Environmental exposures are important risk factors for advanced liver fibrosis in African American adults

JHEP Rep. 2023 Feb 6;5(4):100696. doi: 10.1016/j.jhepr.2023.100696. eCollection 2023 Apr.


Background & aims: The prevalence and aetiology of liver fibrosis vary over time and impact racial/ethnic groups unevenly. This study measured time trends and identified factors associated with advanced liver fibrosis in the United States.

Methods: Standardised methods were used to analyse data on 47,422 participants (≥20 years old) in the National Health and Nutrition Examination Survey (1999-2018). Advanced liver fibrosis was defined as Fibrosis-4 ≥2.67 and/or Forns index ≥6.9 and elevated alanine aminotransferase.

Results: The estimated number of people with advanced liver fibrosis increased from 1.3 million (95% CI 0.8-1.9) to 3.5 million (95% CI 2.8-4.2), a nearly threefold increase. Prevalence was higher in non-Hispanic Black and Mexican American persons than in non-Hispanic White persons. In multivariable logistic regression analysis, cadmium was an independent risk factor in all racial/ethnic groups. Smoking and current excessive alcohol use were risk factors in most. Importantly, compared with non-Hispanic White persons, non-Hispanic Black persons had a distinctive set of risk factors that included poverty (odds ratio [OR] 2.09; 95% CI 1.44-3.03) and susceptibility to lead exposure (OR 3.25; 95% CI 1.95-5.43) but did not include diabetes (OR 0.88; 95% CI 0.61-1.27; p =0.52). Non-Hispanic Black persons were more likely to have high exposure to lead, cadmium, polychlorinated biphenyls, and poverty than non-Hispanic White persons.

Conclusions: The number of people with advanced liver fibrosis has increased, creating a need to expand the liver care workforce. The risk factors for advanced fibrosis vary by race/ethnicity. These differences provide useful information for designing screening programmes. Poverty and toxic exposures were associated with the high prevalence of advanced liver fibrosis in non-Hispanic Black persons and need to be addressed.

Impact and implications: Because liver disease often produces few warning signs, simple and inexpensive screening tests that can be performed by non-specialists are needed to allow timely diagnosis and linkage to care. This study shows that non-Hispanic Black persons have a distinctive set of risk factors that need to be taken into account when designing liver disease screening programs. Exposure to exogenous toxins may be especially important risk factors for advanced liver fibrosis in non-Hispanic Black persons.

Keywords: ALD, alcohol-associated liver disease; ALT, alanine aminotransferase; APC, annual percent change; Aetiology; BMI, body mass index; CI, confidence interval; Environmental toxins; FIB-4, Fibrosis-4; HBV, hepatitis B virus; HCV, hepatitis C virus; HR, hazard ratio; KI, kidney insufficiency; LF, liver fibrosis; MA, Mexican American; NAFLD, non-alcoholic fatty liver disease; NEI, no exposure identified; NHANES, National Health and Nutrition Evaluation Survey; NHB, non-Hispanic Black; NHW, non-Hispanic White; Non-invasive scores; O, other race; PCB, polychlorinated biphenyl; Q1–Q4, quartiles 1–4; Racial disparities; Screening; ULN, upper limit of normal; USFLI, US Fatty Liver Index; VH, viral hepatitis; WC, waist circumference.