To the Editor: Liver cirrhosis significantly affects population health and represents a major global health challenge. The comorbidities and complications associated with cirrhosis lead to poor quality of life for patients and impose a substantial economic burden worldwide. This health challenge is especially acute in China, where the prevalence and incidence of chronic liver disease surpass global averages.1 However, comprehensive epidemiological data on liver cirrhosis in China remain scarce. A majority of the existing studies rely on insurance databases or specific population cohorts, which may not accurately reflect the characteristics and burden of disease in the general population. This study analyzed all of the hospitalized patients with liver cirrhosis in Sichuan, China, from 2015 to 2021. Data were obtained from hospitalization summary reports provided by the Health Information Center of Sichuan Province. Detailed methodology is available in the Supplementary Methods section, https://links.lww.com/CM9/C812. For statistical analysis, continuous variables were expressed as mean ±standard deviation. Annual trends were assessed using linear and Poisson regression. Statistical significance was determined using two-tailed tests, with P-values of 0.05). Similarly, the age-standardized incidence rate rose from 55 to 63 per 100,000 person-years (0.14-fold increase; APC: 1.87%; 95% CI: −2.72% to 6.68%, P >0.05), with a mean of 64.7 per 100,000 person-years during 2015–2021 Figure 1A. The overall incidence of liver cirrhosis increased from 2015 to 2017 and has remained nearly stable since. A prominent sex disparity was observed, with incidence rates in males consistently more than twice those in females throughout the seven-year period. Notably, the incidence among females showed a more pronounced upward trend (APC: 4.2%; 95% CI: −2.01% to 10.79%; P >0.05) Figure 1A.Figure 1: Epidemiology of liver cirrhosis during 2015−2021 in Sichuan Province of China. (A) Annual incidence of liver cirrhosis per 100,000 person-years by gender. P >0.05. (B) Annual incidence of liver cirrhosis per 100,000 person-years by age. P >0.05. (C) Cumulative incidence rate of liver cirrhosis by age group from 2015 to 2021. Poisson regression was applied to assess temporal variations. (D) Annual in-hospital cirrhotic mortalities by gender. P >0.05. (E) Annual in-hospital cirrhotic mortalities by age and gender. (F) Annual prevalence of liver cirrhosis by gender. (G) Liver cirrhosis demographics in 2021: Stages and age-specific prevalence by gender. Linear regression was applied to assess temporal variations. (H) Annual changes in the number of hospitalizations. (I) Length of stay per patient from 2017 to 2021. (J) Annual changes in total costs for hospitalization. (K) Annual trends in TIPS treatment rates. TIPS: Transjugular intrahepatic portosystemic shunt.Age-stratified analysis revealed distinct patterns of cirrhosis incidence across age groups. Among children (≤14 years), incidence remained very low, at ~0.7 per 100,000 person-years. Rates among individuals aged 15–64 years were relatively stable at ~55 per 100,000. In contrast, the elderly population (≥65 years) experienced a marked increase from 134 to 175 per 100,000 between 2015 and 2017, followed by a plateau at ~171 per 100,000 during 2017–2021 Figure 1B. Cumulative incidence over the seven-year period demonstrated a strong association between aging and cirrhosis risk, with incidence rates progressively increasing across age groups Figure 1C. A slight downward trend in mortality was observed in recent years, declining from 4.7% to 4.4% (P >0.05) Figure 1D. The sex difference was most pronounced in middle-aged patients and diminished among the elderly. A clear age-related increase in mortality was observed, peaking at 12.5% among patients aged ≥85 years Figure 1E. The prevalence of liver cirrhosis increased 1.3-fold, reaching 0.11% in 2021. Although prevalence rose by 1.2-fold in males and 1.5-fold in females over the seven-year period, males remained the majority. Across all of the age groups, prevalence was significantly higher in males than in females (P <0.001) Figures 1F and G. Geographical analysis showed the highest cirrhosis prevalence in Panzhihua, Deyang, and Zigong—major heavy industry centers in Sichuan province, China Supplementary Table 3, https://links.lww.com/CM9/C812. Among patients with compensated cirrhosis, common comorbidities included cancer (32.5%), hypertension (31.0%), pneumonia (25.3%), diabetes (21.6%), and cholelithiasis (20.4%). Sex differences were notable, with cholelithiasis being 1.76 times more prevalent in females than in males, whereas cancer prevalence in males was 1.80 times higher than in females. Diabetes was nearly twice as prevalent in decompensated cirrhosis cases (40.0%) compared with compensated patients. In contrast, hypertension was less common among decompensated patients (15.6%) Supplementary Figure 2A, https://links.lww.com/CM9/C812. Common infections associated with compensated cirrhosis are detailed in Supplementary Table 4, https://links.lww.com/CM9/C812. Common complications among decompensated patients included ascites (55.9%), esophageal gastric variceal bleeding (43.1%), infection (31.2%), and liver cancer (24.1%). Spontaneous bacterial peritonitis was the leading infection type among patients with decompensated cirrhosis and in those who died. Liver cancer showed a marked sex disparity, affecting 28.0% of males compared with 14.3% of females Supplementary Figure 2B, https://links.lww.com/CM9/C812. Over the seven-year period, healthcare demand for cirrhosis patients doubled, while the average hospital stay decreased by 1.5 days Figures 1H and I and Supplementary Figure 3A, https://links.lww.com/CM9/C812. The annual total length of stay per patient also declined by one day Supplementary Figure 3B, https://links.lww.com/CM9/C812. Both total hospitalization costs and annual costs for hospitalization per patient rose significantly, primarily due to increased expenses among decompensated patients (P <0.001 for total and decompensated cirrhosis) Figure 1J and Supplementary Figure 3C, https://links.lww.com/CM9/C812. Notably, transjugular intrahepatic portosystemic shunt (TIPS) procedures increased fivefold during this period Figure 1K. This epidemiological study of liver cirrhosis in China reported a mean incidence of 64.7 per 100,000 person-years (2015–2021), which is lower than the 89.6 per 100,000 person-years reported in Ontario, Canada, but higher than rates observed in European countries Supplementary Table 5, https://links.lww.com/CM9/C812. The prevalence reported in our study is also lower than the 0.87% documented in a separate Chinese epidemiological study published in 2023.2 Variations in risk factor prevalence, diagnostic practices, healthcare utilization patterns, and study population characteristics may account for these differences. The 0.11% prevalence observed in 2021 is likely an underestimate, as the analysis was limited to hospitalized patients, particularly those with decompensated cirrhosis. Geographic analysis revealed higher prevalence rates in industrial cities, suggesting potential environmental contributions to the disease burden. Male incidence was significantly higher than female incidence; a disparity consistently reported in international studies. Contributing factors may include higher alcohol consumption and greater prevalence of metabolic syndrome among men and the potentially protective effects of estrogen in women. Nevertheless, female incidence rates showed an upward trend, possibly driven by shifts in lifestyle and environmental exposures. The rising incidence of cirrhosis largely reflects China’s aging population and increased life expectancy in Sichuan province. As aging is a well-established risk factor—and with China’s elderly population projected to reach 395 million by 2050—preventing and managing liver cirrhosis will pose significant challenges.3 Furthermore, the growing prevalence of non-alcoholic fatty liver disease represents another significant driver of the rising incidence of cirrhosis.1 Although our etiological analysis was limited, the findings indicate a rising proportion of viral cirrhosis, potentially driven by population aging and advances in diagnostic capabilities. The rise and subsequent stabilization of alcoholic cirrhosis may reflect the impact of alcohol-related health education and policy interventions implemented in recent years. Notably, the male-to-female ratio in alcoholic cirrhosis declined over time, aligning with findings from a 2015 Beijing study4 underscoring the need for targeted alcohol interventions among women. Comorbidity patterns revealed clinically meaningful indicators. Approximately 30% of compensated cirrhosis cases were initially identified during hypertension-related admissions, highlighting the importance of liver screening in younger hypertensive outpatients. The subsequent decline in hypertension prevalence, coupled with a twofold increase in diabetes among decompensated patients, serves as a key indicator of disease progression, underscoring the value of comorbidity monitoring for early intervention. Healthcare utilization analysis indicated improved hospitalization efficiency with shortened length of stay. The in-hospital mortality rate was 7.2%, lower than 9.49% in Germany.5 Treatment costs rose with a fivefold increase in TIPS procedures, suggesting a potential association with improved outcomes. Study limitations include hospitalized-patient restriction, regional focus, hospital-diagnosed cases only, and incomplete etiological documentation. In conclusion, this study reported cirrhosis incidence of 64.7 per 100,000 person-years (2015−2021) and prevalence of 0.11% (2021). Risk factors included advancing age, male sex, and heavy industrial residence. Common comorbidities were cancer, hypertension, pneumonia, diabetes, and cholelithiasis. TIPS intervention combined with chronic liver disease management reduced in-hospital mortality. Funding This work was supported by the National Natural Science Foundation of China (Nos. 82470648, 82322011, 82241054, 82170623, 82170625), and the 135 Projects for Disciplines of Excellence of West China Hospital, Sichuan University (Nos. ZYYC23026 and ZYGD23029). Conflicts of interest None.
Ye et al. (Thu,) studied this question.