Alcohol as a risk factor for mortality in liver transplant patients in Sweden.

OBJECTIVES: Liver transplantation (LT) is the only available cure for end-stage liver disease and one of the best treatment options for hepatocellular carcinomas (HCC). Patients with known alcohol-associated cirrhosis (AC) are routinely assessed for alcohol dependence or abuse before LT. Patients with other liver diseases than AC may consume alcohol both before and after LT. The aim of this study was to assess the effects of alcohol drinking before and after LT on patient and graft survival regardless of the etiology of liver disease. MATERIALS AND METHODS: Between April 2012 and December 2015, 200 LT-recipients were interviewed using the Lifetime Drinking History and the Addiction Severity Index questionnaire. Patients were categorized as having AC, n = 24, HCC and/or hepatitis C cirrhosis (HCV), n = 69 or other liver diseases, n = 107. Patients were monitored and interviewed by transplantation-independent staff for two years after LT with questions regarding their alcohol consumption. Patient and graft survival data were retrieved in October 2019. RESULTS: Patients with AC had an increased hazard ratio (HR) for death after LT (crude HR: 4.05, 95% CI: 1.07-15.33, p = 0.04) and for graft loss adjusted for age and gender (adjusted HR: 3.24, 95% CI 1.08-9.77, p = 0.04) compared to the other patients in the cohort. There was no significant effect of the volume of alcohol consumed before or after LT on graft loss or overall survival. CONCLUSION: Patients transplanted for AC have a worse prognosis, but we found no correlation between alcohol consumed before or after LT and graft or patient survival.

Alcohol and drug use prior to liver transplantation: more common than expected in patients with non-alcoholic liver disease.

Objective: Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease, acute liver failure or hepatocellular carcinoma (HCC). Patients with known alcoholic liver cirrhosis (ALC) are usually assessed by an addiction specialist, but patients with other liver diseases may also exhibit harmful drinking. This study aims to assess the drinking habits in LT-recipients with or without a diagnosis of ALC. Patients and methods: Between April 2012 and December 2015, 190 LT-recipients were interviewed using the Lifetime Drinking History (LDH) and the Addiction Severity Index (ASI). Patients were categorized according to their diagnoses: ALC (group A, n = 39), HCC or hepatitis C (group B, n = 56) or other liver diseases (group C, n = 95). Data were analysed using descriptive statistic methods. Results: Fifteen of 95 patients (15.8%) in group C - a cohort without suspected addiction problems - had either alcohol consumption or binge drinking within the upper quartile of the overall cohort. The aetiology of liver disease in this subgroup included mainly cholestatic and cryptogenic liver disease. Illicit drugs had been used by 35% of all patients. Cannabis and amphetamine were the most common drugs and had the longest duration of regular use. Conclusions: LT candidates without known alcohol or drug use may have a clinically significant consumption of alcohol and previous illicit drug use. Efforts should be put on identification of these patients during LT evaluation. The use of structured questionnaires such as the ASI and the LDH could facilitate detection of alcohol and drug problems.

Statin Use Is Associated With Improved Outcomes of Patients With Primary Sclerosing Cholangitis.

BACKGROUND & AIMS: There is increasing evidence that statins can benefit patients with chronic liver diseases, but their effects have not been studied in patients with primary sclerosing cholangitis (PSC). We performed a nationwide study in Sweden to determine the effects of exposure to drugs, including statins, in patients with PSC. METHODS: We studied a population-based cohort of patients in Sweden with PSC and concomitant ulcerative colitis or Crohn's disease from 2005 through 2014 (n = 2914), followed through 2016. We collected analyzed data from the patient register, the prescribed drug register, the death certificate register and the cancer register. We calculated risk or death, liver transplantation, bleeding of esophageal varices, and cancer in relation to drug exposure. RESULTS: The mean age of patients at the time of diagnosis with PSC was 41.4 years (inter-quartile range [IQR], 25.6-56.1 years). The total follow-up time was 11769 person-years, during which 3.4% of patients received liver transplants and 19.9% died. Proportions of patients exposed to drugs were: ursodeoxycholic acid, 60.2%; 5-aminosalicylic acid, 74.4%; azathioprine or mercaptopurins, 33.7%; and statins, 13.9%. Statin use was associated with a reduced risk of all-cause mortality (hazard ratio [HR], 0.68; 95% CI, 0.54-0.88) and death or liver transplantation (HR, 0.50; 95% CI, 0.28-0.66). Use of azathioprine was also associated with reduced mortality (HR, 0.66; 95% CI, 0.52-0.84) and risk of death or liver transplantation (HR, 0.65; 95% CI, 0.50-0.83). Exposure to ursodeoxycholic acid did not affect mortality (HR, 1.04; 95% CI, 0.87-1.25). CONCLUSION: In a population-based cohort of patients in Sweden with PSC, we associated use of statins and azathioprine with decreased risks of death and death or liver transplantation. Exposure to ursodeoxycholic acid was not associated with reduced mortality.

Statins and Angiotensin-Converting Enzyme Inhibitors are Associated with Reduced Mortality and Morbidity in Chronic Liver Disease.

Liver fibrosis is a common response to many chronic liver diseases. The aim of our study was to explore whether pharmacotherapy for concurrent diseases affects overall mortality, liver-related mortality and liver-related morbidity in patients with chronic liver disease. We performed a register-based cohort study of all patients with a first-time diagnosis of chronic liver disease between 2005 and 2012 in Sweden (n = 70 546). Data from the Patient Register, the Prescribed Drug Register and the Death Certificate Register were linked. We studied whether the use of statins, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and antibiotics affected the risk of total mortality, liver-specific mortality and morbidity. We found a reduction in mortality risk for statin users (n = 11,245) with hazard ratios from 0.57 (95% CI: 0.32-0.99) for patients with autoimmune hepatitis to 0.84 (95% CI: 0.75-0.95) for patients with alcoholic liver disease. There was a significantly reduced liver-related mortality for patients with alcoholic liver disease who used angiotensin-converting enzyme inhibitors, 0.85 (95% CI: 0.65-0.96). There were increased overall mortality risks for antibiotic users (n = 44,572), with hazard ratios up to 1.67 (95% CI, 1.55-1.80) for viral hepatitis. Statin use was associated with decreased risks of liver-specific mortality and morbidity, and reduced total mortality foremost among patients with alcoholic liver disease. Angiotensin -converting enzyme inhibitors was associated with reduced liver-related mortality among patients with alcoholic liver disease.

Exogenous alpha 1-antitrypsin down-regulates SERPINA1 expression.

The main goal of the therapy with purified human plasma alpha1-antitrypsin (A1AT) is to increase A1AT levels and to prevent lungs from elastolytic activity in patients with PiZZ (Glu342Lys) A1AT deficiency-related emphysema. Potential hepatic gains of this therapy are unknown. Herein, we investigated the effect of A1AT therapy on SERPINA1 (gene encoding A1AT) expression. The expression of SERPINA1 was determined in A1AT or A1AT plus Oncostatin M (OSM) treated primary human hepatocytes isolated from liver tissues from A1AT deficient patients and control liver tissues. In addition, SERPINA1 mRNA was assessed in lung tissues from PiZZ emphysema patients with and without A1AT therapy, and in adherent human peripheral blood mononuclear cells (PBMC) isolated from healthy PiMM donors. In a dose-dependent manner purified A1AT lowered SERPINA1 expression in hepatocytes. This latter effect was more prominent in hepatocytes stimulated with OSM. Although it did not reach statistical significance (P = 0.0539)-analysis of lung tissues showed lower SERPINA1 expression in PiZZ emphysema patients receiving augmentation therapy relative to those without therapy. Finally, exogenously added purified A1AT (1mg/ml) reduced SERPINA1 expression in naïve as well as in lipopolysaccharide (LPS)-stimulated human adherent PBMCs. Exogenous A1AT protein reduces its own endogenous expression. Hence, augmentation with native M-A1AT protein and a parallel reduction in expression of dysfunctional mutant Z-A1AT may be beneficial for PiZZ liver, and this motivates further studies.

Pregnancy outcome in more than 5000 births to women with viral hepatitis: a population-based cohort study in Sweden.

Previous studies have shown inconsistent results with respect to hepatitis B (HBV), hepatitis C (HCV) and pregnancy outcome. The aim of this study was to investigate pregnancy outcome in women with HBV or HCV. In a nationwide cohort of births between 2001 and 2011 we investigated the risks of adverse pregnancy outcomes in 2990 births to women with HBV and 2056 births to women with HCV using data from Swedish healthcare registries. Births to women without HBV (n = 1090 979), and births without HCV (n = 1091 913) served as population controls. Crude and adjusted relative risks (aRR) were calculated using Poisson regression analysis. Women with HCV were more likely to smoke (46.7 vs. 8.0%) and to have alcohol dependence (18.9 vs. 1.3%) compared with population controls. Most women with HBV were born in non-Nordic countries (91.9%). Maternal HCV was associated with a decreased risk of preeclampsia (aRR: 0.39, 95% CI: 0.24-0.64), but an increased risk of preterm birth (aRR: 1.32, 95% CI: 1.08-1.60) and late neonatal death (7-27 days: aRR: 3.79, 95% CI: 1.07-13.39) Preterm birth were also more common in mothers with HBV, aRR: 1.21 (95% CI: 1.02-1.45). Both HBV and HCV are risk factors for preterm birth, while HCV seems to be associated with a decreased risk for preeclampsia. Future studies should corroborate these findings.

The underreporting of hepatocellular carcinoma to the cancer register and a log-linear model to estimate a more correct incidence.

The Cancer Register (CR) in Sweden has reported that the incidence of primary liver cancer (PLC) has slowly declined over the last decades. Even though all cancers, irrespective of diagnostic method, should be reported to the CR, the PLC incidence may not reflect the true rate. Improved diagnostic tools have enabled diagnosis of hepatocellular carcinoma based on noninvasive methods without histological verification, possibly associated with missed cancer reports or misclassification in the CR. Our objective was to study the completeness and assess the underreporting of PLC to the CR and to produce a more accurate estimate based on three registers. The CR, the Cause of Death Register, and the Patient Register were investigated. Differences and overlap were examined, the incidence was estimated by merging data from the registers, and the number reported to none of the registers was estimated using a log-linear capture-recapture model. The results show that 98% of the PLCs reported to the CR were histologically verified; 80% were hepatocellular carcinoma and 20% were intrahepatic cholangiocarcinoma. Unspecified liver cancer decreased over time and constituted <10% of all reported liver cancers. The CR may underestimate the liver cancer incidence by 37%-45%, primarily due to missed cancer reports. The estimated annual number of liver cancers increased over time, but the standardized incidence was stable around 11 per 100,000. Hepatitis C-associated liver cancer increased and constituted 20% in 2010. CONCLUSION: There was an underreporting of PLC diagnosed by noninvasive methods; the incidence was considerably higher than estimated by the CR, with a stable incidence over time; reporting needs to improve and combining registers is recommended when studying incidence. (Hepatology 2017;65:885-892).

Increased risk of preterm birth in women with autoimmune hepatitis - a nationwide cohort study.

BACKGROUND & AIMS: The aim of our study was to investigate the risks of pregnancy and childbirth complications in women with autoimmune hepatitis compared to the population controls. METHODS: In a nationwide cohort study of all pregnancies between 2006 and 2011 we investigated the risks of adverse pregnancy outcome in 171 births in women with diagnosed autoimmune hepatitis using the data from the Swedish Medical Birth and Patient Registries. Births to women without autoimmune hepatitis served as population controls (n = 576 642). Relative risks (RR) with 95% confidence intervals (CI) were calculated using Poisson regression models adjusting for potential confounders. RESULTS: Women with AIH had an increased risk of gestational diabetes (RR = 4.35, 95% CI 2.21-8.57), of preterm birth (RR = 3.21, 95% CI 1.97-4.92) and of low-birth-weight child (RR = 2.51, 95% CI 1.51-4.19). We found no statistically significant association between autoimmune hepatitis and pre-eclampsia, caesarean section, low 5-min Apgar score, small for gestational age birth, congenital malformation and neonatal mortality. CONCLUSIONS: Autoimmune hepatitis is a risk factor for adverse pregnancy outcomes. High quality prenatal and antenatal care is important for women with autoimmune hepatitis and their infants.

Adverse outcomes of pregnancy in women with non-alcoholic fatty liver disease.

BACKGROUND & AIMS: Non-alcoholic fatty liver disease (NAFLD) is considered the most common liver disease in the world, but little is known about its potential association with pregnancy outcomes. We aimed to investigate pregnancy outcomes in NAFLD. METHODS: The Swedish Medical Birth Register (MBR) was used to identify births between 1992 and 2011 (N = 1 960 416). By linkage with the National Patient Register, we identified women with a diagnosis of NAFLD. The MBR was then used to identify outcomes: gestational diabetes, pre-eclampsia, Caesarean section, Apgar score <7 at 5 min, preterm birth (<37 weeks), low birth weight (<2500 g), infants born small for gestational age and congenital malformations. As controls, we used women with no diagnosis for NAFLD divided into two groups; with and without polycystic ovary syndrome (PCOS). Poisson regression was used to estimate relative risks (RRs) adjusted for maternal age, smoking status and body mass index at early pregnancy, parity and prepregnancy diabetes. RESULTS: We identified 110 pregnancies in women with NAFLD. Using women without a diagnosis of NAFLD or PCOS as controls; NAFLD was associated with gestational diabetes [adjusted RRs 2.78; 95% confidence interval (CI): 1.25-6.15], pre-eclampsia (aRR 1.95; 95% CI 1.03-3.70), Caesarean section (aRR 1.52; 95% CI 1.19-1.94), preterm birth (aRR 2.50; 95% CI 1.38-4.55) and with low birth weight (aRR 2.40; 95% CI 1.21-4.78). CONCLUSION: Women with a diagnosis of NAFLD prior to giving birth have increased risks for adverse pregnancy outcome independently of body mass index and diabetes, and should be carefully monitored during antenatal care.

Alcohol intake measured by phosphatidylethanol in blood and the lifetime drinking history interview are correlated with the extent of psoriasis.

BACKGROUND: Psoriasis has been reported to be associated with alcohol consumption. OBJECTIVE: To investigate the level of alcohol intake in individuals with psoriasis and correlate intake with the extent of disease and pruritus. METHODS: Twenty-nine outpatients (15 females and 14 males) with stable chronic plaque psoriasis of moderate severity were recruited. The Psoriasis Area and Severity Index (PASI) and the degree of pruritus (visual analogue scale) were compared with measures of drinking habits as determined by the Lifetime Drinking History (LDH), the Alcohol Use Disorders Identification Test and whole-blood phosphatidylethanol (PEth), an alcohol-specific biomarker. RESULTS: The majority of patients were social drinkers with moderate alcohol consumption as determined by PEth and LDH. Alcohol consumption correlated significantly with the PASI score. There was no correlation between alcohol use and pruritus. CONCLUSION: The level of alcohol consumption is correlated with the extent of psoriasis.

Increased risks of epilepsy and neuropsychiatric diseases in children of mothers with alcoholic liver disease.

BACKGROUND: Pregnancy in women with liver disease may increase the risk of fetal complication. Data on disease frequencies in children born to mothers with alcoholic liver disease do not exist, although we do know that prenatal alcohol exposure may affect the fetus negatively. AIMS: The aim of this study was to assess the relative risk of neuropsychiatric diseases in children who were born to mothers with chronic liver diseases. METHODS: We linked the Hospital Discharge Register, Medical Birth Register and Pharmaceutical Register in Sweden between 1969 and 2009 to identify women with liver disease. We identified their children, up to the age of 16 in the Medical Birth Register, born between 1973 and 2009. Between 2005 and 2009, we identified every prescription that was dispensed to these children. RESULTS: We identified 5 124 children of mothers with alcoholic liver disease. There were 22,960 children of mothers with non-alcoholic liver disease. For controls, we used 10 sex-, age- and birthplace-matched children. There were more children born to mothers with alcoholic liver disease before the birth who had been dispensed antiepileptics (n = 11, RR = 3.2 (1.6-6.4)), neuroleptics (n = 7, RR = 5.0 (2.0-12.5)) and drugs to treat attention deficit hyperactivity disorders (n = 22, RR = 5.9 (3.7-9.4)) compared with sex-, age- and regionally adjusted controls. Children born to mothers with non-alcoholic liver disease had significantly increased risk of being dispensed drugs to treat attention deficit disorders (RR = 2.2 (1.8-2.6)). CONCLUSIONS: Mothers with alcoholic liver disease have increased risks of having children with severe neurological and psychiatric disorders.

Mothers with alcoholic liver disease and the risk for preterm and small-for-gestational-age birth.

AIMS: To study pregnancy outcome in women with alcoholic liver disease (ALD). METHODS: Using the Swedish nation-wide Patient and Medical Birth Registers, we investigated risk of adverse pregnancy outcome in 720 women diagnosed with ALD before and 1720 diagnosed after birth and compared them with 24 460 population-based control births. RESULTS: Women with ALD diagnosed before or after birth were generally of higher age and body mass index, more likely to smoke cigarettes during pregnancy and to have a low socio-economic status compared with controls. Women diagnosed with ALD before birth had an increased risk of moderately and very preterm birth, adjusted odd ratio (OR) = 1.53 (95% confidence interval (CI): 1.37-1.72 and 1.15-2.06 95%), respectively. Infants of mothers with ALD before birth were more often small-for-gestational age, adjusted OR = 1.22 (95% CI: 1.05-1.43), and were at increased risk for low Apgar scores (<7) at 5 min, adjusted OR = 1.49 (95% CI: 1.15-1.92) compared with controls. Similar associations with slightly lower-risk estimates were found among women diagnosed with ALD after birth. CONCLUSIONS: ALD is associated with adverse-birth outcomes, highlighting the importance of screening women for alcohol dependence in antenatal care.

Alcohol consumption in patients with primary sclerosing cholangitis.

AIM: To assess the alcohol drinking patterns in a cohort of primary sclerosing cholangitis (PSC) patients and the possible influence on the development of fibrosis. METHODS: Ninety-six patients with PSC were evaluated with a validated questionnaire about a patient's lifetime drinking habits: the lifetime drinking history (LDH) questionnaire. In addition, clinical status, transient elastography and biochemistry values were analysed and registered. Patients were defined as having either significant or non-significant fibrosis. Significant fibrosis was defined as either an elastography value of ≥ 17.3 kPa or the presence of clinical signs of cirrhosis. Patients were divided into two groups depending on their alcohol consumption patterns; no/low alcohol consumption (one drink or unit/d) and moderate/high alcohol consumption (≥ 1 drink or unit/d). LDH data were calculated to estimate lifetime alcohol intake (LAI), current alcohol intake, drinks per year before and after diagnosis of PSC. We also calculated the number of episodes of binge-drinking (defined as consuming ≥ 5 drinks per occasion) in total, before and after the diagnosis of PSC. RESULTS: The mean LAI was 3882 units of alcohol, giving a mean intake after onset of alcohol consumption of 2.6 units per week. Only 9% of patients consumed alcohol equal to or more than one unit per day. Current alcohol intake in patients with significant fibrosis (n = 26) was less than in patients without significant fibrosis (n = 70), as shown by lower values of phosphatidylethanol (B-PEth) (0.1 µmol/L vs 0.33 µmol/L, respectively, P = 0.002) and carbohydrate-deficient transferrin (CDT) (0.88% vs 1.06%, respectively, P = 0.02). Self-reported LAI was similar between the two groups. Patients with significant fibrosis reduced their alcohol intake after diagnosis from 103 to 88 units per year whereas patients without fibrosis increased their alcohol intake after PSC diagnosis from 111 to 151 units/year. There were no correlations between elastography values and intake of alcohol (units/year) (r = -0.036). CONCLUSION: PSC patients have low alcohol consumption. The lack of correlation between fibrosis and alcohol intake indicates that a low alcohol intake is safe in these patients.

Increased risk of esophageal varices, liver cancer, and death in patients with alcoholic liver disease.

BACKGROUND AND AIMS: During the last decades, a multitude of different treatments for chronic liver disease have been introduced. New surveillance programs have been established to detect esophageal varices and liver cancer. The aims of our study were to assess whether the prognosis for patients hospitalized with liver diseases between 1969 and 2006 had improved and to study the differences in mortality and complications between patients with alcoholic liver disease and nonalcoholic liver diseases. METHODS: We used the Swedish Hospital Discharge Register and Cause of Death Register at the National Board of Health and Welfare in Sweden between 1969 and 2006 to identify and follow-up a cohort of patients with liver disease according to the International Classification of Diseases-8, -9, and -10. RESULTS: There were 36,462 patients hospitalized with alcoholic and 95,842 with nonalcoholic liver diseases. The main finding was that patients hospitalized with alcoholic liver disease had an increased mortality risk, compared to patient with nonalcoholic liver disease, 1.89 (1.85 to 1.92). In addition, the patients with alcoholic liver disease had an increased risk for esophageal varices and liver cancer. There was a reduced risk for hospitalization with esophageal varices for patients with nonalcoholic liver disease up to 1998. CONCLUSIONS: We found that the prognosis for patients hospitalized with chronic liver diseases had not improved. Patients with alcoholic liver disease have an increased risk of complications, which suggest that the disease is more aggressive and are in need of closer follow-up than other chronic liver diseases.

Different drinking patterns for women and men with alcohol dependence with and without alcoholic cirrhosis.

AIM: The aim of our study was to investigate if there were differences in drinking patterns in patients with alcohol dependence (AD), with or without cirrhosis. METHODS: We examined three groups in regard to differences in drinking patterns. We collected information from 50 patients with alcoholic cirrhosis (AC), 50 patients with AD, and 40 patients with non-alcoholic cirrhosis (NAC). We used the structured interview Lifetime Drinking History (LDH) to measure the alcohol consumed. Information regarding the total lifetime alcohol intake (LAI), drinking days (DD), drinks per drinking day (DDD), their beverage preferences, and their binge consumption was collected during interviews. RESULTS: Women drank less than men. Women with AC reported 9,198 drinks as binge drinking compared to 25,890 drinks for women with AD without liver cirrhosis (P < 0.05), Women with AC reported 14,009 drinks of alcohol consumed during their lifetime compared to 45,658 drinks consumed by men with AC (P < 0.0001). Women with AD had drunk 5.8 DDD, and men had 8.5 DDD (P < 0.05). Both women and men with AC had significantly fewer DDD compared to men and women with AD without cirrhosis, 4.4 drinks for women (P = 0.046) and 6.2 for men (P = 0.048) with AC. CONCLUSIONS: Patients with AC seem to be predisposed to the hepatotoxic effects of alcohol- and the affected women seem to be even more sensitized. Binge drinking, rather than continuous drinking, does not seem to be especially associated with the development of cirrhosis. That women had drunk less alcohol during binge drinking further emphasizes this.

Morbidity and mortality in liver diseases in Sweden 1969-2001 in relation to alcohol consumption.

OBJECTIVE: In Sweden, there is stable or slightly increased total alcohol consumption but a decrease in mortality in liver disease. The aim of the study was to determine the temporal relation between alcohol-related liver disease morbidity and mortality and type of alcohol beverage consumption. MATERIAL AND METHODS: Data on patients with liver disease from the Swedish Hospital Discharge Register and from the Causes of Death Register between 1969 and 2001 were analysed. Data on the registered sales of the different beverages were taken from the Swedish State Monopoly. RESULTS: Liver disease mortality increased from 1969 to 1976, coinciding with the increase in sales of spirits. Both mortality and spirits sales decreased thereafter, whereas there was no decrease in beer or wine sales. Hospitalization rates were reduced after 1987. Depending on age and gender, there was a 30-80% 5-year mortality rate following discharge. Among men, but not among women, differences in the alcohol and non-alcohol-related liver diagnoses in the Hospital Discharge Register and in the Cause of Death Register were sometimes recorded in the same patient. CONCLUSIONS: There was a reduction in hospitalization rates and mortality in liver diseases, and the reduction in mortality in liver diseases in Sweden from 1969 to 2001 seems to be associated with sales of spirits. Patients hospitalized for liver disease have a poor prognosis. There were difficulties in differentiating between alcohol and non-alcohol liver diseases.

Improved prognosis for patients hospitalized with esophageal varices in Sweden 1969-2002.

Liver cirrhosis may be complicated by the development of esophageal varices. The treatment of esophageal varices has changed radically during the last 30 years. Our aim was to study whether the prognosis for patients with esophageal varices had improved in Sweden between 1969 and 2002. We linked register data from the Hospital Discharge Register and from the Causes of Death Register at The National Board of Health in Sweden between 1969 and 2002 to identify and follow-up all patients with esophageal varices according to International Classification of Diseases-8, -9, and -10. There were 12,281 patients hospitalized with esophageal varices, and for all patients there was an increase in the 5-year survival in the years between 1969 and 1979 as opposed to the years between 1990 and 2002. Better survival occurred for women compared with men, for younger patients compared with older, and for patients hospitalized in the latest decade compared with the earlier decades. We found a significant decrease in the mortality caused by esophageal varices during the years studied but no decrease attributable to other causes. In conclusion, mortality for patients hospitalized with esophageal varices in Sweden decreased between 1969 and 2002. The decrease is seen for both 1- and 5-year mortality, and this suggests that the use of new treatment strategies both for acute variceal hemorrhage and secondary prophylaxis has had an impact on prognosis.