Changing etiological spectrum of cirrhosis in China: a systematic review and meta-analysis

Cirrhosis remains a major public health challenge in China and has historically been driven mainly by chronic viral hepatitis. However, alcohol-related liver disease and metabolic liver disease have received increasing attention in recent decades. Changes in hepatitis B vaccination, antiviral therapy, blood safety, alcohol consumption, and metabolic risk factors may have altered the reported etiological profile of cirrhosis. Existing evidence remains largely region-specific, hospital-based, or limited to particular time periods. This systematic review and meta-analysis aimed to characterize the reported etiological spectrum of cirrhosis in mainland China and to describe temporal and regional patterns.

We searched PubMed, Scopus, Embase, Web of Science, CNKI, Wanfang Data, and Sinomed for studies published from January 1990 to December 2025. Observational studies reporting the etiological distribution of cirrhosis in adults or children in mainland China were included. For adults, the principal etiological ranking was based on mutually exclusive categories, with single reported etiologies and explicitly reported mixed etiologies analyzed separately. Temporal and regional analyses used inclusive factor-related groupings, in which mixed etiologies contributed to each relevant etiological factor. For children, broad reported etiological categories were summarized because many pediatric studies did not fully subclassify post-hepatitic cirrhosis by viral subtype. Pooled proportions were estimated using random-effects models, and heterogeneity was assessed using the I² statistic.

A total of 71 studies were included, comprising 59 studies contributing adult data and 12 studies contributing pediatric data. In adults, hepatitis B virus (HBV)-only cirrhosis was the most frequently reported single etiology, with a pooled proportion of 54.5% (95% CI: 51.2–57.8), followed by alcohol-only cirrhosis at 11.8% (95% CI: 10.1–13.6) and hepatitis C virus (HCV)-only cirrhosis at 5.9% (95% CI: 4.3–7.7). Cryptogenic cirrhosis accounted for 5.3% (95% CI: 4.1–6.6), and schistosomiasis-related cirrhosis accounted for 3.9% (95% CI: 0.7–9.4). In children, viral/post-hepatitic cirrhosis was the most frequently reported broad category, accounting for 47.9% (95% CI: 33.3–62.6). In inclusive temporal and regional analyses among adults, HBV-related cirrhosis remained the most frequently reported factor-related grouping across study periods and regions, while alcohol-related cirrhosis showed non-monotonic temporal variation and was highest in 2020–2025.

HBV remains the leading reported etiology of cirrhosis in mainland China, although the reported etiological profile has become more diverse over time. Alcohol-related cirrhosis, HCV-related regional burden, and under-recognized metabolic liver disease warrant further attention. Given substantial heterogeneity, these estimates should be interpreted as descriptive summaries rather than nationally uniform proportions. These findings support continued HBV prevention and treatment, expanded HCV screening, linkage to care, and direct-acting antivirals (DAAs) treatment coverage, improved ascertainment of metabolic liver disease, and more standardized reporting of mixed-etiology cirrhosis.