title: The incidence and risk factors of hepatocellular carcinoma in patients with nonalcoholic steatohepatitis.
abstract: Nonalcoholic steatohepatitis (NASH) is a well-recognized cause of cirrhosis and has been increasingly associated with the development of hepatocellular carcinoma (HCC). The aims of this study were to (1) estimate the incidence of HCC in patients with NASH-related cirrhosis, (2) compare incidence in NASH-related cirrhosis with hepatitis C virus (HCV)-related cirrhosis, and (3) identify risk factors of HCC in patients with NASH-related cirrhosis compared with HCV-related cirrhosis. Adult patients with cirrhosis secondary to chronic HCV (n = 315) or NASH (n = 195) were evaluated at our hepatobiliary clinic between 2003 and 2007. To assess for HCC development, all patients were monitored using serial abdominal computed tomography and serum alpha-fetoprotein every 6 months. Kaplan-Meier analysis was performed to estimate the cumulative incidence of HCC. Descriptive statistics were computed for all factors. Univariate and multivariate Cox regression analysis were used to assess associations between HCC and factors of interest. The median follow-up was 3.2 years (25th percentile [P25], 75th percentile [P75]: 1.7, 5.7) during which 25/195 (12.8%) of NASH-cirrhotic and 64/315 (20.3 %) of HCV-cirrhotic patients developed HCC (P = 0.03). Yearly cumulative incidence of HCC was found to be 2.6% in patients with NASH-cirrhosis, compared with 4.0% in patients with HCV cirrhosis (P = 0.09). Multivariate regression analysis revealed that older age (P = 0.006) and alcohol consumption (P = 0.002) were independent variables associated with development of HCC in patients with NASH-cirrhosis. Compared with nondrinkers, patients who reported any regular alcohol consumption were at greater risk for HCC development (hazard ratio: 3.6; P25, P75: 1.5, 8.3).
  
  
  CONCLUSIONS
  Patients with NASH cirrhosis have a greatly increased risk of liver cancer. Alcohol consumption, a modifiable risk factor, appears to be the most significant factor associated with risk of HCC development in our study population.
authors.affiliation: Department of Gastroenterology and Hepatology, The Cleveland Clinic, Cleveland, OH 44195, USA.
authors.forename: Mustafa S
authors.initials: MS
authors.lastname: Ascha
authors.forename: Ibrahim A
authors.initials: IA
authors.lastname: Hanouneh
authors.forename: Rocio
authors.initials: R
authors.lastname: Lopez
authors.forename: Tarek Abu-Rajab
authors.initials: TA
authors.lastname: Tamimi
authors.forename: Ariel F
authors.initials: AF
authors.lastname: Feldstein
authors.forename: Nizar N
authors.initials: NN
authors.lastname: Zein
mesh_terms: D000428:Alcohol Drinking / Q000009:adverse effects; D006528:Carcinoma, Hepatocellular / Q000453:epidemiology* / Q000209:etiology; D005234:Fatty Liver / Q000150:complications*; D005260:Female; D006526:Hepatitis C / Q000150:complications*; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications* / Q000821:virology; D008113:Liver Neoplasms / Q000453:epidemiology* / Q000209:etiology; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States / Q000453:epidemiology