Burden of MASLD-related cirrhosis and liver cancer in 2023Prevalence

Over the past decades, the burden of cirrhosis and liver cancer attributable to MASLD exhibited an increasing trend (Fig. 1). Specifically, China had the highest number of MASLD-related CLD including cirrhosis and MASLD-related liver cancer cases in 2023, at 288,635,767 (95% UI: 264,471,288.01–317,923,080.69) and 13,780 (95% UI: 10,967.43–17,291.16), respectively (Table 1, Table S1). These estimates should not be interpreted as all-cause cirrhosis or clinically diagnosed decompensated cirrhosis. Rather, they reflect the GBD-defined NAFLD attributable cirrhosis burden, reported here using current MASLD terminology. The corresponding estimates accounted for 22.88% and 22.31% of the global GBD-estimated MASLD-related prevalence totals (1,261,565,156 [95% UI: 1,160,281,259.64–1,394,724,446.36] and 61,759 [95% UI: 46,892.60–79,766.68) prevalence cases), respectively12,19.

Fig. 1

Trends for the age-standardized prevalence (A and B), incidence (C and D), and mortality (E and D) rates of MASLD-related CLD including cirrhosis (left) and liver cancer (right) in Brazil, China, Germany, Japan, South Korea, South Africa, UK, and US from 2010 to 2023. MASLD metabolic dysfunction-associated steatotic liver disease. CLD chronic liver diseases

Table 1 The numbers and age-standardized rates of MASLD-related chronic liver diseases including cirrhosis and liver cancer in eight countries in 2023

For MASLD-related CLD including cirrhosis, South Africa showed the highest age-standardized prevalence rates (ASPR), with 16,823.00 (95% UI: 15,325.48–18,684.93), followed by Brazil at 16,275.08 (95% UI: 14,865.29–18,044.69). Among high-income countries, the US, with the largest baseline number among developed nations, saw an increase from 34,379,299.33 (95% UI: 31,541,629.89–38,122,866.73) to 42,967,994.91 (95% UI: 39,406,149.42–47,525,913.57) during the study period, with an ASPR of 9,543.63 (95% UI: 8,737.60–10,610.27) in 2023.

In terms of MASLD-related liver cancer, South Korea reported the highest ASPR, with 2.31 (95% UI: 1.25–3.97), followed by South Africa at 1.12 (95% UI: 0.86–1.49). Notably, Japan was the only country where the number of prevalent cases of MASLD-related liver cancer decreased, from 4,405.28 (95% UI: 3,521.68–5,500.14) in 2010 to 3,560.28 (95% UI: 2,532.00- 4,916.77) in 2023. This trend contrasts sharply with that of other selected countries and may reflect successful public health measures in Japan regarding liver cancer screening or the management of risk factors associated with MASLD.

Incidence

In 2023, China reported the highest number of CLD including cirrhosis cases attributable to MASLD at 9,365,112 (95% UI: 8,596,338.43–10,153,430.95), with an age-standardized incidence rates (ASIR) of 605.13 (95% UI: 548.26–655.54) per 100,000, which is higher than the global estimate of 582.67 (95% UI: 535.36–630.51) per 100,000 [19]. In addition, the US documented 1,484,534 new cirrhosis cases (95% UI: 1,359,319.66–1,617,824.43), followed by Brazil with 1,444,395 cases (95% UI: 1,335,734.42–1,554,711.48), corresponding to ASIR of 394.46 (95% UI: 362.05–430.39) and 629.80 (95% UI: 581.45–680.67) per 100,000 population, respectively Table 2.

Table 2 The numbers and age-standardized rates change (2010–2023) of prevalence, incidence, and mortality of MASLD-related chronic liver diseases including cirrhosis and liver cancer

Regarding the incidence burden of MASLD-related liver cancer, China reported the highest number of incident cases at 10,201 (95% UI: 8,130.64–12,849.61), significantly surpassing all other countries. South Korea, however, had the highest ASIR at 1.21 per 100,000 population (95% UI: 0.76–1.85), which is higher than the global estimate of 0.50 (95% UI: 0.38–0.63) per 100,000.

Mortality

In 2023, US recorded the highest mortality attribute to MASLD-related CLD including cirrhosis at 6,241 (95% UI: 4,279.55–8,683.63), followed by China with 4,933 (95% UI: 3,282.90–6,910.09) deaths, ranking them among the highest globally (89,762 [95% UI: 64,645.31–120,282.02]). However, the UK had the highest age-standardized mortality rates (ASMR) at 2.72 per 100,000 population (95% UI: 2.06—3.41), followed by Germany with a rate of 2.21 (95% UI: 1.58–2.92), which is also higher than the global estimate of 0.99 (95% UI: 0.72–1.32) per 100,000.

As for liver cancer, the estimated number of deaths in China was 9,259 (95% UI: 7,287.91–11,340.51), the highest burden among the countries analyzed. This figure accounted for 21.19% of the global total (41,721 [95% UI: 31,558.60–52,601.47]. The US followed with 2,782 deaths (95% UI: 2,289.57–3,358.09). In terms of ASMR, South Africa had the highest rate at 0.93 per 100,000 population (95% UI: 0.70–1.26), followed by the South Korea at 0.92 per 100,000 (95% UI: 0.57–1.31), both higher than the global estimate of 0.46 (95% UI: 0.35–0.58) per 100,000. Among the eight countries analyzed, Brazil had the lowest mortality rate at 0.15 per 100,000 (95% UI: 0.12–0.17). The proportion of MASLD-related liver cancer attributed to risk factors varied by country in 2023 (Figure S1).

Trends in MASLD-related cirrhosis and liver cancer burden, 2010–2023MASLD-related cirrhosis

From 2010 to 2023, the number and ASRs of all the three measures (prevalence, incidence, and mortality) for MASLD-related CLD including cirrhosis showed substantial heterogeneity in disease burden trends across nations (Table S2). Specifically, South Africa experienced the largest number of cirrhosis prevalence and incidence cases increased by 52.73% (95% UI: 50.47–54.87%) and 33.22% (95% UI: 29.76–37.43), respectively. However, ASMR presented decreasing trends, with AAPC of −0.71% (95% CI: -1.86–−0.44%) (Table S3). China exhibited the highest percentage change of ASIR at 13.09% (95% UI 11.70–14.44), indicating the most substantial increase in incidence, while the South Korea showed a percentage change of −8.32% (95% UI −15.12–−2.61), representing the only decline among the countries studied. In addition, ASMR showed significant declines in China, the South Korea, and Japan, but the South Korea exhibited the most pronounced decreasing trend, with an EAPC of −3.00 (95% CI −3.34–−2.66). In stark contrast, the UK and the US exhibited significant increases in ASMR with values of 28.04% (95% UI: 17.64–40.31) and 26.78% (95% UI 14.83–38.27), respectively.

MASLD-related liver cancer

Table S2 shown the trends from 2010 to 2023 in the ASRs and liver cancer cases in eight countries. Specifically, the UK experienced the most pronounced increase in the number of prevalence, new cases, and deaths, with a PC of 100.22% (95% UI 44.94–177.85), 96.31% (95% UI 69.45–125.05), and 96.38% (95% UI 78.26–117.84). Similarly, between 2010 and 2023, the UK experienced the most pronounced increase in the age-standardized prevalence, incidence and mortality rates of MASLD-related liver cancer. Moreover, the prevalence-associated EAPC (3.44%; 95% CI, 2.87–4.01) and AAPC (4.02%; 95% CI, 3.85–4.20), incidence-associated EAPC (3.24%; 95% CI, 2.61–3.87) and AAPC (3.89%; 95% CI, 3.62–4.16), and mortality-associated EAPC (3.12%; 95% CI, 2.47–3.77) and AAPC (3.90%; 95% CI, 2.99–4.81) were the highest in the UK, indicating a rapid escalation trend in this disease burden (Table S3). Notably, Japan was the only country to show a decline trend among all measures, including the number cases, ASRs, EAPC and AAPC of prevalence, incidence and mortality, reflecting a significant decline in disease burden, successful public health interventions, and disease prevention efforts.

Trends in MASLD-related cirrhosis and liver cancer by sex

In 2023, the prevalence, incidence, and mortality rates of MASLD-related CLD including cirrhosis and liver cancer were generally higher in males than in females across most countries analyzed (Fig. 2). However, in China, the prevalence and incidence of cirrhosis were slightly higher in females, although the mortality rates were comparable between sexes. Generally, the ASMR was higher in females than in males, with Germany and the UK exhibiting the highest rates, while China and the South Korea reported the lowest rates. Regarding liver cancer, Japan and the South Korea showed a slightly higher prevalence in females, a trend also observed in the incidence rates in the South Korea and the UK. In Brazil, the three measures (prevalence, incidence, and mortality rates) were comparable between sexes. Additionally, in Japan, the South Korea, Germany, and Brazil, women had slightly higher MASLD-related liver cancer mortality rates than men.

Fig. 2

The age-standardized prevalence, incidence, and mortality rates of MASLD-related CLD including cirrhosis, and liver cancer classified by gender in 2023. A MASLD-related cirrhosis prevalence; B MASLD-related liver cancer prevalence; C MASLD-related cirrhosis incidence; D MASLD-related liver cancer incidence; E MASLD-related cirrhosis mortality; F MASLD-related liver cancer mortality. CLD chronic liver diseases

As shown in Tables S4 and S5, the prevalence, incidence, and mortality of MASLD-related CLD including cirrhosis and liver cancer have displayed significant upward trends in recent years. Regarding the trends of MASLD-related cirrhosis, South Africa reported the highest increases in both prevalence and incidence, with prevalence rates increasing by 55.89% in males, while incidence rose by 32.02%. However, the ASRs rose the most in China (Fig. 3), with prevalence in males increasing by 13.89% and incidence by 12.78%. The EAPC for prevalence was also the highest in males, highlighting the sustained growth in these measures. In contrast, South Korea experienced a decline in both the number and ASRs for incidence, with a negative change across both measures. The burden of liver cancer also exhibited a rising trend. Particularly, there was a marked rise in the number of cases in the UK, with prevalence increasing by 110.29% males and incidence rising by 102.97%, reflecting a substantial upward trend in the disease burden. Conversely, Japan exhibited a decline in both the number of cases and the ASRs, particularly for prevalence and incidence, with negative changes across these measures and a corresponding negative EAPC.

Fig. 3

The age-standardized change of prevalence, incidence, and mortality of MASLD-related CLD including cirrhosis, and liver cancer classified by gender from 2010–2023. A MASLD-related cirrhosis prevalence; B MASLD-related liver cancer prevalence; C MASLD-related cirrhosis incidence; D MASLD-related liver cancer incidence; E MASLD-related cirrhosis mortality; F MASLD-related liver cancer mortality. CLD chronic liver diseases

MASLD-related cirrhosis and liver cancer burden by age

The prevalence of MASLD-related CLD including cirrhosis varies significantly by age and countries (Fig. 4). Prevalence is generally higher in middle-aged populations (50–64 years), with countries like South Africa exhibiting the highest rates. However, in certain countries like China and Brazil, female prevalence is comparable to or even exceeds male prevalence, particularly in older age groups. The incidence of MASLD-related cirrhosis follows a similar pattern, with higher rates observed in men, though women surpass men in incidence after the age of 75 in most countries, including Japan and the US.

Fig. 4

The age-standardized rates of prevalence, incidence, and mortality of MASLD-related CLD including cirrhosis, and liver cancer classified by age and countries. A MASLD-related cirrhosis prevalence; B MASLD-related liver cancer prevalence; C MASLD-related cirrhosis incidence; D MASLD-related liver cancer incidence; E MASLD-related cirrhosis mortality; F MASLD-related liver cancer mortality. CLD chronic liver diseases

For MASLD-related liver cancer, the prevalence peaks in the 80–84 age group, showing consistent higher rates in males than females across most countries. The incidence follows a similar trend, with the highest rates observed in older age groups, particularly in South Korea and Japan. Mortality rates also rise with age, reaching their highest in the 80–84 age group, with significant gender disparities, as male mortality is generally higher than female mortality across most countries.

Relationship between MASLD-related cirrhosis and liver cancer and SDI

Figure 5 illustrates the trends in age-standardized incidence and mortality rates of MASLD-related CLD including cirrhosis across SDI quintile categories in 8 countries from 2010 to 2023. A general upward trend was observed in most regions. However, the ASIR in South Korea initially increased slightly before significantly declining as SDI values rose. Regarding ASMR, when the SDI was below 0.7, the cirrhosis burden remained relatively stable with rising SDI. However, beyond an SDI of 0.8, significant variations in the impact of SDI across these regions were evident observed. The UK and Germany experienced the steepest increases in disease burden, while the USA saw more modest growth. Notably, South Korea was the only country where the burden decreased as the SDI value increased.

Fig. 5

SDI analysis results. A Incidence for MASLD-related CLD including cirrhosis; B Mortality for MASLD-related CLD including cirrhosis; C Incidence for MASLD-related liver cancer; D Mortality for MASLD-related liver cancer. CLD chronic liver diseases

For MASLD-related liver cancer, the correlation between SDI and the ASIR mirrored that of the ASMR. Overall, a general increase in disease burden was identified in most regions, with both the age-standardized incidence and mortality rates showing a pronounced rise as SDI values increased. However, in Japan and South Korea, the disease burden significantly decreased as SDI values rose.

Decomposition analysis for cirrhosis and liver cancer burden, 2010–2023

A decomposition analysis examined the contributions of population aging, population growth, and epidemiological changes to incidence and mortality attributable to MASLD-related CLD including cirrhosis between 2010 and 2023 (Figure S2). In China, the sharp rise in cases was primarily driven by increased epidemiological risk (96.89%) and population growth (54.98%), while population aging had a counteracting effect (-51.88%). The South Korea, however, saw a slight decrease in absolute incident cases, driven by a strong negative contribution from epidemiological rates. In addition, the US and the UK experienced the largest increases in deaths, primarily driven by epidemiological changes. Detailed results are provided in Table S6.

In terms of MASLD-related liver cancer, population aging was the primary driver of rising liver cancer incidence in most countries, with contributions exceeding 40% in Brazil, South Korea, China, the US, and South Africa. The US, UK, and Germany experienced a multi-factor driven increase in incidence, with significant contributions from both aging and an increase in age-specific rates. Furthermore, population aging was a significant contributor to increased death counts in all nations, with its impact ranging from 24.92% in Germany to 107.2% in China. In Japan, although population aging contributed positively, its effect was counteracted by a significant negative contribution from epidemiological changes (-283.17%), resulting from a decline in age-specific death rates.