Cirrhosis incidence across socioeconomic and demographic groups in Sweden: a register-based cohort study.
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BACKGROUND: Liver cirrhosis is a leading global cause of morbidity and mortality, with rising incidence driven by alcohol-related liver disease (ALD) and metabolic dysfunction-associated steatotic liver disease (MASLD). Pronounced socioeconomic disparities in ALD-related and MASLD-related cirrhosis highlight the need for targeted prevention strategies in disadvantaged groups. We aimed to investigate socioeconomic and demographic differences in cirrhosis incidence, clinical presentation, and aetiology over time in Sweden. METHODS: We conducted a nationwide, register-based cohort study, including all individuals aged 15 years or older residing in Sweden between 2001 and 2022. Incident cirrhosis cases were identified using validated algorithms. Age-standardised incidence rates (ASIRs) and incidence rate ratios (IRRs) were estimated by sex, region of birth, and household income, with cirrhosis diagnoses subclassified by aetiology and presence of major adverse liver outcomes (MALOs). Individuals were categorised into household income quartiles: low (first quartile [lowest income]), medium (second and third quartiles), and high (fourth quartile [highest income]). Temporal trends in estimated ASIRs were assessed. FINDINGS: 49 550 incident cases of cirrhosis were identified (median age at diagnosis was 64 years [IQR 56-73], 17 776 [36%] were female and 31 774 [64%] were male). The ASIR increased by 30%, from 22·4 per 100 000 persons (95% CI 21·4-23·5) in 2001 to 29·1 (28·0-30·1) in 2022. Individuals in the lowest income group had a three-fold higher risk of cirrhosis than those in the highest (IRR 3·11 [95% CI 3·03-3·20]). MALO status-specific IRRs were similar across income groups, indicating comparable disease severity at diagnosis. ASIRs of ALD-related and MASLD-related cirrhosis increased in all income groups, most notably among those with low income. Viral hepatitis-related cirrhosis increased in this group until 2016, followed by a steep decrease. INTERPRETATION: Cirrhosis incidence in Sweden is increasing and unequally distributed across income groups. These findings are likely to be relevant beyond Sweden, given similar trends in MASLD-related and ALD-related cirrhosis reported across other high-income countries. Targeted prevention and early detection are needed to reduce the growing burden, especially among socioeconomically disadvantaged populations. FUNDING: The Swedish Cancer Society (Cancerfonden), The Swedish Research Council for Health, Working life and Welfare (Forte), The Royal Swedish Academy of Sciences, The Swedish Gastroenterology Fund (Mag-Tarmfonden), The Swedish Research Council (Vetenskapsrådet), and Region Stockholm (CIMED and clinical researcher award).