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Original research
Mortality in biopsy-proven alcohol-related liver disease: a population-based nationwide cohort study of 3453 patients
  1. Hannes Hagström1,2,3,
  2. Maja Thiele4,
  3. Bjorn Roelstraete5,
  4. Jonas Söderling5,
  5. Jonas F Ludvigsson5,6,7,8
  1. 1 Division of Hepatology, Department of Upper GI, Karolinska University Hospital, Stockholm, Sweden
  2. 2 Clinical Epidemiology Unit, Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
  3. 3 Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
  4. 4 Department of Gastroenterology and Hepatology, Odense University Hospital and University of Southern Denmark, Odense, Denmark
  5. 5 Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
  6. 6 Department of Pediatrics, Örebro University Hospital, Örebro, Sweden
  7. 7 Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, Nottingham, UK
  8. 8 Department of Medicine, Columbia University College of Physicians and Surgeons, New York City, New York, USA
  1. Correspondence to Dr Hannes Hagström, Department of Medicine, Karolinska Institutet, 171 77 Solna, Sweden; hannes.hagstrom{at}


Objective Patients with alcohol-related liver disease (ALD) are at increased risk of death, but studies have rarely investigated the significance of histological severity or estimated relative risks compared with a general population. We examined mortality in a nationwide cohort of biopsy-proven ALD.

Design Population-based cohort study in Sweden comparing 3453 individuals with an International Classification of Disease (ICD) code for ALD and a liver biopsy from 1969 to 2017 with 16 535 matched general population individuals. Swedish national registers were used to ascertain overall and disease-specific mortality, starting follow-up at the latest of first ICD diagnosis or liver biopsy plus 3 months. Cox regression adjusted for relevant confounders was used to estimate HRs in ALD and histopathological subgroups.

Results Median age at diagnosis was 58 years, 65% were men and 52% had cirrhosis at baseline. Five-year cumulative mortality was 40.9% in patients with ALD compared with 5.8% in reference individuals. The risk for overall mortality was significantly increased (adjusted HR (aHR)=4.70, 95% CI 4.35 to 5.08). The risk of liver-related death was particularly high (43% of all deaths, aHR=167.6, 95% CI 101.7 to 276.3). Mortality was significantly increased also in patients with ALD without cirrhosis and was highest in the first year after baseline but persisted after ≥10 years of follow-up (aHR=2.74, 95% CI 2.37 to 3.16).

Conclusion Individuals with biopsy-proven ALD have a near fivefold increased risk of death compared with the general population. Individuals with ALD without cirrhosis were also at increased risk of death, reaffirming the need to increase vigilance in the management of these individuals.

  • alcoholic liver disease
  • ethanol
  • epidemiology

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  • Contributors Study conception and design: All Acquisition of data: JFL. Statistical analysis: JS analysis and interpretation of data: All drafting of the manuscript: HH Critical revision: All guarantor of the article: JFL. All authors approved the final version of the article, including the authorship list.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval The study was approved by the Regional Ethics Committee in Stockholm (2014/1287-31/4).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Data may be obtained from a third party and are not publicly available. Data requests are kindly referred to the senior author (JFL).

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