Monday, May 21, 2012

A report on the incidence and mortality of liver cirrhosis - underscores why early diagnosis is important -

Reference: Fialla, A.D., O.B. de Muckadell, and A. Touborg Lassen, Incidence, etiology and mortality of cirrhosis: a population-based cohort study. Scand J Gastroenterol, 2012. 47(6): p. 702-9.

It’s not often I get to comment on an epidemiological based study, so this is exciting! A study from Finland on the case incidence of cirrhosis. 

Brief Summary: The main objective of this study was to detail the incidence and mortality of cirrhosis patients. A total of 1369 patients were identified as having cirrhosis from the discharge diagnoses from the Funen Patient Administrative System (FPAS) from Funen, Denmark. The patients were identified and differentiated based on their age, etiology (autoimmune hepatitis, alcohol cirrhosis, viral hepatitis, cryptogenic hepatitis, etc.), gender, and complications at diagnosis (present, absent). The incidence and mortality rates were then calculated for each of the previously mentioned clinical variables.

Results: The incidence was twice as high for women as it was for men with all age groups. As for mortality, the mortality rate was significantly higher for men, age above 70 years compared with other age groups, complications present at diagnosis, and etiology due to alcoholic disease or cryptogenic cirrhosis.

Implications for Practice: If a patient is diagnosed with symptoms and is male, age > 70, has complications and an etiology due to alcoholic or cryptogenic cirrhosis, then there is a higher mortality rate. Most importantly, the authors noted that it is important to diagnosis patients as early as possible for cirrhosis, because the likelihood of diagnosis will decrease significantly. This was notable since patients which had complications at time of diagnosis (and thus a more further-along disease progression) had a 28% higher odds of mortality than those who did not initially present with complications.    

Discussion: Good study here. Like I said before, I don’t get to review epidemiology based papers too much, so it was good to do one finally. I can’t tell you how fun it was to read this paper! It was interesting to find that males have a higher rate of mortality than females. I am curious as to why this is.
As the authors mentioned in the discussion section, the time of diagnosis is obviously critical here; patients with alcoholic and cryptogenic cirrhosis generally have a worse mortality rate than those with other etiological based causes, because their disease-progression is generally worse at initial diagnosis. It was stunning to see that of the 1369 cirrhosis patients admitted into the sample cohort, 1076 (~79%) were alcohol induced! 

Commentary on Statistics and Study Design: Overall, good statistics and study design here. I would have analyzed the paper in a very similar fashion to how the authors actually did it. I especially like how the authors included both a uni- and multi-variate analysis, and reported the final results (Table 4). I would have removed any variables which were significant in the multi-variate model to produce more precise odds ratios for the most significant variables, but since there were so few variables in the analysis here, the approach the authors took is OK. It would not have resulted in a big difference.
In the methods section, the authors said that they tested for interactions, but they did not report on them in the rest of the paper. I assume this means those interactions were not significant? This would be useful information to know. Other than that, great paper overall.

A big thanks to our buddies in Denmark for doing this! Hope to get there one day

Source- The Gastroenterology Blog

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