Liver Disease: More Than An Epidemic

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Liver disease has become an epidemic in the United States. Despite new therapies on almost all fronts, the incidence of new liver disease is clearly on the rise and nearly one in three Americans have some type of it. While the vast majority will have significant but non-life threatening disease, the country is experiencing a significant rise in liver related deaths. Cirrhosis, a consequence of all chronic liver diseases, is characterized by complications such as liver cancer, ascites, gastrointestinal bleeding, encephalopathy, infections and kidney failure. These complications can be fatal, utilize significant health care resources and carry personal, social and financial burdens on patients and their families.

From 1999 to 2016, annual deaths from cirrhosis increased in the U.S. by 65 percent and annual deaths from liver cancer doubled to more than 11,000 per year. Deaths due to cirrhosis are expected to triple by 2030 and the National Cancer Institute has stated that primary liver cancer is the solid organ cancer whose incidence is increasing the most, even more than lung, breast, colon and pancreas. These statistics beg the question of why and where are deaths from cirrhosis so dramatically on the rise. With hepatitis C on the way to eradication with new curative therapies and hepatitis B being controlled with effective therapies, the increase in deaths from cirrhosis is driven by an increasing prevalence of alcoholic and non-alcoholic fatty liver diseases.

Increases in deaths due to liver disease were greatest amongst the Caucasian, Hispanic-American and Native American populations. All U.S. states showed an increase in cirrhosis related deaths except Maryland. The areas of the country with the highest increase in deaths were the South and West with Kentucky, New Mexico, Arkansas, Indiana and Alabama. All states had significant increases in deaths from liver cancer, with Arizona and Kansas leading the pack. New York, while experiencing an increase in liver related deaths and liver cancer, has seen a slower increase than most of the remainder of the country. New York ranks 45th in alcohol related cirrhosis while Louisiana and California are first with the highest number of people with alcoholic related cirrhosis.

Most concerning is that people aged 25-34, regardless of race or gender, experienced the greatest rise in cirrhosis related mortality and this is entirely driven by alcohol related liver disease. For the record, it takes a lot of alcohol to develop cirrhosis at an early age. Alcohol use and abuse among young people, even teenagers, is on the rise. It is perhaps an even greater problem than the catastrophic opioid epidemic sweeping the nation. The rapid increase in deaths from alcoholic cirrhosis among young people brings new challenges to health care.

How can we intervene to prevent alcohol-related disease when most people aged between 25-34 rarely seek preventive medical care and only present when something dramatic has occurred? It takes a good 10 years or more of active drinking to develop cirrhosis. If we are to intervene to prevent alcoholic cirrhosis from occurring at age 25-34 then we need to begin discussions with children as early as elementary or middle school.

Morbidity and mortality from liver disease is increasing across the country. The two conditions that account for this are alcohol and non-alcohol related fatty liver disease. Both of these conditions are preventable with education and behavioral modification. It seems a prudent idea for our health care system to allocate significant dollars on disease prevention, education and behavior modification. This will save money and lives in the future. I urge our policy makers to take this approach, especially in the west and south where the problem is the greatest and the resources allocated the least.

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