Differences in hepatocellular carcinoma risk, predictors and trends over time according to etiology of cirrhosis

Abstract

Background and aimsHepatocellular carcinoma (HCC) risk is high in cirrhosis. We sought to describe differences in HCC risk, predictors and trends over time according to etiology of cirrhosis.MethodsWe identified 116,404 patients with cirrhosis diagnosed between 2001–2014 in the VA healthcare system and determined incident HCC cases occurring from the date of cirrhosis diagnosis until 01/31/2017. Patients were divided by cirrhosis etiology into hepatitis C virus (HCV, n = 52,671), alcoholic liver disease (ALD, n = 35,730), nonalcoholic fatty liver disease (NAFLD, n = 17,354), or OTHER (n = 10,649).ResultsDuring a mean follow-up of 4.3 years, 10,042 new HCC cases were diagnosed. Patients with HCV had >3 times higher incidence of HCC (3.3 per 100 patient-years) than patients with ALD (0.86/100 patient-years), NAFLD (0.90/100 patient-years) or OTHER (1.0/100 patient-years), an association that persisted after adjusting for baseline characteristics. HCC incidence was 1.6 times higher in patients with cirrhosis diagnosed in 2008–2014 (2.47/100 patient-years) than in 2001–2007 (1.55/100 patient-years).Independent predictors of HCC among all cirrhosis etiologies included: age, male sex, Hispanic ethnicity, high serum alpha fetoprotein, alkaline phosphatase and AST/√ALT ratio and low serum albumin and platelet count. Diabetes was associated with HCC in ALD-cirrhosis and NAFLD-cirrhosis, and BMI in ALD-cirrhosis.ConclusionsHCC risk is 3 times greater in cirrhotic patients with HCV than ALD or NAFLD. HCC risk continues to increase over time in analyses extending to 2017 in cirrhosis of all etiologies. Multiple readily available risk factors for HCC were identified that were influenced by cirrhosis etiology and could be used to develop HCC risk estimation models.

Diabetes Is Associated With Increased Risk of Hepatocellular Carcinoma in Patients With Cirrhosis From Nonalcoholic Fatty Liver Disease

“…(36) A recent retrospective cohort study used a nation-wide VA database to investigate the risk factors for HCC in patients with cirrhosis. (19) This study included 116,404 patients with cirrhosis, of whom 17,354 had NAFLD as the underlying etiology of liver disease. The annual incidence rate of HCC was 0.9% per year.…”

“…(17,18) There are very few studies that have evaluated the association between diabetes and HCC in patients with NASH cirrhosis, and the results of these studies were mixed. (7,19,20) Our recent study showed that diabetes was associated with 2.1-fold increased risk of HCC in non-HCV patients with cirrhosis. (20) Because of the small number of patients with NASH cirrhosis, the association between diabetes and HCC in patients with NASH cirrhosis did not reach statistical significance (hazard ratio [HR] of 2.4; 95% confidence interval [CI] = 0.6-15.8).…”

Opioid prescriptions are associated with hepatic encephalopathy in a national cohort of patients with compensated cirrhosis

“…We identified all patients aged 18‐64 years with cirrhosis, defined as the presence of two or more International Classification of Diseases, Ninth Revision (ICD‐9) codes for cirrhosis (571.5 or 571.2) on separate dates. Previous validation studies have demonstrated that the presence of two outpatient ICD‐9 codes improves the positive predictive value of correctly identifying cirrhosis based on a gold standard of medical record review . The ‘diagnosis date’ of cirrhosis was defined as the first ICD‐9 code present in the database.…”

“…Previous validation studies have demonstrated that the presence of two outpatient ICD-9 codes improves the positive predictive value of correctly identifying cirrhosis based on a gold standard of medical record review. 17,18 The 'diagnosis date' of cirrhosis was defined as the first ICD-9 code present in the database.…”

Editorial: hepatocellular carcinoma in the absence of cirrhosis—a nightmare without solution

“…However, the denominator of patients with NAFLD in the catchment area of each medical centre could be in the thousands. In fact, the risk of HCC in patients with NAFLD was recently estimated to be 0.021 per 100 patient‐years, which is substantially lower than the risk in patients with cirrhosis (1‐3 per 100 patient‐years) . The sensitivity and specificity of currently available HCC screening tests (ultrasonography and serum AFP) are too low and the costs and harms of subsequent confirmatory tests for screen‐positive patients (liver biopsy, multiphasic MRI and CT) are too high for screening in pre‐cirrhotic liver disease to be a sensible and cost‐effective proposition.…”