Retrospective Cohort Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 27, 2020; 12(11): 993-1003
Published online Nov 27, 2020. doi: 10.4254/wjh.v12.i11.993
Cannabis use history is associated with increased prevalence of ascites among patients with nonalcoholic fatty liver disease: A nationwide analysis
Catherine J Choi, Stanley H Weiss, Umair M Nasir, Nikolaos T Pyrsopoulos
Catherine J Choi, Umair M Nasir, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07101, United States
Stanley H Weiss, Department of Medicine, Biostatistics and Epidemiology, Rutgers New Jersey Medical School, Newark, NJ 07103, United States
Nikolaos T Pyrsopoulos, Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ 07103, United States
Author contributions: Choi CJ designed the study, acquired data, performed statistical analysis, drafted, and edited this manuscript; Weiss SH supervised the design and reviewed statistical analysis of the study and edited the manuscript; Nasir UM acquired data, and edited the draft; Pyrsopoulos NT designed and supervised the study, and edited the manuscript.
Institutional review board statement: The activities described in our study do not meet the regulatory definition of human subjects research, and therefore our study was deemed not requiring approval by Rutgers Institutional Review Board (IRB).
Conflict-of-interest statement: Dr. Pyrsopoulos is a recipient of research grants from Mallinckrodt, Valeant, Gilead, Bayer, Beigene, Genfit, Prometheus, Grifols, Intercept, Zydus, and Eisai. Dr. Pyrsopoulos also has served as a consultant for Bayer, and Eisai. The other authors have no potential conflicts of interest to report.
STROBE statement: The authors have read the STROBE Statement—a checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—a checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Nikolaos T Pyrsopoulos, FACP, MD, PhD, Director, Doctor, Professor, Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers-New Jersey Medical School, 185 S. Orange Avenue, MSB H-535, Newark, NJ 07103, United States.
Received: June 4, 2020
Peer-review started: June 4, 2020
First decision: July 30, 2020
Revised: August 27, 2020
Accepted: October 23, 2020
Article in press: October 23, 2020
Published online: November 27, 2020

Recent studies have revealed the endocannabinoid system as a potential therapeutic target in the management of nonalcoholic fatty liver disease (NAFLD). Cannabis use is associated with reduced risk for NAFLD, we hypothesized that cannabis use would be associated with less liver-related clinical complications in patients with NAFLD.


To assess the effects of cannabis use on liver-related clinical outcomes in hospitalized patients with NAFLD.


We performed a retrospective matched cohort study based on querying the 2014 National Inpatient Sample (NIS) for hospitalizations of adults with a diagnosis of NAFLD. The NIS database is publicly available and the largest all-payer inpatient database in the United States. The patients with cannabis use were selected as cases and those without cannabis were selected as controls. Case-control matching at a ratio of one case to two controls was performed based on sex, age, race, and comorbidities. The liver-related outcomes such as portal hypertension, ascites, varices and variceal bleeding, and cirrhosis were compared between the groups.


A total of 49911 weighed hospitalizations with a diagnosis of NAFLD were identified. Of these, 3820 cases were selected as the cannabis group, and 7625 non-cannabis cases were matched as controls. Patients with cannabis use had a higher prevalence of ascites (4.5% vs 3.6%), with and without cannabis use, P = 0.03. The prevalence of portal hypertension (2.1% vs 2.2%), varices and variceal bleeding (1.3% vs 1.7%), and cirrhosis (3.7% vs 3.6%) was not different between the groups, with and without cannabis use, all P > 0.05. Hyperlipidemia, race/ethnicity other than White, Black, Asian, Pacific Islander or Native American, and higher comorbidity score were independent risk factors for ascites in the cannabis group. Among non-cannabis users, obesity and hyperlipidemia were independent protective factors against ascites while older age, Native American and higher comorbidity index were independent risk factors for ascites.


Cannabis was associated with higher rates of ascites, but there was no statistical difference in the prevalence of portal hypertension, varices and variceal bleeding, and cirrhosis.

Keywords: Nonalcoholic fatty liver disease, Fatty liver, Cannabis, Marijuana use, Liver diseases, Hospitalization

Core Tip: Recent studies showed the lower prevalence of nonalcoholic fatty liver disease (NAFLD) among cannabis users compared to non-cannabis users, therefore suggestive of cannabis’s modulatory role in the development of NAFLD. However, our case-control matching analysis, based on sex, age, race, and comorbidity, showed cannabis use as independently associated with higher rates of ascites in patients with NAFLD. A conceivable explanation for the finding is the dominant effect of cannabinoid receptor type 1 through its hepatic profibrotic effects in patients with NAFLD.