Natural history of histologically proven alcohol-related liver disease: A systematic review

• Published in: Journal of hepatology 2019-09, Vol.71 (3), p.586-593
• Main Authors: Parker, Richard, Aithal, Guruprasad P., Becker, Ulrik, Gleeson, Dermot, Masson, Steven, Wyatt, Judith I., Rowe, Ian A.
• Format: Article
• Language: English
• Subjects: Adult; Alcohol; Alcoholic liver diseases; Biopsy; Cirrhosis; Disease Progression; Fatty liver; Fatty Liver, Alcoholic - epidemiology; Fatty Liver, Alcoholic - mortality; Fatty Liver, Alcoholic - pathology; Female; Fibrosis; Humans; Liver - pathology; Liver cirrhosis; Liver Cirrhosis, Alcoholic - epidemiology; Liver Cirrhosis, Alcoholic - mortality; Liver Cirrhosis, Alcoholic - pathology; Liver diseases; Male; Meta-analysis; Middle Aged; Mortality; Natural history; Patients; Prevalence; Prognosis; Steatohepatitis; Steatosis; Systematic review
• ISSN: 0168-8278; 1600-0641
• DOI: 10.1016/j.jhep.2019.05.020

[Display omitted] •Approximately 15% of hazardous drinkers may have normal liver histology.•Progression to cirrhosis is most common in people with steatohepatitis (10% per year).•Liver-related factors are the predominant cause of death in people with steatohepatitis or cirrhosis.•Hepatic steatosis is not benign, with an annual mortality rate of ∼6%/year, but deaths are mainly non-liver related. To date, studies into the natural history of alcohol-related liver disease (ALD) have lacked long-term follow-up, large numbers of participants, or both. We performed a systematic review to summarise studies that describe the natural history of histologically proven ALD. PubMed and Medline were searched for relevant studies according to pre-specified criteria. Data were extracted to describe the prevalence of ALD, histological progression of disease and mortality. Single-proportion meta-analysis was used to combine data from studies regarding rates of progression or mortality. Thirty-seven studies were included, reporting data from 7,528 participants. Amongst cohorts of hazardous drinkers, on average 15% had normal histological appearance, 27% had hepatic steatosis, 24% had steatohepatitis and 26% had cirrhosis. The annualised rates of progression of pre-cirrhotic disease to cirrhosis were 1% (0–8%) for patients with normal histology, 3% (2–4%) for hepatic steatosis, 10% (6–17%) for steatohepatitis and 8% (3–19%) for fibrosis. Annualised mortality was 6% (4–7%) in patients with steatosis and 8% (5–13%) in cirrhosis. In patients with steatohepatitis on biopsy a marked difference was seen between inpatient cohorts (annual mortality 15%, 8–26%) and mixed cohorts of inpatients and outpatients (annual mortality 5%, 2–10%). Only in steatosis did non-liver-related mortality exceed liver-specific causes of mortality (5% per year vs. 1% per year). These data confirm the observation that alcohol-related hepatic steatohepatitis requiring admission to hospital is the most dangerous subtype of ALD. Alcohol-related steatosis is not a benign condition as it is associated with significant risk of mortality. Knowledge of the natural history of a disease allows clinicians and patients to understand the risks that are associated with a medical condition. In this study we systematically gathered all the published data regarding the natural history of alcohol-related liver disease in people who had a liver biopsy. We used this data to define the prevalence of the disease, the annual ris