Clinical trends in hepatocellular carcinoma from 2005 to 2019 with a focus on metabolic diseases: a German nationwide study

INTRODUCTION: Hepatocellular carcinoma (HCC) is the leading primary liver cancer and is associated with a high mortality rate. Liver cirrhosis represents the main risk factor for HCC; however, its underlying etiologies have shifted over the last decade. This German population-based study investigated the effects of the changing trends on etiologies of HCC hospital admissions. METHODS: We analyzed 369 369 HCC-admissions in German hospitals from 2005 to 2019 based on the diagnosis-related groups via German International Classification of Diseases and Operation and Procedure key System codes. Temporal trends and associations were assessed using linear and multivariate logistic regression. RESULTS: HCC admissions increased significantly by 21.8%, from 19 594 in 2005 to 25 899 in 2019, while the in-hospital mortality rate decreased from 13.6 to 10.8%. The most common underlying etiology was alcohol-related liver disease (ALD), accounting for 55.5% of all HCC etiologies, followed by viral hepatitis (32.3%). While admissions of patients with ALD increased by 34.5% from 4008 to 5392, viral hepatitis declined significantly from 3532 to 1580. Metabolic dysfunction-associated steatotic liver disease (MASLD) underlying for HCC represented 4.5%, but exhibited the strongest increase of 3.7-fold among all etiologies. The in-hospital mortality rate of ALD-associated HCC decreased from 15.3 to 11.6%, whereas in viral hepatitis-associated HCC, it remained more similar (11.5 vs. 11.0%). Cardiometabolic risk factors significantly increased in HCC admissions over time ( P < 0.001). Furthermore, HCC admissions exhibited a greater burden of metabolic comorbidities than other malignancies. CONCLUSIONS: This study highlights the increase in underlying ALD, MASLD, and metabolic risk factors in HCC admissions. Especially, cardiometabolic risk factors appear to play a significant role as drivers of hospital admissions in patients with HCC.