Abstract
OBJECTIVE:
Little is known about metabolic factors in cirrhotic patients in China. Therefore, we aimed to quantify the prevalence of both metabolic factors and non-alcoholic steatohepatitis-related liver cirrhosis in China.
METHODS:
The medical records of 1,582 patients diagnosed with liver cirrhosis from June 2003 to July 2013 at Daping Hospital (Chongqing, China) were retrospectively reviewed through a computer-generated search.
RESULTS:
Serum hepatitis B virus surface antigen was present in 1,083 (68.5%) patients, and hepatitis B was found to be the only etiological factor in 938 (59.3%) of all patients. Obesity, diabetes mellitus, and arterial hypertension were observed in 229 (14.5%), 159 (10.1%), and 129 (8.2%) patients, respectively. From 2012-2013, the proportion of non-alcoholic steatohepatitis-related liver cirrhosis increased to 3.2%, whereas the average proportion of non-alcoholic steatohepatitis-related liver cirrhosis in the previous ten years was 1.9%. The incidence of hepatocellular carcinoma was much higher in males than in females (6.3% vs. 3.7%, respectively, p=0.036). Obesity and diabetes mellitus did not significantly increase the incidence of hepatocellular carcinoma in the whole cirrhotic group. The presence of hepatitis B virus was the only risk factor for hepatocellular carcinoma in cirrhotic patients (p<0.001).
CONCLUSIONS:
Although hepatitis B virus remains the main etiology of liver cirrhosis in China, steatohepatitis-related liver cirrhosis is increasing in frequency. Hepatitis B virus was the sole significant risk factor for hepatocellular carcinoma in the whole cirrhotic group in the present study, in contrast to obesity and diabetes mellitus, for which only a trend of increased hepatocellular carcinoma was found.
Non-Alcoholic Steatohepatitis; Non-Alcoholic Fatty Liver Disease; Liver Cirrhosis; Obesity; Metabolism
INTRODUCTION
The main etiology of liver cirrhosis (LC) in China is hepatitis B virus (HBV)
infection (11. Liang X, Bi S, Yang W, Wang L, Cui G, Cui F, et al.
Epidemiological serosurvey of hepatitis B in China--declining HBV prevalence due
to hepatitis B vaccination. Vaccine. 2009;27(47):6550-7,
10.1016/j.vaccine.2009.08.048.
http://dx.doi.org/10.1016/j.vaccine.2009...
). However, the changing
proportions of the various potential etiological factors over the last 10 years
remain poorly documented, especially the presence of metabolic characteristics such
as obesity (or increased body mass index [BMI]), diabetes mellitus (DM),
hypertension and alcoholism. In Western countries, non-alcoholic steatohepatitis
(NASH)-related cirrhosis is increasingly considered as a major causal factor of
cirrhosis. Moreover, hepatocellular carcinoma (HCC) is related to NASH-related
cirrhosis in Germany (22. Schutte K, Kipper M, Kahl S, Bornschein J, Gotze T, Adolf D, et
al. Clinical characteristics and time trends in etiology of hepatocellular
cancer in Germany. Digestion. 2013;87(3):147–59,
10.1159/000346743.
http://dx.doi.org/10.1159/000346743...
). For several
possible reasons, few data exist regarding NASH-related LC in China. First,
NASH-related cirrhosis is diagnosed by exclusion, and ruling out all other possible
causes is difficult. Second, the histological characteristic features of
non-alcoholic fatty liver disease (NAFLD) such as fatty infiltration tend to be lost
in NASH-related cirrhosis (33. Nayak NC, Vasdev N, Saigal S, Soin AS. End-stage nonalcoholic
fatty liver disease: evaluation of pathomorphologic features and relationship to
cryptogenic cirrhosis from study of explant livers in a living donor liver
transplant program. Hum Pathol. 2010;41(3):425–30,
10.1016/j.humpath.2009.06.021.
http://dx.doi.org/10.1016/j.humpath.2009...
). Third, there
is a lack of strict criteria for diagnosing NASH-related cirrhosis. According to one
nationwide Japanese survey, 2.1% of cirrhosis cases were attributable to
NASH-related cirrhosis based on the researchers’ own criteria, which mainly
diagnosed NASH-related cirrhosis as cryptogenic cirrhosis associated with obesity
(BMI over 25), DM or metabolic syndrome (Met-s) (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
).
If appropriate criteria are used, NASH-related cirrhosis may account for two thirds
of cases currently labeled as cryptogenic cirrhosis (33. Nayak NC, Vasdev N, Saigal S, Soin AS. End-stage nonalcoholic
fatty liver disease: evaluation of pathomorphologic features and relationship to
cryptogenic cirrhosis from study of explant livers in a living donor liver
transplant program. Hum Pathol. 2010;41(3):425–30,
10.1016/j.humpath.2009.06.021.
http://dx.doi.org/10.1016/j.humpath.2009...
). Herein, we retrospectively analyzed etiological factors in LC in
patients admitted to our hospital over the past 10 years to evaluate the proportion
and time trend of NASH-related LC, with special emphasis on the factors favoring HCC
development.
PATIENTS AND METHODS
The medical records of patients diagnosed with LC from June 2003 to July 2013 at Daping Hospital (Chongqing, China) were retrospectively reviewed through a computer-generated search. The study included 1,582 patients.
LC was diagnosed based on clinical symptoms, imaging data, and/or histological
findings (only 41 patients had a liver biopsy in the present series). Classical
criteria for each etiology potentially involved in LC were applied to categorize
cirrhotic patients. For NASH-related LC, we adopted the following criteria. First,
all NASH-related LC had to be cryptogenic LC and had to be coupled with alcohol
consumption of less than 20 grams per day. Second, the BMI of each patient had to be
over 25, with or without DM or Met-s; this was slightly different from the Japanese
criteria (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
), which did not include obesity
as a necessary criterion. If the above two criteria were met, then the patient was
clinically suspected of having NASH-related LC. Furthermore, if histological
findings such as micronodular cirrhosis, perisinusoidal fibrosis or fatty changes
were found, then the patient was histologically diagnosed with NASH-related LC.
Among the 30 patients diagnosed with NASH-related LC, only one patient was
histologically diagnosed with NASH-related LC by liver biopsy.
Clinical information (age, gender, alcohol consumption, virus infection, hepatic complications) was also collected for all patients with LC. Metabolic risk factors such as obesity, DM and arterial hypertension were systematically collected based on the diagnostic history. The Child-Pugh criteria were used to grade cirrhosis.
Statistical analysis
The dichotomous data and continuous data were analyzed by the chi-square test and Student’s t test, respectively, using Statistical Package for the Social Sciences (SPSS, version 15.0; Chicago, IL, USA). Logistic regression was used to analyze the selected risk factors for HCC. When examining the differences between males and females, Fisher’s exact test and the Mann-Whitney U test were also used. A p-value of <0.05 was considered statistically significant.
RESULTS
Etiology of LC
A total of 1,582 patients diagnosed with LC from 2003-2013 were included in this retrospective study. A total of 1,097 (69.4%) patients were male, 485 (30.6%) were female, and 87 (5.5%) were diagnosed with HCC during hospitalization.
In our study, 14 etiological categories were set for LC (Table 1). The most common etiology was HBV; hepatitis B surface antigen (HBs Ag) was present in the sera of 1,083 (68.5%) patients. HBV was found to be the only etiological factor in 938 (59.3%) patients. Hepatitis C virus (HCV) accounted only for 1.8% of cases (1.0% of patients had HCV alone, 0.5% had HCV combined with HBV, and 0.3% had HCV combined with alcohol abuse). Hepatitis E virus combined with HBV was found in only two patients. In total, 298 (18.7%) patients had a history of alcohol abuse (135 of them also had HBV infection, and 5 patients also had HCV infection; alcohol was the dominant factor in 158 patients). There were 32 patients with autoimmune hepatitis (AIH), 69 patients with primary biliary cirrhosis (PBC), 4 patients with AIH combined with PBC, and 6 patients with Wilson’s disease. For NASH-related LC, 30 patients (1.9%) met our criteria. Thirteen patients had other identified etiologies, including intra-hepatic bile-duct stones (9 patients), Budd-Chiari syndrome (2 patients), parasitic infection (1 patient), and veno-occlusive disease (1 patient). The remaining 167 patients had cryptogenic LC, as defined by the absence of identified causes, including NASH-related LC criteria.
Etiological differences between males and females
HBV was clearly the main etiology in both males and females (59.8% vs. 57.9%, respectively, p>0.05) (Figure 1). The percentages of patients with alcohol abuse, HBV plus alcohol abuse, and HCV plus alcohol abuse were higher in males vs. females (11.2% vs. 1.0%, p<0.01; 12.2% vs. 0.2%, p<0.01; and 0.5% vs. 0%, p<0.01, respectively). However, the percentages of AIH and PBC were much higher in females vs. males (4.9% vs. 0.7%, p<0.01; 12.6% vs. 0.7%, p<0.01, respectively). No difference between males and females existed for NASH-related LC (1.7% vs. 2.3%, respectively, p=0.47).
Time trend of metabolic factors and HCC in cirrhotic patients
The metabolic information recorded during the periods from 2003-2008 and 2008-2013 was compared (Table 2). Whereas the total number of patients from 2008-2013 was two times higher than the number in the period from 2003-2008 (1,091 and 491, respectively), no significant differences were noted in terms of age, sex ratio, or BMI between the two time periods. Trends of increased obesity, DM, hypertension and HBs Ag positivity were observed in the second five-year period. In contrast, the proportion of HCC significantly decreased in the period from 2008-2013 (4.7% vs. 7.3%, p=0.033) (Table 2).
NASH-related LC
Among the total of 197 patients with cryptogenic LC, 30 patients met our criteria for NASH-related LC. As shown in Figure 2, the proportion of NASH-related LC increased in the last two years of the study to 3.2%, compared with 1.9% for the whole study period.
Among the 30 patients with NASH-related LC, 19 patients were men, and 11 were women (no statistical significance). Ascites and upper gastrointestinal bleeding (UGB) were the main complications in patients with NASH-related LC, and the complication rate of both ascites and UGB was higher in women, but the difference was not significant. For Child-Pugh grading of NASH-related LC, the rate of Child A was lower in women than in men, but the difference was not significant. HCC was not found in women or men with NASH-related LC. (Table 3).
Selected risk factors for HCC
Among the 87 patients with HCC, 69 patients were men, and 18 patients were women. As shown in Table 4, only the sex ratio (male to female) and HBs Ag positivity rate were significantly increased in HCC patients compared with non-HCC patients (p<0.05) by univariate analysis. Metabolic factors, which included obesity, DM, and hypertension, were not significantly different between men and women. HBs Ag positivity was the sole risk factor for HCC in cirrhotic patients (p<0.001) in a multivariate analysis. Obesity and DM did not increase the HCC incidence in the whole cirrhotic group (5.7% vs. 5.5%, respectively, p=0.862; 5.0% vs. 5.6%, respectively, p=0.849). However, among patients with cirrhosis induced only by HBV, a trend of increased rates of HCC in obese and DM patients was found (8.4% vs. 6.5%, respectively, p=0.436; 7.1% vs. 6.7%, respectively, p=0.589).
DISCUSSION
In our study, HBV remained the main etiological factor (68.5%) for LC in China,
whereas HCV was by far the most frequent cause of cirrhosis (60.9%) according to a
nationwide survey in Japan (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
). HCV accounted
for only 1.8% of our cirrhotic patients. Alcoholic liver disease and hepatitis C are
the most common causes of cirrhosis in the Western world, whereas hepatitis B is the
prevailing cause in most parts of Asia and sub-Saharan Africa (55. Schuppan. D, Afdhal. NH. Liver cirrhosis. Lancet.
2008;371(9615):838–51, 10.1016/S0140-6736(08)60383-9.
http://dx.doi.org/10.1016/S0140-6736(08)...
). For example, in the United Kingdom (66. Fleming KM, Aithal GP, Solaymani-Dodaran M, Card TR, West J.
Incidence and prevalence of cirrhosis in the United Kingdom, 1992-2001: A
general population-based study. J Hepatol. 2008;49(5):732–8,
10.1016/j.jhep.2008.05.023.
http://dx.doi.org/10.1016/j.jhep.2008.05...
), a total of 3,360 incident cases of cirrhosis in patients
aged 25 or older were diagnosed with LC between 1992 and 2001, and 35.9% of these
cases were induced by alcohol, whereas only 5.4% were induced by viral hepatitis. In
the USA, 7% of cirrhosis cases were attributable to HBV, and 27% were to HCV from
1989-2000(77. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The
contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis
and primary liver cancer worldwide. J Hepatol. 2006;45(4):529–38,
10.1016/j.jhep.2006.05.013.
http://dx.doi.org/10.1016/j.jhep.2006.05...
). Globally, 57% of cirrhosis
cases were attributable to either HBV (30%) or HCV (27%) (77. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The
contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis
and primary liver cancer worldwide. J Hepatol. 2006;45(4):529–38,
10.1016/j.jhep.2006.05.013.
http://dx.doi.org/10.1016/j.jhep.2006.05...
). In China, as reported in our study, 59.3% of cirrhosis
cases were only related to HBV infection. In a large community-based study in
eastern China (88. Huang P, Zhu LG, Zhai XJ, Zhu YF, Yue M, Su J, et al. Hepatitis C
virus infection and risk factors in the general population: a large
community-based study in eastern China, 2011–2012. Epidemiol Infect. 2015;Jan
20:1–10.), a total of 149,175
individuals were investigated in 60 communities in three counties in Jiangsu
province from 2011-2012. Of these subjects, 1,175 (0.79%, 95% confidence interval
(CI) 0.74-0.83) were anti-HCV antibody positive. The prevalence was even lower in
children (0.09%, 95% CI 0.04-0.17). A seroepidemiological survey of HCV conducted in
2007 revealed a lower rate of anti-HCV antibody positivity (0.80%) in Chongqing,
Southwest China than in the general population (99. Qing Wang, Lianyou Hu, Daihong Zhao, Sun M. Seroepidemiological
Survey and Analysis of Virus Hepatitis C in Chongqing. J Prev Med Inf.
2007;23(2):152–4.). Thus, the prevalence of hepatitis C as a cause of LC is low in
Chongqing, China.
The difference between Asia or sub-Saharan Africa and the Western world may be
related to the wide implementation of HBV programs, which has not been financially
possible in numerous developing countries. In 1992, the World Health Organization
(WHO) recommended that all countries include a hepatitis B vaccine in their routine
infant immunization programs. As of 2003, the WHO/UNICEF estimated 42% hepatitis B
vaccination coverage in the global birth cohort (77. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The
contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis
and primary liver cancer worldwide. J Hepatol. 2006;45(4):529–38,
10.1016/j.jhep.2006.05.013.
http://dx.doi.org/10.1016/j.jhep.2006.05...
). In China, the HBV infection prevalence decreased from 9.7% (in 1992)
to 7.2% (in 2006) after the introduction of a universal HBV vaccination program in
1988 (1010. Tanaka M, Katayama F, Kato H, Tanaka H, Wang J, Qiao YL, et al.
Hepatitis B and C Virus Infection and Hepatocellular Carcinoma in China: A
Review of Epidemiology and Control Measures. Journal of Epidemiology.
2011;21(6):401–16, 10.2188/jea.JE20100190.
http://dx.doi.org/10.2188/jea.JE20100190...
). However, in our study, we did not
observe the theoretically expected decrease in the development of HBV-induced LC,
possibly because HBV infection was present prior to the start of the vaccination
campaign; the development of cirrhosis usually requires a long period of time (1111. Yim HJ, Lok AS. Natural history of chronic hepatitis B virus
infection: what we knew in 1981 and what we know in 2005. Hepatology. 2006;43(2
Suppl 1):S173–81.). Nevertheless, the efficacy of the Chinese
HBV immunization program is indicated by the decreased prevalence of HBV carrier
status to 2.1% among all children and to 1.0% among those born after 1999, together
with the presence of anti-HBs antibodies (11. Liang X, Bi S, Yang W, Wang L, Cui G, Cui F, et al.
Epidemiological serosurvey of hepatitis B in China--declining HBV prevalence due
to hepatitis B vaccination. Vaccine. 2009;27(47):6550-7,
10.1016/j.vaccine.2009.08.048.
http://dx.doi.org/10.1016/j.vaccine.2009...
,1212. Liang X, Bi S, Yang W, Wang L, Cui G, Cui F, et al. Evaluation
of the impact of hepatitis B vaccination among children born during 1992–2005 in
China. J Infect Dis. 2009;200(1):39–47, 10.1086/599173.
http://dx.doi.org/10.1086/599173...
). Therefore, it is likely
that HBV-related etiology of Chinese LC will be significantly reduced in the
future.
In Western countries, NAFLD is now considered to be the most common cause of chronic
liver disease, with 20–30% of the total population presenting with NAFLD (1313. Michelotti GA, Machado MV, Diehl AM. NAFLD, NASH and liver
cancer. Nat Rev Gastroenterol Hepatol. 2013;10(11):656–65,
10.1038/nrgastro.2013.183.
http://dx.doi.org/10.1038/nrgastro.2013....
,1414. Vernon G, Baranova A, Younossi ZM. Systematic review: the
epidemiology and natural history of non-alcoholic fatty liver disease and
non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther.
2011;34(3):274–85, 10.1111/apt.2011.34.issue-3.
http://dx.doi.org/10.1111/apt.2011.34.is...
).
In China, NAFLD affects approximately 15% of adults and is present in 68.5% of obese
children (1515. Fan JG. Epidemiology of alcoholic and nonalcoholic fatty liver
disease in China. J Gastroenterol Hepatol. 2013;28 Suppl
1:11–7.,1616. Fan JG, Farrell GC. Epidemiology of non-alcoholic fatty liver
disease in China. J Hepatol. 2009;50(1):204–10,
10.1016/j.jhep.2008.10.010.
http://dx.doi.org/10.1016/j.jhep.2008.10...
). The proportion of NASH-related LC (1.9%) in our study was similar
to that in Japan (2.1%) (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
). However, our
study was retrospective and may not represent the incidence of LC in the general
population. In our study, an increasing frequency was noted over the ten years
covered by the study; this trend is likely to result in a significant increase in
patients with NASH-related LC in the future.
A limitation of the current study, especially in the context of a retrospective study, is that diagnosing LC related to NASH requires a BMI higher than 25. However, our criteria were based on those adopted by the Japanese nationwide study, with the difference that a BMI higher than 25 was necessary but not the sole criterion to consider cryptogenic cirrhosis as NASH-related cirrhosis because abnormal glucose metabolism, arterial hypertension and high triglyceride levels in the patients were also considered. Although NASH can be found in lean patients, the identification of metabolic features or performance of a liver biopsy is required for an accurate diagnosis. Due to the retrospective nature of our study, we could not document the number of lean patients; thus, we adopted a BMI higher than 25 as a necessary criterion. Notably, a liver biopsy may lack relevant metabolic features when cirrhosis is present and therefore may not always contribute to determining the etiology.
Although we considered obesity and DM in our study when diagnosing NASH-related LC, we did not find significant differences in the proportions of obesity, DM and hypertension when comparing the 2003-2008 and 2008-2013 time periods.
Several studies have reported that Met-s (obesity or DM) not only promotes the
development of LC but also increases the risk of HCC (1717. Caldwell SH, Crespo DM, Kang HS, Al-Osaimi AMS. Obesity and
hepatocellular carcinoma. Gastroenterology. 2004;127(5):S97-S103,
10.1053/j.gastro.2004.09.021.
http://dx.doi.org/10.1053/j.gastro.2004....
–1919. Mena A, Pedreira JD, Castro A, Lopez S, Vazquez P, Poveda E.
Metabolic syndrome association with fibrosis development in chronic hepatitis B
virus inactive carriers. J Gastroenterol Hepatol. 2014;29(1):173–8,
10.1111/jgh.2014.29.issue-1.
http://dx.doi.org/10.1111/jgh.2014.29.is...
). In China,
obesity has become an important health problem because the prevalence of obesity in
adults, which was 7.1% in 2002, has increased by 97.2% since 1992 (2020. Kristi R DG, Paul KW, Xigui Wu. Prevalence and risk factors of
overweight and obesity in China. Brief Epidemiologic Report.
2007;15(1):10–8.,2121. CM C. Overview of obesity in Mainland China. Obesity reviews.
2008;9(suppl 1):14–21.).
In children, a dramatic increase in obesity has been observed, with a two- to
three-fold increase in Beijing and Shanghai between 1985 and 1995. In addition, the
prevalence of overweight and obese children approached 29% in 2000 in 7- to
12-year-old boys and 15–17% in girls (2121. CM C. Overview of obesity in Mainland China. Obesity reviews.
2008;9(suppl 1):14–21.). A
2013 study from Tianjing, China, also found that the prevalence of obesity in
children under 7 years old approached 8.2% (2222. Dongdong Liu WL, Gongshu Liu. Survey on obesity of 24343
children under 7 years old in Tianjing. Zhong Guo Fu You Bao Jian.
2013;28(22):3646–7.). These data illustrate the rapid development of obesity in both
adults and children. In the USA, data from the 2009-2010 National Health and
Nutrition Examination Survey reveal that 36% of Americans are obese and that 30% of
the general adult population may have NAFLD (2323. Corey KE, Kaplan LM. Obesity and liver disease: the epidemic of
the twenty-first century. Clin Liver Dis. 2014;18(1):1–18,
10.1016/j.cld.2013.09.019.
http://dx.doi.org/10.1016/j.cld.2013.09....
). In the USA, the yearly cumulative HCC incidence in NASH-related LC
was 2.6%, compared with 4.0% among patients with HCV-related cirrhosis, over an
average follow-up period of 3.2 years (2424. Ascha MS, Hanouneh IA, Lopez R, Tamimi TA, Feldstein AF, Zein
NN. The incidence and risk factors of hepatocellular carcinoma in patients with
nonalcoholic steatohepatitis. Hepatology. 2010;51(6):1972–8,
10.1002/hep.23527.
http://dx.doi.org/10.1002/hep.23527...
).
Therefore, the rapid development of obesity in China could be contributing to an
increase in NAFLD, leading to the increased prevalence of NASH-related LC shown in
our study. The importance of obesity in the natural history of NASH-related LC
explains why we decided to integrate this risk factor as a necessary criterion for
diagnosing NASH-related LC in our study.
Although the increases in NASH-related LC and obesity may lead to a higher incidence
of HCC, we unexpectedly found that the HCC incidence was significantly lower in the
time period from 2008-2013 than in the period from 2003-2005. Another recent study,
which used data from the Cancer Registration Database records in Shanghai, China,
also noted a decreasing HCC incidence (2525. Jing Gao CW, Li Xie, Pingping Bao. Incidence and mortality of
primary liver cancer in Shanghai, 2006-2008. Tumor.
2012;32(7):526–30.).
This study additionally found that the age-standardized incidence rates for each
year and the age-standardized mortality rates decreased from 2006-2008 and that the
incidence and mortality rates increased with age. The incidence and mortality rates
of primary liver cancer were relatively higher in the suburbs than in urban areas
and were also higher in males than in females. Additionally, a study from Taiwan
found that male gender was a risk factor for HCC, which is in accordance with our
results based on univariate analysis. However, DM and obesity were not associated
with HCC in areas where either HBV or HCV was endemic (2626. Chen CT, Chen JY, Wang JH, Chang KC, Tseng PL, Kee KM, et al.
Diabetes mellitus, metabolic syndrome and obesity are not significant risk
factors for hepatocellular carcinoma in an HBV- and HCV-endemic area of Southern
Taiwan. Kaohsiung J Med Sci. 2013;29(8):451–9,
10.1016/j.kjms.2012.12.006.
http://dx.doi.org/10.1016/j.kjms.2012.12...
). In our study, obesity and DM were not associated with HCC
in the whole cirrhotic population, in accordance with the Taiwanese study. However,
when considering only the HBV-related cirrhotic subgroup, we observed a
statistically insignificant trend of increased HCC in patients who were obese or
diabetic. The prevalence of NAFLD-related HCC is rising worldwide: 4–22% of HCC
cases in Western countries are now attributed to NAFLD (1313. Michelotti GA, Machado MV, Diehl AM. NAFLD, NASH and liver
cancer. Nat Rev Gastroenterol Hepatol. 2013;10(11):656–65,
10.1038/nrgastro.2013.183.
http://dx.doi.org/10.1038/nrgastro.2013....
). Additionally, 10–75% of cases of NAFLD-related HCC occur
in patients without cirrhosis (2727. Kawada N, Imanaka K, Kawaguchi T, Tamai C, Ishihara R, Matsunaga
T, et al. Hepatocellular carcinoma arising from non-cirrhotic nonalcoholic
steatohepatitis. J Gastroenterol. 2009;44(12):1190–4,
10.1007/s00535-009-0112-0.
http://dx.doi.org/10.1007/s00535-009-011...
,2828. Yasui K, Hashimoto E, Tokushige K, Koike K, Shima T, Kanbara Y,
et al. Clinical and pathological progression of non-alcoholic steatohepatitis to
hepatocellular carcinoma. Hepatol Res. 2012;42(8):767–73,
10.1111/hepr.2012.42.issue-8.
http://dx.doi.org/10.1111/hepr.2012.42.i...
). A higher BMI in childhood increases the
risk of primary liver cancer in adults (2929. Berentzen TL, Gamborg M, Holst C, Sorensen TI, Baker JL. Body
mass index in childhood and adult risk of primary liver cancer. J Hepatol.
2014;60(2):325–30, 10.1016/j.jhep.2013.09.015.
http://dx.doi.org/10.1016/j.jhep.2013.09...
).
In our study, HCC was not found in patients with NASH-related LC, whereas HCC was
present in 31.5% of NASH-related LC cases in the Japanese nationwide study (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
). A study from England found that NAFLD
accounted for 41 (34.8%) cases of HCC in2010 (3030. Jessica Dyson BJ, Dipankar Chattopadyhay, Rajiv Lochan, Janine
Graham, Debasish Das. Hepatocellular cancer: The impact of obesity, type 2
diabetes and a multidisciplinary team. Journal of hepatology. 2014;60:110–7,
10.1016/j.jhep.2013.08.011.
http://dx.doi.org/10.1016/j.jhep.2013.08...
). Another study on HCC from Germany also found an increasing
proportion of NASH in HCC patients (22. Schutte K, Kipper M, Kahl S, Bornschein J, Gotze T, Adolf D, et
al. Clinical characteristics and time trends in etiology of hepatocellular
cancer in Germany. Digestion. 2013;87(3):147–59,
10.1159/000346743.
http://dx.doi.org/10.1159/000346743...
). With
the promotion of an HBV vaccination program and the improvement of economic
development, this type of time trend may also occur in China. Therefore, we should
expand our attention from patients with cirrhosis caused by chronic viral hepatitis
to those with cirrhosis induced by NASH in the future. Additionally, patients with
NASH-related LC must be followed in the coming decades, paying special attention to
the effects in obese children, as the vaccination program has protected them from
HBV.
For NASH-related LC, we found that female patients were older than males and that the
rates of complications and Child-Pugh grade C tended to be higher in women, which is
in accordance with the Japanese nationwide study (44. Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M.
Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol.
2010;45(1):86-94, 10.1007/s00535-009-0128-5.
http://dx.doi.org/10.1007/s00535-009-012...
). However, the difference in our study was not significant, possibly
due to the small sample size. The epidemiological study in Japan observed a higher
NAFLD prevalence in men than in women. However, in contrast to men, NAFLD increased
with age in women, showing a higher prevalence among women aged 40-49 years and
after menopause (3131. Rodrigues MH, Bruno AS, Nahas-Neto J, Santos ME, Nahas EA.
Nonalcoholic fatty liver disease and metabolic syndrome in postmenopausal women.
Gynecol Endocrinol. 2014;30(5):325–9,
10.3109/09513590.2013.875992.
http://dx.doi.org/10.3109/09513590.2013....
). Aging is considered as
a risk factor for NAFLD in pre-menopausal women (3232. Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T.
Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal
women. World J Gastroenterol. 2012;18(3):237–43,
10.3748/wjg.v18.i3.237.
http://dx.doi.org/10.3748/wjg.v18.i3.237...
). Our study showed an average age of 60 years for women who developed
NASH-related LC, indicating that they were menopausal women. Because estradiol has
been reported to attenuate hepatic stellate cell activation and therefore decrease
the fibrotic process (3333. Shimizu I, Ito S. Protection of estrogens against the
progression of chronic liver disease. Hepatol Res. 2007;37(4):239–47,
10.1111/hep.2007.37.issue-4.
http://dx.doi.org/10.1111/hep.2007.37.is...
), estradiol
diminution after menopause might contribute to the development of NASH-related
cirrhosis.
Our study has several limitations. First, because the study was retrospective, it was not possible to collect certain important metabolic parameters such as blood glucose for all cirrhotic patients, which may have led to underestimation of the rate of DM in LC. Second, histological data were rarely obtained for our patients, which confined the diagnosis of NASH-related cirrhosis to clinical, biochemical, and imaging data. However, it should be recalled that when cirrhosis is histologically present, the etiological features may disappear, so a liver biopsy may not be able to ascertain NASH-related cirrhosis. Third, the relatively small number of NASH-related LC cases might explain the absence of significant differences when considering important risk factors reported in other studies. Finally, the history of NAFLD and the duration of obesity or DM could not be obtained from the database.
In conclusion, HBV remains the main etiology of LC in China. However, NASH-related LC has clearly increased in frequency in recent years. Further studies are warranted to evaluate the exact importance of obesity and diabetes in HCC development in the overall cirrhotic population.
ACKNOWLEDGMENTS
This work was supported by the National Natural Science Foundation of China (Grant No. 81170382 and 81200297).
REFERENCES
-
1Liang X, Bi S, Yang W, Wang L, Cui G, Cui F, et al. Epidemiological serosurvey of hepatitis B in China--declining HBV prevalence due to hepatitis B vaccination. Vaccine. 2009;27(47):6550-7, 10.1016/j.vaccine.2009.08.048.
» http://dx.doi.org/10.1016/j.vaccine.2009.08.048 -
2Schutte K, Kipper M, Kahl S, Bornschein J, Gotze T, Adolf D, et al. Clinical characteristics and time trends in etiology of hepatocellular cancer in Germany. Digestion. 2013;87(3):147–59, 10.1159/000346743.
» http://dx.doi.org/10.1159/000346743 -
3Nayak NC, Vasdev N, Saigal S, Soin AS. End-stage nonalcoholic fatty liver disease: evaluation of pathomorphologic features and relationship to cryptogenic cirrhosis from study of explant livers in a living donor liver transplant program. Hum Pathol. 2010;41(3):425–30, 10.1016/j.humpath.2009.06.021.
» http://dx.doi.org/10.1016/j.humpath.2009.06.021 -
4Michitaka K, Nishiguchi S, Aoyagi Y, Hiasa Y, Tokumoto Y, Onji M. Etiology of liver cirrhosis in Japan: a nationwide survey. J Gastroenterol. 2010;45(1):86-94, 10.1007/s00535-009-0128-5.
» http://dx.doi.org/10.1007/s00535-009-0128-5 -
5Schuppan. D, Afdhal. NH. Liver cirrhosis. Lancet. 2008;371(9615):838–51, 10.1016/S0140-6736(08)60383-9.
» http://dx.doi.org/10.1016/S0140-6736(08)60383-9 -
6Fleming KM, Aithal GP, Solaymani-Dodaran M, Card TR, West J. Incidence and prevalence of cirrhosis in the United Kingdom, 1992-2001: A general population-based study. J Hepatol. 2008;49(5):732–8, 10.1016/j.jhep.2008.05.023.
» http://dx.doi.org/10.1016/j.jhep.2008.05.023 -
7Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J Hepatol. 2006;45(4):529–38, 10.1016/j.jhep.2006.05.013.
» http://dx.doi.org/10.1016/j.jhep.2006.05.013 -
8Huang P, Zhu LG, Zhai XJ, Zhu YF, Yue M, Su J, et al. Hepatitis C virus infection and risk factors in the general population: a large community-based study in eastern China, 2011–2012. Epidemiol Infect. 2015;Jan 20:1–10.
-
9Qing Wang, Lianyou Hu, Daihong Zhao, Sun M. Seroepidemiological Survey and Analysis of Virus Hepatitis C in Chongqing. J Prev Med Inf. 2007;23(2):152–4.
-
10Tanaka M, Katayama F, Kato H, Tanaka H, Wang J, Qiao YL, et al. Hepatitis B and C Virus Infection and Hepatocellular Carcinoma in China: A Review of Epidemiology and Control Measures. Journal of Epidemiology. 2011;21(6):401–16, 10.2188/jea.JE20100190.
» http://dx.doi.org/10.2188/jea.JE20100190 -
11Yim HJ, Lok AS. Natural history of chronic hepatitis B virus infection: what we knew in 1981 and what we know in 2005. Hepatology. 2006;43(2 Suppl 1):S173–81.
-
12Liang X, Bi S, Yang W, Wang L, Cui G, Cui F, et al. Evaluation of the impact of hepatitis B vaccination among children born during 1992–2005 in China. J Infect Dis. 2009;200(1):39–47, 10.1086/599173.
» http://dx.doi.org/10.1086/599173 -
13Michelotti GA, Machado MV, Diehl AM. NAFLD, NASH and liver cancer. Nat Rev Gastroenterol Hepatol. 2013;10(11):656–65, 10.1038/nrgastro.2013.183.
» http://dx.doi.org/10.1038/nrgastro.2013.183 -
14Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34(3):274–85, 10.1111/apt.2011.34.issue-3.
» http://dx.doi.org/10.1111/apt.2011.34.issue-3 -
15Fan JG. Epidemiology of alcoholic and nonalcoholic fatty liver disease in China. J Gastroenterol Hepatol. 2013;28 Suppl 1:11–7.
-
16Fan JG, Farrell GC. Epidemiology of non-alcoholic fatty liver disease in China. J Hepatol. 2009;50(1):204–10, 10.1016/j.jhep.2008.10.010.
» http://dx.doi.org/10.1016/j.jhep.2008.10.010 -
17Caldwell SH, Crespo DM, Kang HS, Al-Osaimi AMS. Obesity and hepatocellular carcinoma. Gastroenterology. 2004;127(5):S97-S103, 10.1053/j.gastro.2004.09.021.
» http://dx.doi.org/10.1053/j.gastro.2004.09.021 -
18Karagozian R, Derdak Z, Baffy G. Obesity-associated mechanisms of hepatocarcinogenesis. Metabolism. 2014.
-
19Mena A, Pedreira JD, Castro A, Lopez S, Vazquez P, Poveda E. Metabolic syndrome association with fibrosis development in chronic hepatitis B virus inactive carriers. J Gastroenterol Hepatol. 2014;29(1):173–8, 10.1111/jgh.2014.29.issue-1.
» http://dx.doi.org/10.1111/jgh.2014.29.issue-1 -
20Kristi R DG, Paul KW, Xigui Wu. Prevalence and risk factors of overweight and obesity in China. Brief Epidemiologic Report. 2007;15(1):10–8.
-
21CM C. Overview of obesity in Mainland China. Obesity reviews. 2008;9(suppl 1):14–21.
-
22Dongdong Liu WL, Gongshu Liu. Survey on obesity of 24343 children under 7 years old in Tianjing. Zhong Guo Fu You Bao Jian. 2013;28(22):3646–7.
-
23Corey KE, Kaplan LM. Obesity and liver disease: the epidemic of the twenty-first century. Clin Liver Dis. 2014;18(1):1–18, 10.1016/j.cld.2013.09.019.
» http://dx.doi.org/10.1016/j.cld.2013.09.019 -
24Ascha MS, Hanouneh IA, Lopez R, Tamimi TA, Feldstein AF, Zein NN. The incidence and risk factors of hepatocellular carcinoma in patients with nonalcoholic steatohepatitis. Hepatology. 2010;51(6):1972–8, 10.1002/hep.23527.
» http://dx.doi.org/10.1002/hep.23527 -
25Jing Gao CW, Li Xie, Pingping Bao. Incidence and mortality of primary liver cancer in Shanghai, 2006-2008. Tumor. 2012;32(7):526–30.
-
26Chen CT, Chen JY, Wang JH, Chang KC, Tseng PL, Kee KM, et al. Diabetes mellitus, metabolic syndrome and obesity are not significant risk factors for hepatocellular carcinoma in an HBV- and HCV-endemic area of Southern Taiwan. Kaohsiung J Med Sci. 2013;29(8):451–9, 10.1016/j.kjms.2012.12.006.
» http://dx.doi.org/10.1016/j.kjms.2012.12.006 -
27Kawada N, Imanaka K, Kawaguchi T, Tamai C, Ishihara R, Matsunaga T, et al. Hepatocellular carcinoma arising from non-cirrhotic nonalcoholic steatohepatitis. J Gastroenterol. 2009;44(12):1190–4, 10.1007/s00535-009-0112-0.
» http://dx.doi.org/10.1007/s00535-009-0112-0 -
28Yasui K, Hashimoto E, Tokushige K, Koike K, Shima T, Kanbara Y, et al. Clinical and pathological progression of non-alcoholic steatohepatitis to hepatocellular carcinoma. Hepatol Res. 2012;42(8):767–73, 10.1111/hepr.2012.42.issue-8.
» http://dx.doi.org/10.1111/hepr.2012.42.issue-8 -
29Berentzen TL, Gamborg M, Holst C, Sorensen TI, Baker JL. Body mass index in childhood and adult risk of primary liver cancer. J Hepatol. 2014;60(2):325–30, 10.1016/j.jhep.2013.09.015.
» http://dx.doi.org/10.1016/j.jhep.2013.09.015 -
30Jessica Dyson BJ, Dipankar Chattopadyhay, Rajiv Lochan, Janine Graham, Debasish Das. Hepatocellular cancer: The impact of obesity, type 2 diabetes and a multidisciplinary team. Journal of hepatology. 2014;60:110–7, 10.1016/j.jhep.2013.08.011.
» http://dx.doi.org/10.1016/j.jhep.2013.08.011 -
31Rodrigues MH, Bruno AS, Nahas-Neto J, Santos ME, Nahas EA. Nonalcoholic fatty liver disease and metabolic syndrome in postmenopausal women. Gynecol Endocrinol. 2014;30(5):325–9, 10.3109/09513590.2013.875992.
» http://dx.doi.org/10.3109/09513590.2013.875992 -
32Hamaguchi M, Kojima T, Ohbora A, Takeda N, Fukui M, Kato T. Aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. World J Gastroenterol. 2012;18(3):237–43, 10.3748/wjg.v18.i3.237.
» http://dx.doi.org/10.3748/wjg.v18.i3.237 -
33Shimizu I, Ito S. Protection of estrogens against the progression of chronic liver disease. Hepatol Res. 2007;37(4):239–47, 10.1111/hep.2007.37.issue-4.
» http://dx.doi.org/10.1111/hep.2007.37.issue-4
Publication Dates
-
Publication in this collection
Aug 2015
History
-
Received
29 Jan 2015 -
Reviewed
20 Mar 2015 -
Accepted
1 June 2015