Less Cirrhosis but Worse Outcomes for Black Patients With NASH

Laird Harrison

April 07, 2022

Compared to White people, Black people are less likely to develop cirrhosis from nonalcoholic steatohepatitis (NASH) but are more likely to die when hospitalized with this condition, researchers say.

The finding highlights the importance of addressing hepatic complications and nonhepatic comorbidities with a comprehensive and interdisciplinary approach that includes social determinants of health, said Emad Qayed, MD, MPH, an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia.

"Clinicians should realize that in Black patients with NASH and NASH cirrhosis, mortality can be high despite a low rate of hepatic complications," he told Medscape Medical News.

The study by Qayed and colleagues was published in the Journal of Clinical Gastroenterology.

A Nationwide Analysis

Previous studies have indicated that Black people are less likely than White people to develop nonalcoholic fatty liver disease (NAFLD), despite the fact that prevalence is increasing. Furthermore, when Black people do develop NAFLD, the disease is less likely to progress to NASH. In cases in which NASH does develop, the evidence has been mixed as to the effect of race on hospital outcomes.

To shed new light on that question, Qayed and colleagues analyzed data from 2016 to 2018 from the National Inpatient Sample, which is produced by the Healthcare Cost and Utilization Project and is sponsored by the Agency of Healthcare Research and Quality.

They identified 43,409 hospitalizations for NASH, with 41,143 White patients and 2266 Black patients. The mean age of the Black patients was less than that of the White patients (56.4 years vs 63.0 years), and Black patients were more likely to be women (69.9% vs 61.6%).

More of the Black patients had hypertension, obesity, chronic kidney disease, and congestive heart failure, while more of the White patients had diabetes, dyslipidemia, and ischemic heart disease.

Among the Black patients, 33.6% had cirrhosis, compared to 56.4% of the White patients. Likewise, among the Black patients, there were fewer manifestations of decompensated cirrhosis compared with the White patients. Black patients were also less likely to have had to undergo upper endoscopy and paracentesis.

The Black patients died in the hospital at a rate of 3.9%, which was not significantly higher than the 3.7% rate for the White patients (unadjusted odds ratio [OR] = 1.06; 95% CI: 0.84 – 1.32; P = .6). But, when the researchers adjusted for age, sex, cirrhosis, risk of mortality (based on the overall number and severity of diseases), and insurance status, there were significantly higher odds of mortality among the Black patients (adjusted OR, 1.34; 95% CI: 1.05 – 1.71; P = .018).

They did not find any association between hospital size, location, or region with mortality.

They also found no difference in mortality between Black patients and White patients among those with and those without cirrhosis. However, they found that Black patients were more likely to have acute kidney injury, chronic kidney disease, and congestive heart failure.

Regarding the reasons for hospitalization, the researchers found liver-related illnesses, such as hepatic failure and noninfectious hepatitis, to be most common among the White patients. Circulatory disorders, such as heart failure, and endocrine disorders, such as diabetes mellitus with complications, were found to be most common among the Black patients.

The length of time in the hospital was longer for the Black patients than the White patients (6.3 days vs 5.6 days; P < .0001). The cost of hospitalization was higher for Black patients as well ($18,603 vs $17,467). This suggests that Black patients were sicker overall, despite their lower rates of liver complications.

"Some of these differences are likely related to socioeconomic factors and clinical comorbidities, such as cardiac and renal disease," Qayed said. "However, the underlying etiologies for such disparities in NASH and cirrhosis remain unclear. Further research is warranted to clarify these etiologies."

NASH as Part of the Metabolic Syndrome

"Clinicians should consider NASH as part of the metabolic syndrome," Paul Martin, MD, chief of digestive health and liver diseases at the University of Miami in Florida, told Medscape Medical News. He was not involved in the study.

"Typically, these patients have a number of risk factors for fatty liver, including obesity and often hyperlipidemia, hypertension, and sleep apnea," he said. "Clinicians should screen their patients for such comorbidities and then treat them."

Genetic factors could also play a role in the difference in susceptibility to fatty liver disease found between Black and White patients, he added.

Martin noted a prevalence of fatty liver in many Hispanic populations and that it is found in Asia but sometimes in the absence of the risk factors associated with it in the United States.

Qayed and Martin report no relevant financial relationships.

J Clin Gastroenterol. Published online April 1, 2022. Abstract

Laird Harrison writes about science, health, and culture. His work has appeared in magazines, newspapers, on public radio, and on websites. He is at work on a novel about alternate realities in physics. Harrison teaches writing at the Writers Grotto. Visit him at lairdharrison.com or follow him on Twitter: @LairdH.

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