sub-Saharan Africa had the highest age-standardised death rate among GBD super-regions for all years of the study period (32·2 [25·8–38·6] deaths per 100 000 population in 2017), and the high-income super-region had the lowest (10·1 [9·8–10·5] deaths per 100 000 population in 2017). The age-standardised death rate decreased or remained constant from 1990 to 2017 in all GBD regions except eastern Europe and central Asia, where the age-standardised death rate increased, primarily due to increases in alcohol-related liver disease prevalence. At the national level, the age-standardised death rate of cirrhosis was lowest in Singapore in 2017 (3·7 [3·3–4·0] per 100 000 in 2017) and highest in Egypt in all years since 1990 (103·3 [64·4–133·4] per 100 000 in 2017). There were 10·6 million (10·3–10·9) prevalent cases of decompensated cirrhosis and 112 million (107–119) prevalent cases of compensated cirrhosis globally in 2017. There was a significant increase in age-standardised prevalence rate of decompensated cirrhosis between 1990 and 2017. Cirrhosis caused by NASH had a steady age-standardised death rate throughout the study period, whereas the other four causes showed declines in age-standardised death rate. The age-standardised prevalence of compensated and decompensated cirrhosis due to NASH increased more than for any other cause of cirrhosis (by 33·2% for compensated cirrhosis and 54·8% for decompensated cirrhosis) over the study period. From 1990 to 2017, the number of prevalent cases more than doubled for compensated cirrhosis due to NASH and more than tripled for decompensated cirrhosis due to NASH. In 2017, age-standardised death and DALY rates were lower among countries and territories with higher SDI.InterpretationCirrhosis imposes a substantial health burden on many countries and this burden has increased at the global level since 1990, partly due to population growth and ageing. Although the age-standardised death and DALY rates of cirrhosis decreased from 1990 to 2017, numbers of deaths and DALYs and the proportion of all global deaths due to cirrhosis increased. Despite the availability of effective interventions for the prevention and treatment of hepatitis B and C, they were still the main causes of cirrhosis burden worldwide, particularly in low-income countries. The impact of hepatitis B and C is expected to be attenuated and overtaken by that of NASH in the near future. Cost-effective interventions are required to continue the prevention and treatment of viral hepatitis, and to achieve early diagnosis and prevention of cirrhosis due to alcohol-related liver disease and NASH.FundingBill & Melinda Gates Foundation.

Hepatocellular carcinoma in the post-hepatitis C virus era: Should we change the paradigm?

Hepatocellular carcinoma (HCC) is a common and deadly malignancy. The disease usually develops on a background of chronic liver disease. Until recently, the most common etiology was infection with the hepatitis C virus (HCV). The advent of direct-acting antiviral (DAA) therapies has been a major breakthrough in HCV treatment. Sustained virologic response can now be achieved in almost all treated patients, even in patients with a high risk for the development of HCC, such as the elderly or those with significant fibrosis. Early reports raised concerns of a high risk for HCC occurrence after DAA therapy both in patients with previous resection of tumors and those without previous tumors. As the World Health Organization’s goals for eradication of HCV are being endorsed worldwide, the elimination of HCV seems feasible. Simultaneous to the decrease in the burden of cirrhosis from HCV, non-alcoholic fatty liver disease (NAFLD) incidence has been increasing dramatically including significant increased incidence of cirrhosis and HCC in these patients. Surprisingly, a substantial proportion of patients with NAFLD were shown to develop HCC even in the absence of cirrhosis. Furthermore, HCC treatment and potential complications are known to be influenced by liver steatosis. These changes in etiology and epidemiology of HCC suggest the beginning of a new era: The post–HCV era. Changes may eventually undermine current practices of early detection, surveillance and management of HCC. We focused on the risk of HCC occurrence and recurrence in the post–HCV era, the surveillance needed after DAA therapy and current studies in HCC patients with NAFLD.

Factors Affecting Psychological Burden on the Informal Caregiver of Patients With Cirrhosis: Looking Beyond the Patient

Cirrhosis leads to considerable morbidity and mortality, compromises quality of life, and often necessitates assistance in activities of daily living. An informal caregiver bears the psychological burden of coping with the needs of the patient and the knowledge of morbid prognosis of a loved one. This aspect is rarely recognized and almost never addressed in a clinical practice. This cross-sectional study assessed the factors influencing psychological burden of cirrhosis on the caregivers in a predominantly lower-middle socioeconomic class Indian population. Patients underwent psychometric tests [Psychometric Hepatic Encephalopathy Score (PHES)], and questionnaires for quantifying caregiver burden [Perceived Caregiver Burden (PCB) and Zarit Burden Interview (ZBI)] and assessing depression [Beck Depression Inventory (BDI)] and anxiety [Beck Anxiety Inventory (BAI)] were administered. One hundred patients with cirrhosis [70% male, 27% with past hepatic encephalopathy (HE), and 53% with minimal HE] and their caregivers (66% women, 81% spouse, 26.51 years of mean relationship) were evaluated. Caregiver burden scores were higher in patients with previous overt HE than in those without previous overt HE [PCB (74.63 vs. 66.15, P=0.001), ZBI (27.93 vs. 21.11, P= 0.023), BDI (11.63 vs. 8.96, P=0.082), and BAI (11.37 vs. 8.12, P= 0.027)]. Similarly, caregivers of patients with minimal HE had higher caregiver burden that those of patients who did not have minimal HE [PCB (70.74 vs. 65.85, P=0.027), ZBI (26 vs. 19.51, P= 0.015)]. Burden scores correlated well with each other and with liver disease severity scores and negatively correlated with socioeconomic status. Repeated hospital admissions, alcohol as etiology, and lower socioeconomic status were the independent predictors of caregiver burden. Higher perceived burden is common in caregivers of patients with cirrhosis. Repeated hospital admissions, alcoholism, and lower socioeconomic status influence caregiver burden.

NASH Is the Most Rapidly Growing Etiology for Acute-on-Chronic Liver Failure-Related Hospitalization and Disease Burden in the United States: A Population-Based Study.

Acute-on-chronic liver failure (ACLF) is characterized by multiple organ failure (OF) with high short-term mortality. There is lack of population-based data on trends on etiology specific ACLF related burden. National Inpatient Sample (2006-2014) was queried using ICD-09 codes for admissions with cirrhosis and ACLF (≥2 extrahepatic OF). Of 1,928,764 admissions for cirrhosis between 2006 and 2014, 112,174 (5.9%) had ACLF (4.5%, 1.2%, and 0.2% with ACLF 1, 2, and 3, respectively). The brain was the most common OF in 11.9%, followed by respiratory failure in 7.7%, cardiac failure in 6.3%, and renal failure in 5.6%. ACLF increased by 24% between 2006 and 2014 with a 63% increase in 179,104 patients with nonalcoholic steatohepatitis (NASH) cirrhosis (3.5% to 5.7%); a 28% increase in patients with 429,306 alcoholic cirrhosis (5.6% to 7.2%); a 25% increase in patients with 1,091,053 with other etiologies (5.2% to 6.5%); and no significant change in 229,301 patients with viral hepatitis (VH) (4.0% to 4.1%). In-hospital mortality was higher among ACLF patients compared with patients without ACLF (44% versus 4.7%; P<0.0001). Each NASH-related ACLF patient compared with other etiologies had a longer mean length of stay (14 versus 12days), was associated with higher median total charges (US $151,196 versus US $134,597), and had more frequent use of dialysis (45% versus 36%) and longterm care (32% versus 26%; P<0.0001 for all). Results remained similar in a subgroup analysis after including half of admissions with cryptogenic cirrhosis as NASH. In conclusion, NASH cirrhosis is the most rapidly growing indication for ACLF-related hospitalization and use of hospital resources. In the setting of improved treatment options for chronic hepatitis, the health care burden of chronic viral-related liver disease remains stable. Population-based strategies are needed to reduce the health care burden of cirrhosis, particularly related to NASH.

A259 TREATMENTS AND OUTCOMES IN PATIENTS WITH LUNG CANCER AND CO-MORBID CIRRHOSIS IN ONTARIO FROM 2007–2016: A POPULATION-BASED STUDY

Background Lung cancer is the most common cause of cancer-related mortality among Canadians. Patients with lung cancer and cirrhosis have historically been excluded from clinical trials evaluating cancer treatment efficacy due to perceived perioperative risk and hepatotoxicity. Thus, outcomes in this patient population are unknown. Given the increasing burden of cirrhosis in Canada, this study aimed to describe lung cancer treatments and outcomes in patients with primary lung cancer and co-morbid cirrhosis.

Nationwide estimates and risk factors of hospital readmission in patients with cirrhosis in the United States.

The burden of cirrhosis on the healthcare system is substantial and growing. Our objectives were to estimate the readmission rates and hospitalization costs as well as to identify risk factors for 90-day readmission in patients with cirrhosis. We conducted a weighted analysis of the 2014 Nationwide Readmission Database to identify adult patients with cirrhosis-related complications in the United States and assessed readmission rates at 30, 60 and 90days post-index hospitalization. Predictors of 90-day readmissions were identified using weighted regression models adjusting for patient and hospital characteristics; the national estimate of hospitalization costs was also calculated. Of the 58954 patients admitted with cirrhosis-related complications in 2014, 14910 (25%) were readmitted within 90days because of cirrhosis-related complications. The main causes of readmission were ascites (56%), hepatic encephalopathy (47%) and bleeding oesophageal varices (9%). Independent predictors of 90-day readmissions were male sex (adjusted OR [aOR]: 1.08, 95% CI, 1.04-1.13), age <60 (aOR: 1.27, 95% CI, 1.22-1.32), privately insured (aOR: 0.74, 95% CI, 0.70-0.77), having ≥3 comorbid conditions (aOR: 1.27, 95% CI, 1.14-1.42) and being discharged against medical advice (aOR: 1.41, 95% CI, 1.25-1.59). The weighted cumulative national cost estimate of the index admission was $1.8 billion, compared to $0.5 billion for readmission. A quarter of patients admitted with cirrhosis-related complications were readmitted within 90days, representing a significant economic burden related to readmission of this population. Interventions and resource allocations to reduce readmission rates among cirrhotic patients is critical.

Changing Trends in Etiology-Based and Ethnicity-Based Annual Mortality Rates of Cirrhosis and Hepatocellular Carcinoma in the United States.

With recent improvements in the treatment of end-stage liver disease (ESLD), a better understanding of the burden of cirrhosis and hepatocellular carcinoma (HCC) is needed in the United States. A population-based study using the US Census and national mortality database was performed. We identified the age-standardized etiology-specific mortality rates for cirrhosis and HCC among US adults ages 20 years or older from 2007 to 2016. We determined temporal mortality rate patterns by joinpoint analysis with estimates of annual percentage change (APC). Age-standardized cirrhosis-related mortality rates increased from 19.77/100,000 persons in 2007 to 23.67 in 2016 with an annual increase of 2.3% (95% confidence interval [CI] 2.0-2.7). The APC in mortality rates for hepatitis C virus (HCV)-cirrhosis shifted from a 2.9% increase per year during 2007 to 2014 to a 6.5% decline per year during 2014 to 2016. Meanwhile, mortality for cirrhosis from alcoholic liver disease (ALD, APC 4.5%) and NAFLD (APC 15.4%) increased over the same period, whereas mortality for hepatitis B virus (HBV)-cirrhosis decreased with an average APC of -1.1%. HCC-related mortality increased from 3.48/100,000 persons in 2007 to 4.41 in 2016 at an annual rate of 2.0% (95% CI 1.3-2.6). Etiology-specific mortality rates of HCC were largely consistent with cirrhosis-related mortality. Minority populations had a higher burden of HCC-related mortality. Conclusion: Cirrhosis-related and HCC-related mortality rates increased between 2007 and 2016 in the United States. However, mortality rates in HCV-cirrhosis demonstrated a significant decline from 2014 to 2016, during the direct-acting antiviral era. Mortality rates for ALD/NAFLD-cirrhosis and HCC have continued to increase, whereas HBV-cirrhosis-related mortality declined during the 10-year period. Importantly, minorities had a disproportionately higher burden of ESLD-related mortality.

Mac-2 Binding Protein Glycosylation Isomer as a Hepatocellular Carcinoma Marker in Patients With Chronic Hepatitis B or C Infection.

Mac‐2 binding protein glycosylation isomer (M2BPGi) is a novel glycoprotein biomarker that correlates with liver fibrosis. It has been investigated in East Asian populations as a hepatocellular carcinoma (HCC) biomarker. We assessed M2BPGi as an HCC biomarker in an ethnically diverse cohort of patients with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection. We enrolled 947 treatment‐naive patients mono‐infected with HBV or HCV without HCC at baseline. Biomarker levels were measured from baseline sera and correlated with longitudinal clinical data. The primary outcome was HCC occurrence during long‐term follow‐up. Median M2BPGi was significantly higher among patients with cirrhosis (2.67 versus 0.80; P < 0.001) and patients who developed HCC (3.22 versus 1.16; P < 0.001). The area under the receiver operating characteristic (AUROC) for M2BPGi and alpha‐fetoprotein (AFP) was similar overall (0.77 versus 0.72; P = 0.15), but M2BPGi outperformed AFP among patients with HBV (0.84 versus 0.75; P = 0.02). M2BPGi performed poorly among patients with HCV (AUROC, 0.51). M2BPGi was an independent predictor of HCC among patients with HBV but not among patients with HCV. M2BPGi performed better in patient subgroups with a lower prevalence of cirrhosis. Conclusion: In our HBV cohort, M2BPGi was more effective than AFP in predicting HCC and was an independent predictor of HCC. However, M2BPGi had limited predictive value in our HCV cohort, likely due to a high cirrhosis burden in this cohort. Further studies are needed to evaluate M2BPGi as an HCC biomarker in broader patient populations with more diverse disease etiology, non‐Asian ethnicity, and more advanced fibrosis.

Economic burden of cirrhosis in Catalonia: a population-based analysis

BackgroundCirrhosis is a chronic disease with high morbidity and mortality. Few studies have evaluated healthcare resource use in patients with cirrhosis.ObjectiveWe aimed to describe the point prevalence of cirrhosis on...

Global Mortality Burden of Cirrhosis and Liver Cancer Attributable to Injection Drug Use, 1990-2016: An Age-Period-Cohort and Spatial Autocorrelation Analysis.

We analyzed the temporal and spatial variations in mortality burden of cirrhosis and liver cancer attributable to injection drug use (IDU) from 1990 to 2016. Mortality data of IDU-attributable cirrhosis and IDU-attributable liver cancer on the global and national scales from 1990 to 2016 were collected from the Global Burden of Disease (GBD) studies. Age-period-cohort (APC) model analysis was used to analyze the global mortality trends of target disease, and spatial autocorrelation analysis based on Geographic Information System was applied to illustrate the clusters of the most epidemic countries. Globally, from 1990 to 2015, mortality rates (age-standardized, per 100,000) of IDU-attributable cirrhosis increased continually from 1.5 to 1.9, while from 0.4 to 0.9 for IDU-attributable liver cancer. The APC model analysis indicated that the increases of mortality were mainly driven by period effects, with the mortality risk increasing by 6.82-fold for IDU-attributable cirrhosis and 3.08-fold for IDU-attributable liver cancer. The spatial analysis suggested that IDU-attributable cirrhosis mortality were geographically clustered from 1990 to 2016, and hot spots were mainly located in less well developed countries of Latin America, East and Central Europe and Central Asia. Our study provides epidemiological evidence for global interventions against advanced liver disease among injection drug users (IDUs).

Demographic and Clinical Profile in Patients with Liver Cirrhosis in a Tertiary Care Hospital in Central Nepal

Liver cirrhosis is an important health problem worldwide and is a common disease in Nepal. The profile of cirrhosis may vary due to different factors. This study was undertaken to see the demographic and clinical profiles of patients with cirrhosis of liver attending a tertiary care hospital in Central Nepal. Six hundred patients with clinical features, laboratory and sonological findings suggestive of chronic liver dysfunction and endoscopic evidence of portal hypertension were included in the study. Their demographic and clinical profile, endoscopic findings, outcomes during hospitalization were studied. Ethical approval was taken from Institutional Review Committee of College of Medical Sciences. SPSS 20 was used for statistical analysis. The mean age of subjects was 54±11.84 years with 435 males (72.5%) and 165 (27.5%) females. Majority of 203 (33.8%) patients were from Mongol ethnicity followed by 127 (21.2%) Khas. Two hundred and twenty (36.6%) were farmers followed by 169 (28.2%) retired personnel. A total of 338 (56.4 %) patients were from rural areas. The commonest aetiology of cirrhosis was chronic alcohol consumption and seen in 552 (92%) patients. Abdominal distension was commonest presenting sign and observed in 561 (93.5%) patients. Ascites seen in 555 (92.5%) patients was the commonest complication followed by UGI bleed in 326 (54.3%) patients. Gastro-oesophageal varices observed in 345 (57.5%) patients, was the most common endoscopic finding followed by portal gastropathy, peptic ulcer and erosive mucosal diseases. In patient mortality was noted in 92 (15.3 %) patients. This study highlights the burden of cirrhosis, usually caused by chronic alcohol consumption in Central Nepal. Majority of subjects were male, middle aged, farmers, from rural areas and predominantly observed in some ethnicity like Mongols. Cirrhotic patients usually Keywords: cirrhosis of liver; complications; endoscopy.

Burden of Cirrhosis and Minimal and Past History of Overt Hepatic Encephalopathy on Caregivers

Burden of Cirrhosis and Minimal and Past History of Overt Hepatic Encephalopathy on Caregivers

Burden of Cirrhosis with Minimal or past Overt Hepatic Encephalopathy on Patients and Caregivers

Burden of Cirrhosis with Minimal or past Overt Hepatic Encephalopathy on Patients and Caregivers

Heavy daily alcohol intake at the population level predicts the weight of alcohol in cirrhosis burden worldwide

Studies assessing alcohol as a population level risk factor for cirrhosis typically focus on per capita consumption. However, clinical studies indicate that daily intake is a strong predictor of alcoholic cirrhosis. We aimed to identify the determinants of alcohol's contribution to the global cirrhosis burden and to evaluate the influence of daily drinking on a population level. We performed a comprehensive analysis of the WHO 2014 Global Status Report on Alcohol and Health. We categorized countries by heavy or moderate drinking based on daily consumption, using U.S. Department of Agriculture definitions of heavy drinking. Additional data on cirrhosis cofactors were also obtained. Uni- and multivariate models were fitted to identify independent predictors of the alcohol-attributable fraction of cirrhosis. The WHO 2014 Report found that half of cirrhosis mortality worldwide is attributable to alcohol, approximating 60% in North America and Europe. In an integrative multivariate model, the designation of countries by moderate or heavy daily drinking had the strongest influence on the weight of alcohol in the cirrhosis burden. The relative contribution from alcohol increased by 11% with a transition from the moderate to heavy classification (p<0.001). Importantly, drinking patterns such as heavy episodic drinking and the type of alcohol did not independently predict the alcohol-attributable fraction of cirrhosis. Heavy daily drinking on a population level significantly influences the weight of alcohol in the cirrhosis burden. Reducing heavy drinking should be considered as an important target for public health monitoring and policies. We carried out an analysis of the WHO 2014 Global Status Report on Alcohol and Health, and categorized countries by their level of drinking (heavy or moderate). We found that half of the global cirrhosis cases, and 60% in both North America and Europe are associated with alcohol intake. We concluded that on a population level heavy daily drinking significantly influences the impact of alcohol on the cirrhosis burden.

Burden of Cirrhosis and Minimal and Past History of Overt Hepatic Encephalopathy on Patients and Caregivers

Burden of Cirrhosis and Minimal and Past History of Overt Hepatic Encephalopathy on Patients and Caregivers

OC-032 Type 2 Diabetes and Obesity will Drive the Burden of Liver Cirrhosis in the Next Two Decades: Abstract OC-032 Table 1

Introduction Over the past 30 years excessive alcohol consumption has been identified as the predominant risk factor underlying the striking rise in standardised mortality rates from liver disease in the UK. However, with the increasing incidence of type 2 diabetes and obesity within the general population, the risk factor profile associated with cirrhosis may change. Aim To estimate the prevalence of clinically significant chronic liver disease amongst adults in a primary care population and identify the impact of different risk factors. Methods Asymptomatic adult patients from a primary care practice covering a population of 4600 in inner city Leicester were screened for risk factors including (1) a diagnosis of type 2 diabetes (2) a raised body mass index (BMI) of ≥27.3 kg/m 2 and (3) hazardous alcohol use. All of those with one or more of risk factors were invited to undergo a liver stiffness measurement using transient elastography (TE). A TE threshold of ≥8 kPa was used to make a diagnosis of clinically significant liver disease. 1 Results Of the 1320 patients identified with risk factors, 705 underwent TE and 82 had an increased liver stiffness measurement of ≥8 kPa (Table 1). Of those patients with hazardous alcohol use as the only risk factor, 3.5 [95% CI 0.73–9.8]% had raised liver stiffness when compared to 7.9 [95% CI 2.9–16.4]% of patients with type 2 diabetes or 8.6% [95% CI 6–11.9]% with a raised BMI. Overall 16/82 (19.5%) patients had hazardous alcohol use (with or without type 2 diabetes and a raised BMI) as a risk factor for an elevated liver stiffness measurment compared to 66/82 (80.5%) with type 2 diabetes and/or a raised BMI (without hazardous alcohol use). Conclusion In the primary care population that was screened for major risk factors of chronic liver disease, a raised BMI and type 2 diabetes accounted for over 80% of those with clinically significant chronic liver disease. Population based interventions are urgently required to address obesity and type 2 diabetes which are likely to contribute to the burden of cirrhosis in the next decade. Reference 1 Roulot D, et al . Transient elastography as a screening tool for liver fibrosis and cirrhosis in a community-based population aged over 45 years. Gut 2011; 60 (7):977–84. Disclosure of Interest None Declared

Tu1669 The Burden of Cirrhosis and Its Complications in the United States: A Comparison Between 1997 and 2013

Tu1669 The Burden of Cirrhosis and Its Complications in the United States: A Comparison Between 1997 and 2013

FRI-419 - Inequality and Economic Factors Impact on the Weight of Alcohol in Cirrhosis Burden and Death Rate: A Worldwide Study

FRI-419 - Inequality and Economic Factors Impact on the Weight of Alcohol in Cirrhosis Burden and Death Rate: A Worldwide Study

The burden of cirrhosis and impact of universal coverage public health care system in Thailand: Nationwide study

Background and rationale. Cirrhosis is responsible for significant health-care costs and morbidity. This study aims to evaluate the burden of illness associated with cirrhosis, its impact on the universal coverage public health care system in Thailand.Material and methods. We used data from the 2010 Nationwide Hospital Admission Data, the National Health Security Office (NHSO), Thailand. Their baseline characteristics, hospital costs, and outcomes were analyzed according to national health insurance categories including medical welfare scheme (MWFS), social security scheme (SSS) and civil servant medical benefit scheme (CSMBS).Results. 92,301 admissions were eligible for analysis. The mean age was 55 ± 12.8 years, and 63.3% of patients were above 50 years old. The majority of patients (79%) belonged to the MWFS group. The MWFS group incurred the lowest medical expense and had the shortest hospital stay compared to the SSS and CSMBS groups. Overall in-hospital mortality was 10.7%. Cirrhosis complications include bleeding esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome, and hepatocellular carcinoma. These complications significantly increased mortality rates compared to patients without complications (26 vs. 8.9%, p < 0.001). In-hospital mortality of patients with cirrhosis complications did not differ among the three national health insurance groups. Respiratory failure and septicemia were associated with the highest risk of death (HR 5.4; 95% CI: 4.8-5.9 and HR 5.2; 95% CI: 4.9-5.6 respectively; P < 0.001).Conclusions. Illness associated with cirrhosis is a significant public health problem in Thailand. Outcomes of cirrhosis complications did not differ between universal public health care coverage systems in Thailand.

Exam 1: Trends in Burden of Cirrhosis and Hepatocellular Carcinoma by Underlying Liver Disease in US Veterans, 2001–2013

Exam 1: Trends in Burden of Cirrhosis and Hepatocellular Carcinoma by Underlying Liver Disease in US Veterans, 2001–2013