Characterization of the increased incidence of alcohol-associated hepatitis noted in Ontario, Canada in past two decades

1. From 2002 to 2021, the incidence rate of alcohol-associated hepatitis in Ontario, Canada increased by 8% annually, with rates rising faster among females.

2. Although more males are affected by alcohol-associated hepatitis in absolute numbers, females have higher rates of liver-related mortality and approximately 50% higher risk of developing cirrhosis. 

Evidence Rating Level: 2 (Good)

Study Rundown: Alcohol-associated hepatitis (AH) is the most severe acute form of alcohol-associated liver disease (ALD) and has high mortality rates. As rates of AH continue to rise among adolescents and young adults (AYAs), there is an urgent need to identify risk groups. Although females are at higher risk of ALD compared to males, the role of sex on progression to major liver-related outcomes, such as cirrhosis and decompensation, among AYAs with AH is poorly understood. This study thus aimed to define the sex-specific epidemiology of AH in AYAs and examine the relationship between female sex and liver-related outcomes after an initial presentation of AH. This retrospective, population-based cohort study included 3,340 AYAs (13-39 years) with an initial presentation of AH without a history of cirrhosis and/or decompensation. From 2002 to 2021, the incidence rate of AH increased by 8% annually, with rates increasing faster among females than males. Compared to males, females were more likely to be diagnosed with cirrhosis and/or decompensation, and among those with cirrhosis, females were more likely to present with decompensation. Female sex was independently associated with a 47% higher subhazard of cirrhosis and/or decompensation. Furthermore, females had a higher cumulative incidence of liver-related mortality at 10 years than males. Overall, this study found a significant increase in rates of AH among AYAs over the past two decades, with females at a greater risk for liver-related outcomes and death. 

Click to read the study in BMC Medicine 

Relevant reading: Alcohol Consumption and Risk of Liver Cirrhosis: A Systematic Review and Meta-Analysis

In-Depth [Retrospective cohort study]: This study used data from the Institute for Clinical Evaluative Sciences (ICES) from Ontario, Canada. Data on AYAs (13-39 years) with an initial presentation of AH without a history of cirrhosis and/or decompensation between January 1 to December 31, 2022, were included in the analysis. In total, 3,340 AYAs with AH were identified (median age = 33 (Interquartile Range, 28-36) years, 1,190 (36%) females). From 2002 to 2021, the incidence rate of AH increased by 8% annually (rate ratio (RR), 1.08; 95% CI, 1.07-1.09), with rates increasing faster among females (RR, 1.11;95% CI, 1.09-1.12) than among males (RR, 1.07; 95% CI, 1.06-1.07). Of the 2,374 individuals (71%) who were alive without cirrhosis six months after AH presentation, 527 (22%) developed incident cirrhosis and/or decompensation after a median follow-up of 4 (IQR, 2-9) years. Compared to males, females were more likely to be diagnosed with cirrhosis and/or decompensation vs males (37% vs 28%; P < .001). Of those with cirrhosis, females were more likely to present with decompensation vs males (47% vs 38%; P < .001). After adjusting for covariates, female sex was independently associated with a 47% higher subhazard of cirrhosis and/or decompensation (subhazard ratio (sHR), 1.47; 95% CI, 1.23-1.76; P < .001). Furthermore, females had a higher cumulative incidence of liver-related mortality at 10 years (11.0%; 95% CI, 8.3%-14.2%) compared to males (6.9%; 95% CI, 5.4%-8.6%) (P = .01). Overall, this study found a significant increase in rates of AH among AYAs over the past two decades, with females at a greater risk for liver-related outcomes and death. These results suggest the need for early identification and treatment for AYAs at risk for AH, as well as sex-specific interventions to manage AH and its progression to cirrhosis following the first presentation. Future studies are required to validate these findings.

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