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NAFLD and alcohol-related liver disease will be responsible for almost all new diagnoses of cirrhosis in Canada by 2040

Flemming JA, Djerboua M, Groome PA, Booth CM, Terrault NA. Hepatology. 2021; Jun 26 [Epub ahead of print]. DOI:

Background and Aims — Mortality secondary to cirrhosis in North America is increasing. We describe the incidence of cirrhosis stratified by birth cohort and cirrhosis etiology and project disease burden to 2040.

Approach and Results — Retrospective cohort study in Ontario, Canada using population-based administrative healthcare data. Individuals with incident cirrhosis (2000-2017) were identified and etiology was defined as hepatitis C (HCV), hepatitis B, non-alcoholic fatty liver disease (NAFLD), alcohol-related disease (ALD) or autoimmune liver disease/Other using validated case definitions. Annual age/sex adjusted cirrhosis incidence rate per 100,000 person-years (PY) was calculated with incidence projection to 2040 using age-period-cohort modeling along with average annual percent change (AAPC) in cirrhosis incidence stratified by birth cohort and etiology. 159, 549 incident cases of cirrhosis were identified. Incidence increased by 26% with an AAPC of 2%/year (95% CI 1.6-2.4, P <.001). The largest increases were for HCV (AAPC 4.1%/year 95% CI 2.6-5.7, P <.001) and NAFLD (AAPC 3.3%/year, 95% CI 2.6-4.1%, P <.001). ALD and HCV cirrhosis in those born >1980 increased by 11.6%/year (95% CI 9.3-13.9, P <.001) and 9.5%/year (95% CI 6.2-13.0, P <.001) respectively. However by 2040, cirrhosis incidence is projected to continue to increase driven mostly by NAFLD, especially in post-menopausal females, and ALD in individuals born >1980.

Conclusions — Cirrhosis incidence will continue to increase over the next two decades secondary to NAFLD with a worrisome rapid rise in ALD cirrhosis among young adults. Public education, policy, and intervention targeting NAFLD risk factors and alcohol use in young adults are urgently needed.