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
Published January 22, 2020, in The Lancet Gastroenterology & Hepatology (opens in a new window)
Cirrhosis 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.
We used data from vital registrations, vital registration samples, and verbal autopsies to estimate mortality. We modeled prevalence of total 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-standardized or age-specific rates per 100,000 population, with 95% uncertainty intervals (UIs). All estimates are presented for five causes: 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.
In 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 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-standardized 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-standardized 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-standardized death rate decreased or remained constant from 1990 to 2017 in all GBD regions except eastern Europe and central Asia, where the age-standardized death rate increased primarily due to increases in alcohol-related liver disease prevalence. At the national level, the age-standardized 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-standardized prevalence rate of decompensated cirrhosis between 1990 and 2017. Of the five causes, hepatitis B caused the greatest proportion of cirrhosis deaths (29.0%) and prevalent cases of both decompensated (27.9%) and compensated (32.6%) cirrhosis in 2017. Cirrhosis caused by NASH had a steady age-standardized death rate throughout the study period, whereas the other four causes showed declines in age-standardized death rate. The age-standardized 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. The number of prevalent cases more than doubled for compensated cirrhosis due to NASH and more than tripled for decompensated cirrhosis due to NASH. The age-standardized death and DALY rates decreased with increasing SDI, whereas age-standardized prevalence increased for decompensated cirrhosis and remained constant for compensated cirrhosis.
Cirrhosis 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 aging. Although the age-standardized 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.
GBD 2017 Cirrhosis Collaborators. 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. The Lancet Gastroenterology & Hepatology. 22 January 2020. doi: 10.1016/S2468-1253(19)30349-8.