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  The Liver Meeting
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Washington on 04-08
November 2022
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Liver-Related Mortality Soared in US After COVID-19 Arrived
  AASLD-The Liver Meeting, November 4-8, 2022, Washington, DC
Mark Mascolini
Age-standardized mortality rates for alcohol-associated liver disease (ALD) and nonalcoholic fatty liver disease (NAFLD) surged in the United States after COVID-19 arrived [1]. Higher death rates disproportionately affected the American Indians/Alaska Natives, non-Hispanic whites, and young people. Study results appeared online around the time of AASLD [2].
Researchers at Xi'an Jiaotong University in Xi'an, China integrated ICD-10 codes and data from the National Vital Statistics System to tabulate US deaths and their causes from 2010 through 2021 and to figure observed versus predicted mortality in 2020-2021 (the COVID years) based on rates reported in 2010-2019. The investigators considered four chronic liver diseases-ALD, NAFLD, HCV infection, and HBV infection-in people 25 and older.
During the 2010-2021 study period, 626,090 US adults with chronic liver disease and 25 years old and older died. ALD accounted for 55% of these deaths, HCV for 33%, NAFLD for 9%, and HBV for 3%.
For ALD, all-cause age-standardized mortality rates (ASMR) per 100,000 people jumped from 9.49 in 2010 to 17.42 in 2021, which translates into a 5.9% rise in average annual percentage change (APC). But APC for ALD rose only 3.5% in the pre-COVID years 2010-2019, then ballooned to 17.6% in the COVID years 2019-2021. Based on 2010-2019 trends, predicted ASMRs for ALD in 2020 and 2021 were 13.04 and 13.41, but actual ASMRs for those years were 15.67 and 17.42.
For NAFLD, over the whole study period all-cause ASMR climbed steadily, but the uptrend steepened sharply after 2019 to yield an APC of 14.5% during the COVID years. Predicted ASMRs for NAFLD in 2020 and 2021 were 2.64 and 2.80, but actual ASMRs came in at 3.11 and 3.44.
Reflecting steady improvement in therapy for HBV and HCV, all-cause ASMR for these infections either stayed stable or fell over the whole study period. For HCV the APC for 2014-2019 was -7.8%, but that decline slowed almost 3-fold in the COVID years 2019-2021 to -2.8%. Predicted ASMRs for HCV in 2020 and 2021 were 4.58 and 4.02, but actual ASMRs for those years were 5.28 and 4.92.
ASMRs for ALD and NAFLD rose throughout the study period for all races and ethnicities, but some racial/ethnic groups did worse than others. The steepest APC came with ALD on the cusp of the pandemic, 2018-20, among American Indians/Alaska Natives (18.0%), followed by whites (11.7%), blacks (10.8%), and Asians (4.9%). During the COVID years APCs for all-cause mortality with NAFLD rose 10.9% in American Indians/Alaska Natives, 11.9% in whites, 11.9% in blacks, 12.9% in Asians, and 13.1% in Hispanics.
Actual versus predicted ASMRs for ALD in 2020 were 88.42 versus 63.72 for American Indians/Alaska Natives, 16.52 versus 13.75 for whites, and 10.30 versus 8.62 for blacks. For NAFLD in 2020, actual versus predicted ASMRs were 8.31 versus 6.15 for American Indians/Alaska Natives, 3.44 versus 2.97 for whites, and 1.34 versus 1.03 for blacks.
Analysis by age group showed that the youngest cohort considered, 25-44, carried the heaviest load in ASMRs for ALD. APC for ASMRs increased significantly in 2019-2021 in all age groups, but the biggest change, 34.6%, came in the youngest group, compared with 13.7% for 45-to-64-year-olds and 12.6% for people 65 or older. All of these gains proved higher than APCs for ALD before COVID.
Actual ASMRs in 2020 and 2021 always outstripped predicted ASMRs for both ALD and NAFLD in every age group. For ALD in 2020 in the 25-44, 45-64, and 65+ groups, actual versus predicted ASMRs were 7.69 versus 5.26, 25.18 versus 21.86, and 17.81 versus 15.91. For ALD in 2021 in those three age groups, actual versus predicted ASMRs were 8.96 versus 5.47, 27.60 versus 22.29, and 19.48 versus 16.54.
The researchers concluded that the United States saw an "alarming rise" in all-cause and liver-related mortality among people with ALD and NAFLD during COVID years, rates that were significantly higher than those predicted from pre-COVID trends. They cited several factors that could contribute to overall increases in ASMRs during the pandemic: access to care, vulnerability to COVID, liver transplant referral rates, loss of health insurance, and COVID severity in localized areas.
1. Gao X, Lv F, He X, et al. Impact of the COVID-19 pandemic on mortality rate of liver disease in the United States: a population-based study, 2010-2021. AASLD-The Liver Meeting, November 4-8, 2022, Washington, DC. Abstract 130.
2. Gao X, Lv F, He X, et al. Impact of the COVID-19 pandemic on liver disease-related mortality rates in the United States. J Hepatol. 2022;S0168-8278(22)02994-4. doi: 10.1016/j.jhep.2022.07.028.