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. 2021 Nov 4:12:100240.
doi: 10.1016/j.lanepe.2021.100240. eCollection 2022 Jan.

Trends and the course of liver cirrhosis and its complications in Germany: Nationwide population-based study (2005 to 2018)

Wenyi Gu  1 , Hannah Hortlik  1 , Hans-Peter Erasmus  1 , Louisa Schaaf  1 , Yasmin Zeleke  1 , Frank E Uschner  1 , Philip Ferstl  1 , Martin Schulz  1 , Kai-Henrik Peiffer  1 , Alexander Queck  1 , Tilman Sauerbruch  2 , Maximilian Joseph Brol  1 , Gernot Rohde  3 , Cristina Sanchez  4 , Richard Moreau  4   5 , Vicente Arroyo  4 , Stefan Zeuzem  1 , Christoph Welsch  1 , Jonel Trebicka  1   4
Affiliations

Trends and the course of liver cirrhosis and its complications in Germany: Nationwide population-based study (2005 to 2018)

Wenyi Gu et al. Lancet Reg Health Eur. .

Abstract

Background: Cirrhosis is known to have a high prevalence and mortality worldwide. However, in Europe, the epidemiology of cirrhosis is possibly undergoing demographic changes, and etiologies may have changed due to improvements in standard of care. The aim of this population-based study was to analyze the trends and the course of liver cirrhosis and its complications in recent years in Germany.

Methods: We analyzed the data of all hospital admissions in Germany within diagnosis-related groups from 2005 to 2018. The diagnostic records of cirrhosis and other categories of diseases were based on ICD-10-GM codes. The primary outcome measurement was in-hospital mortality. Trends were analyzed through Poisson regression of annual number of admissions. The impact of cirrhosis on overall in-hospital mortality were assessed through the multivariate multilevel logistic regression model adjusted for age, sex, and comorbidities.

Findings: Of the 248,085,936 admissions recorded between 2005 and 2018, a total of 2,302,171(0•94%) were admitted with the diagnosis of cirrhosis, mainly as a comorbidity. Compared with other chronic diseases, patients admitted with cirrhosis were younger, mainly male and had the highest in-hospital mortality rate. Diagnosis of cirrhosis was an independent risk factor of in-hospital mortality with the highest odds ratio (OR:6•2[95%CI:6.1-6•3]) among all diagnoses. The prevalence of non-alcoholic fatty liver disease has increased four times from 2005 to 2018, while alcoholic cirrhosis is 20 times than other etiologies. Bleeding was found to be decreasing over time, but ascites remained the most common complication and was increasing.

Interpretation: This nationwide study demonstrates that cirrhosis represents a considerable healthcare burden, as shown by the increasing in-hospital mortality, also in combination with other chronic diseases. Alcohol-related cirrhosis and complications are on the rise. More resources and better management strategies are warranted.

Funding: The funders had no influence on this study.

Keywords: ALD, alcoholic liver diseases; DAA, direct-acting antiviral; DALYs, disability-adjusted life years; HBV, hepatitis B virus; HCV, hepatitis C virus; ICD, International Classification of Diseases; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis; OPS, operation and procedure key system; YLDs, years lived with disability; YLLs, years of life lost; cirrhosis; hospital admission; male; mortality.

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Conflict of interest statement

Jonel Trebicka has received speaking and/or consulting fees from Gore, Bayer, Alexion, MSD, Gilead, Intercept, Norgine, Grifols, Versantis, and Martin Pharmaceutical. Philip Ferstl received consultancy for SNIPR Biome. S. Zeuzem received consulting and/or lecture fees from Bayer Health Care and consultancies for AbbVie, BMS, Gilead, Janssen, Merck.

Figures

Fig 1
Fig. 1
Panel A. Flowchart of diagnosis-related groups database of German hospital admissions between 2005 and 2018. Panel B. Number of admissions with cirrhosis or its complications as main diagnosis or comorbidity for each year from 2005 to 2018. Proportion of cirrhosis admissions with regard to all admissions for each year from 2005 to 2018 was shown by dotted line. Panel C. Number of admissions of different chronic diseases as main diagnosis with cirrhosis as comorbidity for each year from 2005 to 2018.
Fig 2
Fig. 2
Panel A. Median age of patients admitted with liver cirrhosis or admitted with another chronic disease without cirrhosis from 2005 to 2018. Panel B. Median age of patients admitted with chronic diseases with and without additional diagnosis of cirrhosis from 2005 to 2018. Panel C. Percentage of male patients admitted with different chronic diseases with and without additional diagnosis of cirrhosis from 2005 to 2018.
Fig 3
Fig. 3
Panel A. In-hospital mortality rate of patients admitted with cirrhosis and diagnosis of different chronic diseases without cirrhosis for each year from 2005 to 2018. Panel B. Age-standardized in-hospital mortality rate of patients admitted with cirrhosis and diagnosis of different chronic diseases without cirrhosis for each year from 2005 to 2018. Panel C. Forest plot of odds ratios of cirrhosis as main or secondary diagnosis, and different diagnoses of chronic diseases of in-hospital mortality in all admissions from 2005 to 2018 using multivariate multilevel logistic regression. Panel D. Forest plot of odds ratios of cirrhosis as main or secondary diagnosis, and different diagnoses of chronic diseases of in-hospital mortality in all admissions from 2005 to 2018 using multivariate multilevel logistic regression. Panel E. Mortality rate of patients admitted with different diseases, with and without additional diagnosis of cirrhosis.
Fig 4
Fig. 4
Panel A. Number of patients admitted with different etiologies of cirrhosis as main diagnosis or comorbidity for each year from 2005 to 2018. Panel B. Fold changes of standardized prevalence of different etiologies of cirrhosis from 2005 to 2018, with year 2005 as reference. Panel C. Fold changes of standardized prevalence of admissions of cirrhosis in patients with and without obesity from 2008 to 2018, with year 2005 as reference. Panel D. Number of different complications in admissions with cirrhosis as main diagnosis or comorbidity for each year from 2005 to 2018. Panel E. Fold changes of standardized prevalence of different complications of cirrhosis from 2005 to 2018, with year 2005 as reference. Abbreviations: HBV, hepatitis B virus; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; HRS, hepatorenal syndrome; NAFLD, non-alcoholic fatty liver disease; NASH, non-alcoholic steatohepatitis.
Fig 5
Fig. 5
Panel A. Number of admissions and prevalence rate per 100,000 population of compensated cirrhosis in male and female patients in different age groups. Panel B. Number of admissions and prevalence rate per 100,000 population of male and female decompensated cirrhosis patients in different age groups. Panel C. Number of deaths and in-hospital mortality rate of compensated cirrhosis in male and female patients in different age groups. Panel D. Number of deaths and in-hospital mortality rate of decompensated cirrhosis in male and female patients in different age groups. Panel E. Number of DALYs and DALY rate per 100,000 population of cirrhosis in male and female patients in different age groups. Abbreviations: DALYs, disability-adjusted life years.
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