The life concerns of 300 million patients with liver disease: How to prevent cirrhosis from turning into liver cancer?

March 18, 2024 is the 24th " National Liver Care Day ". This year's publicity theme is " Early prevention and early screening, stay away from cirrhosis ", calling on the whole society to take action to popularize knowledge on the prevention and treatment of liver fibrosis, actively screen, standardize treatment, and follow up regularly, so as to reduce the occurrence of cirrhosis.

1. Current status of liver cirrhosis in my country

Cirrhosis of the liver ranks 11th among the most common causes of death in the world, with an annual death toll of 1 million, more men than women. There are about 300 million patients with liver disease in my country, and deaths from cirrhosis account for 11% of the global deaths from cirrhosis. Hepatitis B virus (HBV) infection is the primary cause of cirrhosis. Most patients with cirrhosis have only one cause, and at this stage, HBV infection is still the main cause of cirrhosis in my country (accounting for 71.15%). At present, there are about 97 million HBV carriers and 20 million patients with chronic active hepatitis B in my country.

With the widespread vaccination of hepatitis B vaccine and the extensive use of antiviral drugs in China, the number of patients with hepatitis B cirrhosis in China has gradually decreased, while non-viral cirrhosis has increased year by year. Among them , alcoholic liver disease has become the second largest cause of cirrhosis (accounting for 11.27%) .

Cirrhosis caused by metabolic-associated fatty liver disease (MAFLD) is increasing rapidly. The incidence of cirrhosis in patients with non-alcoholic steatohepatitis is as high as 15% to 25% within 10 to 15 years. It is estimated that the number of MAFLD patients in China will increase from about 244 million in 2016 to about 315 million in 2030, of which about 750,000 will be newly diagnosed with MAFLD-related decompensated cirrhosis.

According to the progression of the disease, cirrhosis can be divided into compensated and decompensated stages. Depending on whether it is accompanied by esophageal gastric varices (EGV) or ascites, cirrhosis can be further divided into 6 stages, of which stages 1 and 2 are compensated stages, stages 3 to 5 are decompensated stages, and stage 6 is the late decompensated stage (see Table 1).

Table 1 Stages of cirrhosis Note: EGVB stands for esophageal gastric varicose bleeding. In recent years, through effective etiological treatment and standardized interventions such as drugs, endoscopy, and interventional treatments, the patient's condition can remain stable for a long time; even patients with decompensated cirrhosis can be in a stable decompensated state, without experiencing acute decompensation of cirrhosis for a considerable period of time, and some patients can even experience recompensation or reversal of cirrhosis.

2. Early prevention and early screening to actively prevent liver cancer

Liver cancer is one of the final outcomes of cirrhosis and also one of the worst outcomes. Even if patients with cirrhosis receive effective etiological treatment, they still cannot completely prevent the occurrence of liver cancer. About 7 million people in China suffer from cirrhosis, and the annual incidence of liver cancer is 1% to 8%. Among them, cirrhosis caused by various reasons is the main risk factor for liver cancer. The relevant guidelines consensus points out that the high-risk groups for liver cancer include: ① Patients with cirrhosis caused by various reasons , including HBV infection, hepatitis C virus infection, alcoholic liver disease, NAFLD, drug-induced liver injury, autoimmune liver disease, Wilson's disease and other diseases. ② Chronic hepatitis B patients aged ≥30 years with a family history of liver cancer, or long-term alcoholism, smoking, clear history of exposure to carcinogenic toxins, combined with diabetes or obesity.

Preventing cirrhosis from developing into liver cancer is one of the main tasks in cirrhosis management.

Liver cirrhosis should be included in chronic disease management, and patients should be followed up regularly to understand liver function, varicose veins and complications, and screen for liver cancer. The screening pathway is shown in Figure 1.

Note: ASH is alcoholic hepatitis; AIH is autoimmune hepatitis; PBC is primary biliary cholangitis

Figure 1 Liver cancer screening program Abdominal ultrasound combined with serum alpha-fetoprotein is a routine screening method for liver cancer in patients with chronic liver disease, and multimodal liver magnetic resonance imaging and/or CT is an enhanced screening method. Low-risk people should undergo routine screening once a year, and medium-risk people should undergo routine screening once every 6 months; high-risk people should undergo routine screening once every 3 to 6 months, and enhanced screening once every 6 to 12 months; extremely high-risk people should undergo routine screening once every 3 months, and enhanced screening once every 6 months .

During the monitoring process, if nodules <1 cm are found by abdominal ultrasound, they should be rechecked once every 3 months; if nodules grow or nodules are >1 cm and serum alpha-fetoprotein is >20 ng/ml, the enhanced screening process for liver cancer should be initiated. If the imaging examination cannot determine the nature of the nodule, diagnostic liver puncture biopsy under imaging guidance can be considered.

References

[1] Chinese Society of Gastroenterology. Consensus on the clinical diagnosis and treatment of liver cirrhosis in China[J]. Journal of Clinical Hepatobiliary Diseases, 2023, 39(9): 2057-2073.

[2] Chinese Society of Hepatology. Guidelines for the diagnosis and treatment of ascites in cirrhosis[J]. Chinese Journal of Hepatology, 2023, 31(8): 813-826.

[3] Chen Ci, Fan Jiangao. Treatment of metabolic-related fatty liver disease effectively prevents cirrhosis and liver cancer[J]. Liver Doctor, 2023(5):17-18.