The Worsening Profile of Alcoholic Hepatitis in the United States.

Alcohol-related liver disease remains a leading cause of liver-related morbidity and mortality in many parts of the world (Liang et al., 2011; Liangpunsakul, 2011; Sandahl et al., 2011). Alcoholic hepatitis (AH) is an important contributor to alcohol-related morbidity and mortality and is a major cause of liver-related admissions to hospitals (Jinjuvadia et al., 2015). It is one of the principal manifestations of alcohol-related liver disease and is classically characterized by jaundice, hepatomegaly, and neutrophilia along with an aspartate transaminase:alanine transaminase ratio of 2 or more (Basra and Anand, 2011). The histological findings of AH include macro- and microvesicular steatosis, cellular ballooning, lobular inflammation along with variable degrees of cholestasis, and pericellular fibrosis which can progress to cirrhosis (Altamirano et al., 2014; Sherlock, 1990). It is now appreciated that the clinical phenotype associated with histological evidence of alcohol-related steatohepatitis can be variable. While many subjects with histological features of alcoholic steatohepatitis are relatively asymptomatic and remain largely in an outpatient setting (Cortez-Pinto et al., 2003), others develop jaundice and can develop severe liver failure and often require hospitalization (Casanova and Bataller, 2014). The classic descriptions of AH date back to several decades ago. At the time, the Maddrey discriminant index was used to predict clinical outcomes; this index is based on the serum bilirubin and the prothrombin time (Maddrey et al., 1978). The interlaboratory variability in the prothrombin time has led to increasing adoption of the Model for End-Stage Liver Disease (MELD) which relies on the international normalized ratio (INR) rather than the prothrombin time (Dunn et al., 2005; Singal and Shah, 2011; Vaa et al., 2011). Both the Maddrey index and the MELD score have also been used to determine the need for pharmacological treatment with steroids or pentoxifylline. Since the early descriptions of AH and the response to various treatments, the general population has aged, become more ethnically diverse, obese, and the prevalence of type 2 diabetes and related comorbidities has increased substantially (Forouhi and Wareham, 2014; Greiver et al., 2014). Conceivably, these could modify the clinical phenotype of affected subjects and even impact their response to therapy. It is also not well known whether the rates of hospitalization, the spectrum of severity particularly among hospitalized subjects, duration of hospitalization, and clinical outcomes are changing over time. Similarly, there are no data from “real-world” cohorts of subjects hospitalized with AH regarding treatment patterns and the response to treatment. Such data are needed to guide policy makers regarding resource allocation to tackle the disease and also to provide evidence of how well current therapies perform in everyday practice. This study is a retrospective analysis of subjects hospitalized with AH from medical centers that use the Cerner® electronic medical record system (Cerner Corporation, Kansas City, MO). The aims of this analysis were to define temporal patterns of rates of hospitalization, race distribution among those admitted with AH, the related comorbidities, clinical features, treatments provided, and the responses to such treatments.