Burden of tuberculosis disease in patients with liver cirrhosis: a systematic review and meta-analysis

Background Liver cirrhosis and tuberculosis (TB) share a bidirectional and clinically significant relationship, with cirrhosis associated immune dysfunction encompassing impaired cell mediated immunity, complement deficiency, and gut associated lymphoid tissue dysfunction substantially elevating susceptibility to both primary TB infection and reactivation of latent TB disease. This risk is further compounded in TB endemic settings and among patients with alcohol related cirrhosis, where the two conditions converge to worsen clinical outcomes. Despite growing recognition of this association, the burden of TB disease in patients with liver cirrhosis remain scarce and inconsistent across the existing literature, limiting evidence based approaches to screening and prevention in this high risk population. Methods We conducted a systematic review and meta-analysis of observational epidemiological studies reporting TB among patients with liver cirrhosis. A search was performed across Embase, PubMed, Web of Science, Scopus, ScienceDirect, Hinari, and Google Scholar for studies published in English from January 1, 2000 − June 15, 2025. Two authors screened studies, extracted data, and assessed methodological quality using the Joanna Briggs Institute appraisal tool. Statistical analyses were performed using STATA version 16. The Freeman–Tukey double arcsine transformation was applied to stabilize variance and normalize proportions. Subgroup analyses were conducted to explore sources of heterogeneity, and leave-one-out sensitivity analysis was performed to assess the robustness of the pooled estimate. Results The search identified 960 articles, of which seven studies (n = 72,039) met the inclusion criteria. The pooled proportion of TB disease among patients with cirrhosis was 4,000 per 100,000 population (95% CI: 3,000–5,000). In subgroup analysis, the pooled proportion was highest in South Asia (4,000 per 100,000; 95% CI: 2,000–7,000). Considerable heterogeneity was observed in the overall pooled estimate (I² = 99.2%, P < 0.001) and persisted across nearly all subgroups (I² = 94.7–99.8%). Conclusions This meta-analysis demonstrates a substantially elevated pooled proportion of TB disease among patients with liver cirrhosis compared to the general population, with considerable demographic and clinical disparities in risk. These findings support heightened clinical vigilance for TB in this population and highlight the need for standardized screening protocols, informed by further prospective research.