Multivariable-adjusted trends in mortality due to alcoholic liver disease among adults in the United States, from 1999-2017

Abstract

OBJECTIVE: Mortality-trends from alcoholic liver disease (ALD) have recently increased and they differ by various factors in the U.S. However, these trends have only been analyzed using univariate models and in reality they may be influenced by various factors. We thus examined trends in age-standardized mortality from ALD among U.S. adults for 1999-2017, using multivariable piecewise log-linear models. METHODS: We collected mortality-data from the Centers for Disease Control and Prevention Wide-ranging Online Data for Epidemiologic Research database, using the Underlying Cause of Death. RESULTS: We identified 296,194 deaths from ALD and 346,386 deaths indirectly attributable to ALD during the period from 1999-2017. The multivariable-adjusted, age-standardized ALD mortality was stable during 1999-2006 (annual percentage change [APC]=-2.24, P=0.24), and increased during 2006-2017 (APC=3.18, P<0.006). Their trends did not differ by sex, race, age or urbanization. Subgroup analyses revealed upward multivariable-adjusted, age-standardized mortality-trends in alcoholic fatty liver (APC=4.64, P<0.001), alcoholic hepatitis (APC=4.38, P<0.001), and alcoholic cirrhosis (APC=5.33, P<0.001), but downward mortality-trends in alcoholic hepatic failure (APC=-1.63, P=0.006) and unspecified ALD (APC=-0.86, P=0.013). Strikingly, non-alcoholic cirrhosis also had an upward multivariable-adjusted, age-standardized mortality-trend (APC=0.69, P=0.046). By contrast, recent mortality-trends were stable for all cause of deaths (APC=-0.39, P=0.379) and downward for malignant neoplasms excluding liver cancer (APC=-2.82, P<0.001), infections (APC=-2.60, P<0.001), cardiovascular disease (APC=-0.69, P=0.044) and respiratory disease (APC=-0.56, P=0.002). The adjusted mortality with ALD as a contributing cause of death also had an upward trend during 2000-2017 (APC=5.47, P<0.001). Strikingly, common comorbidities of ALD, including hepatocellular carcinoma, cerebrovascular and ischemic heart cardiovascular diseases and sepsis, had upward trends during the past 14 to 16 years. CONCLUSIONS: ALD had an upward multivariable-adjusted, age-standardized mortality-trend among U.S. adults, without significant differences by sex, race, age or urbanization. Three ALD subtypes (alcoholic fatty liver, alcoholic hepatitis and alcoholic cirrhosis) and non-alcoholic cirrhosis had upward morality-trends, while other ALD subtypes and other causes of death did not.