Sustained virological response in chronic hepatitis C patients by direct-acting antiviral treatment significantly reduces liver stiffness over 24 weeks posttreatment

Abstract

To investigate whether direct-acting antiviral (DAA) treatment affected liver fibrosis testing, including transient elastography (TE), aspartate aminotransferase-to-platelet ratio index (APRI), and Fibrosis-4 (FIB-4) index, after establishing a sustained virological response for 24 weeks. This prospective cohort study was conducted between October 1, 2019, and September 30, 2020, at Rajavithi Hospital, Bangkok, Thailand. All the patients had significant liver fibrosis (TE ≥ 7.0 kPa) at baseline and completed 12 weeks of DAA therapy. After achieving SVR, liver stiffness measurements were repeated for at least 24 weeks. The primary outcome was a > 30% improvement in TE score at the end of the study compared to baseline. A multivariate logistic regression model was used to identify the parameters associated with the primary outcome. Temporal changes in APRI and FIB-4 indices from baseline to 24 weeks posttreatment were also examined. A total of 110 chronic HCV patients were included in our cohort, of which 57 (52.3%) achieved the primary outcome. The median TE decreased from 15.05 (8.76–23.68) kPa at pretreatment to 9.60 (6.50–14.40) kPa at 24 weeks posttreatment (P < .001). Those who had a baseline TE ≥ 9.5 kPa had higher odds of meeting the primary outcome, and this remained significant after adjusting for age, sex, baseline body mass index, underlying diabetes mellitus, HCV genotype 3, baseline laboratory levels, and treatment regimens (OR 3.04; 95% CI 1.22–7.60, P = .017). Similar to TE, the median APRI and FIB-4 index displayed a considerable reduction from baseline to 24 weeks after successful therapy. Modern DAA treatment has been associated with considerable improvement in liver stiffness measured by TE in chronic HCV patients who achieve SVR, with roughly 52% of patients experiencing a reduction of > 30% in TE over 24 weeks posttreatment compared to baseline. This probably indicates early fibrosis regression, although the effect of resolution of inflammation after treatment completion cannot be ruled out.

1. Introduction

Hepatitis C virus (HCV) infection is a leading cause of chronic liver disease, with an estimated 71 million people infected worldwide.^[1,2] Chronic HCV infection causes cirrhosis and hepatocellular carcinoma, which have increased the healthcare burden in recent decades.^[3,4] Direct-acting antiviral (DAA) medication with > 95% efficacy against HCV provides an unprecedented opportunity to cure these negative health effects.^[5] In patients with chronic HCV, assessment of the stage of liver fibrosis is crucial for treatment decision-making and determining posttreatment prognosis.^[2] Liver biopsy is the gold standard for assessing liver fibrosis status, but its invasive nature, inability to be repeated frequently, and susceptibility to sampling variation means that noninvasive liver fibrosis markers have recently been recommended for determining liver disease severity.^[2,6]

The degree of liver fibrosis prior to HCV treatment is commonly determined using noninvasive liver fibrosis markers, such as the aspartate aminotransferase-to-platelet ratio index (APRI)^[7] and the Fibrosis-4 (FIB-4) index,^[8] which are reliable indices.^[9,10] In addition, liver stiffness measurement by transient elastography (TE; FibroScan®) is a validated noninvasive method for evaluating liver fibrosis in HCV patients with high accuracy and reproducibility.^[11]

Historically, combination therapy with pegylated interferon (Peg-IFN) and ribavirin (RBV) has been the standard of care for patients with chronic HCV.^[12] This combination therapy significantly halts fibrosis progression and reverses liver fibrosis and cirrhosis in patients with HCV, as measured by liver histology.^[13] However, in current clinical practice, TE has mostly replaced liver biopsy. TE has been widely studied in various settings, including the monitoring of fibrosis progression in patients with HCV recurrence after liver transplantation^[14] and the reduction of liver stiffness following IFN-based therapy.^[15,16]

Although DAA therapy is currently the standard of care for patients with chronic HCV,^[12,17] few studies have examined dynamic changes in noninvasive liver fibrosis markers and TE after achieving a sustained virological response (SVR) in HCV-infected patients treated with DAA.^[18–20] This study aimed to assess the effect of SVR from DAA therapy on changes in noninvasive liver fibrosis markers and TE over 24 weeks posttreatment and to examine the association of certain factors with any such changes.

2. Materials and methods

2.1. Study design

This prospective cohort study was conducted at the outpatient clinic of the Department of Medicine at Rajavithi Hospital, a tertiary referral center in Bangkok, Thailand, from October 1, 2019, to September 30, 2020. The study was conducted in accordance with the ethical principles of the Declaration of Helsinki and approved by the ethics committee of Rajavithi Hospital (No. 227/2563).

2.2. Participants

Data were collected from all patients with chronic HCV who were treated with a complete course of DAA and had an SVR at 12 weeks after treatment. The inclusion criteria were as follows: aged 18 to 70 years; diagnosed with chronic HCV infection in the presence of serum anti-HCV antibody for > 6 months and detection of HCV RNA in serum (detection limit = 15 IU/mL; the COBAS® Ampliprep/COBAS® TaqMan® HCV test, Roche Molecular Diagnostics, CA, USA); preexisting significant liver fibrosis (≥F2) determined by TE ≥ 7.0 kPa^[21]; completed a 12-week course of DAA therapy; and achieved SVR (defined as serum HCV RNA undetectable at 12 weeks after the end of the treatment).

We excluded patients who: had co-infection with hepatitis B virus or human immunodeficiency virus; had abstained from alcohol for <6 months; had severely decompensated cirrhosis (defined by Child-Turcotte-Pugh score > 9); had severe renal impairment (defined by glomerular filtration rate < 30 mL/min); were pregnant or lactating; had uncontrolled underlying diseases, such as autoimmune disease, major depression, thyroid dysfunction, and other severe comorbid diseases; had hepatocellular carcinoma or other malignancies at the baseline of treatment; had significant elevation of liver enzymes (aminotransferases > 5-fold the upper limit of normal [ULN]); or missed follow-up visits at the end of treatment, 12 weeks and/or 24 weeks posttreatment.

2.3. Transient elastography and liver fibrosis markers

Liver stiffness measurements were performed at baseline and 24 weeks posttreatment by a single operator (Thanaya Techasirioangkun, RN) who had experienced over 1000 cases using TE (Fibroscan®, Echosens, France). A valid TE result requires at least 10 successful measurements, a success rate (the ratio of valid measurements to the total number of measures) > 60%, and an interquartile range (IQR) (reflects variations among measurements) < 30% of the median value.^[22] Significant fibrosis (F2), advanced fibrosis (F3), and cirrhosis were defined as TE cutoff levels of 7.0 to 9.4, 9.5 to 13.4, and ≥13.5 kPa, respectively.^[21,23] baseline and 24 weeks posttreatment laboratory data were used to calculate APRI and FIB-4 values using the formula APRI = ([AST/ULN]/platelet count [× 10⁹/L]) × 100^[7] and FIB-4 = (age × AST)/(platelet count [× 10⁹/L] × ALT1/2),^[8] and the ULN = 40 U/L for aspartate aminotransferase (AST).

2.4. Treatment regimens

Patients infected with HCV genotype (GT) 3, regardless of underlying cirrhosis, were treated with sofosbuvir (SOF; MyHep®, Mylan Laboratories Limited) plus pegylated interferon (Peg-IFN; Pegasys®, Roche Pharmaceuticals, or PegIntron®, Merck Sharp & Dohme Corp.), weight-based ribavirin (RBV; Copegus®, Roche Pharmaceuticals, or Rebetol®, Merck Sharp & Dohme Corp.), and triple-drug therapy (SOF + Peg-IFN + RBV) for 12 weeks.

Patients infected with HCV GT1, GT2, GT4, or GT6 without cirrhosis were treated with a fixed-dose combination of SOF + Ledipasvir (SOF + LDV) in a single tablet (Ledvir®, Mylan Laboratories Limited) for 12 weeks, whereas those with cirrhosis were treated with SOF + LDV plus weight-based RBV (SOF + LDV + RBV) for 12 weeks.

2.5. Data collection and outcomes assessment

Data from medical records were consecutively collected for demographics (e.g., age, sex, body mass index (BMI), comorbid diseases, degree of liver fibrosis) and laboratory data including liver biochemical tests, serum creatinine, complete blood count, and coagulation tests at baseline and 24 weeks posttreatment. Elevated AST, alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were defined as values higher than the ULN, which was > 40 U/L, >40 U/L, and > 129 U/L, respectively. The start date of the given DAA was used as the baseline treatment. Direct sequencing of the HCV core gene using an ABI3500 Genetic Analyzer (Applied Biosystems, CA, USA) was used to identify the HCV genotype. HCV RNA levels were measured at baseline and 12 weeks after therapy completion.

The primary outcome of the study was to assess whether there was a significant change in liver stiffness, defined as a decline of > 30% in TE from baseline to 24 weeks posttreatment, in all patients who achieved SVR. This threshold was set on the basis that the TE manufacturer accepted IQR fluctuations of up to 30% in relation to the median value in a valid scan and that this particular outcome criterion was used in other studies.^[16,19,24] The secondary outcomes were to identify factors associated with TE regression and investigate the temporal impact of treatment on liver fibrosis markers.

2.6. Statistical analysis

All statistical analyses were performed using the SPSS software (version 17.0; SPSS Inc., Chicago, IL, USA). Demographic data and baseline characteristics were examined using descriptive statistics. Categorical data were assessed using the chi-squared test or Fisher’s exact test, as appropriate, and continuous data were assessed using the independent t-test or the Mann–Whitney U test. The factors associated with posttreatment significant liver stiffness regression analyzed by univariable and multivariate logistic regression analysis were age, sex, BMI, diabetes mellitus, HCV GT3, baseline AST, ALT, ALP, TE (reference, 9.5 and 13.5 kPa), and Peg-IFN-free treatment regimens, and the results were presented as odds ratios (OR) with 95% confidence intervals (95% CI). All statistical tests were 2-tailed, with P < .05 considered statistically significant.

3. Results

3.1. Baseline characteristics

A total of 110 consecutive patients with chronic HCV monoinfection who achieved SVR and underwent serial TE were enrolled prospectively. The mean age of the study participants was 56.09 years (standard deviation [SD] 9.74), and males accounted for 65.5%. The baseline median liver stiffness was 15.05 (IQR 8.77–23.67) kPa, and the population was classified as having significant fibrosis (TE 7.0–9.4 kPa), advanced fibrosis (TE 9.5–13.4 kPa), and cirrhosis (TE ≥ 13.5 kPa) in 28.2%, 11.8%, and 60%, respectively. The pretreatment median HCV viral load was 1,390,616 IU/mL (IQR 417,390–3,298,500 IU/mL), and the genotype distribution was GT1 at 42.7%, GT3 at 42.7%, and GT6 at 14.6% of the patients. The DAA treatment regimens were SOF + LDV ± RBV for 12 weeks in 57.3% (GT1 and GT6) of patients and SOF + Peg-IFN + RBV for 12 weeks in 42.7% (GT3) of patients (Table 1).

Table 1.

Demographic and laboratory data of patients.

Parameter	Total (n = 110)
Age (yrs), mean ± SD	56.09 ± 9.74
Male sex, n (%)	72 (65.5)
BMI (kg/m2), mean ± SD	25.35 ± 4.58
Comorbid diseases, n (%)
Hypertension	13 (11.8)
Diabetes mellitus	12 (10.9)
Dyslipidemia	7 (6.4)
Coronary artery disease	4 (3.6)
Liver stiffness (kPa), median (IQR)	15.05 (8.77–23.67)
Significant fibrosis (TE 7.0–9.4 kPa), n (%)	31 (28.2)
Advanced fibrosis (TE 9.5–13.4 kPa), n (%)	13 (11.8)
Cirrhosis (TE ≥ 13.5 kPa), n (%)	66 (60)
HCV viral load (IU/mL), median (IQR)	1,390,616 (417,390–3,298,500)
HCV genotype, n (%)
1	47 (42.7)
3	47 (42.7)
6	16 (14.6)
DAAs treatment regimen, n (%)
SOF + LDV ± RBV	63 (57.3)
SOF + Peg-IFN + RBV	47 (42.7)
Biochemical markers
Total bilirubin (mg/dL), median (IQR)	0.70 (0.46–1.10)
AST (U/L), median (IQR)	51 (30–97)
ALT (U/L), median (IQR)	52 (26–100)
ALP (U/L), median (IQR)	87 (66–106)
Albumin (g/dL), median (IQR)	4.30 (4.05–4.60)
INR, median (IQR)	1.04 (1.00–1.10)
Hemoglobin (g/dL), mean ± SD	13.30 ± 2.21
Platelet (x 109/L), mean ± SD	180.86 ± 79.85
Creatinine (mg/dL), mean ± SD	0.90 ± 0.20
APRI, median (IQR)	0.74 (0.38–1.68)
FIB-4, median (IQR)	2.25 (1.35–4.56)

ALP = Alkaline phosphatase, ALT = Alanine aminotransferase, APRI = Aspartate aminotransferase-to-platelet ratio index, AST = aspartate aminotransferase, BMI = Body mass index, DAA = Direct-acting antiviral agents, FIB-4 = Fibrosis-4, HCV = Hepatitis C virus; INR, International normalized ratio, LDV = Ledipasvir, Peg-IFN = Pegylated interferon, RBV = Ribavirin, SOF = Sofosbuvir, TE = Transient elastography.

The median (IQR) total bilirubin, AST, ALT, ALP, and albumin values at baseline were 0.70 (0.46–1.10) mg/dL, 51 (30–97) U/L, 52 (26–100) U/L, 87 (66–106) U/L, and 4.30 (4.05–4.60) mg/L, respectively. The mean hemoglobin level was 13.30 g/dL (standard deviation [SD], 2.21), and the mean platelet count was 180.86 × 10⁹/L (SD 79.85). The median (IQR) values for APRI and FIB-4 were 0.74 (0.38–1.68) and 2.25 (1.35–4.56), respectively (Table 1).

3.2. Significant declines in liver stiffness and liver fibrosis markers at 24 weeks after achieving sustained virological response

Of the patients who received DAA therapy and achieved SVR with their paired liver stiffness measurement obtained using TE pretreatment and 24 weeks posttreatment, 58 (52.7%) met the primary outcome (TE improvement of at least 30%) (Fig. 1). The median TE decreased from 15.05 (IQR 8.76–23.68) kPa at pretreatment to 9.60 (IQR 6.50–14.40) kPa at 24 weeks posttreatment (P < .001) (Fig. 2a).

Figure 1.

The proportion of patients with at least a 30% improvement in liver stiffness measurement relative to baseline at 24 weeks after achieving sustained virological response. TE = transient elastography.

Figure 2.

Median (IQR) intra-patient liver stiffness and liver fibrosis markers at baseline and 24 weeks after achieving sustained virological response. (A) Liver stiffness. (B) APRI. (C) FIB-4. All comparisons are made with baseline levels. APRI = aspartate aminotransferase-to-platelet ratio index, FIB-4 = Fibrosis-4.

Among all patients in the cohort, the median APRI value decreased from 0.74 (IQR 0.38–1.68) at pretreatment to 0.30 (IQR 0.20–0.60) at 24 weeks posttreatment (P < .001) (Fig. 2b), and the median FIB-4 value decreased from 2.25 (IQR 1.35–4.56) at pretreatment to 1.67 (IQR 1.08–2.54) at 24 weeks posttreatment (P = .001) (Fig. 2c).

3.3. Patients with a high baseline transient elastography but no elevated alkaline phosphatase have a higher chance of achieving the primary outcome

The results of univariate and multivariate analyses are summarized in Table 2. In the univariate analysis, baseline high ALP (OR 0.98; 95% CI 0.97–0.99) and baseline TE ≥ 9.5 kPa (OR 2.41; 95% CI 1.01–5.73) were substantially negatively and positively associated with achieving the primary outcome (a TE improvement of at least 30%), respectively. After adjusting for other covariates listed in Table 2, these associations remained significant, with an OR of 0.98 (95% CI 0.97–0.99) and 3.04 (95% CI 1.22–7.60) for baseline high ALP and baseline TE ≥ 9.5 kPa, respectively.

Table 2.

Univariate and multivariate analysis of variables for association with ≥ 30% improvement in liver stiffness measurement.

Variable	Univariate	P-value	Multivariate	P-value
	Odds ratio (95% CI)		Odds ratio (95% CI)
Age (yrs)	0.99 (0.96–1.03)	.765
Female gender	0.87 (0.40–1.91)	.726
BMI (kg/m2)	1.03 (0.95–1.12)	.526
Diabetes mellitus	1.32 (0.39–4.43)	.658
Genotype 3	0.50 (0.23–1.08)	.078
Baseline elevated AST	1.00 (0.99–1.01)	.548
Baseline elevated ALT	1.00 (0.99–1.01)	.914
Baseline elevated ALP	0.98 (0.97–0.99)	.026*	0.98 (0.97–0.99)	.010*
Baseline TE ≥ 9.5 kPa	2.41 (1.01–5.73)	.047*	3.04 (1.22–7.60)	.017*
Baseline TE ≥ 13.5 kPa	2.00 (0.92–4.34)	.079
Peg-IFN-free treatment regimens	1.85 (0.86–3.99)	.117

ALP = Alkaline phosphatase, ALT = Alanine aminotransferase, AST = Aspartate aminotransferase, BMI = body mass index, Peg-IFN = Pegylated interferon, TE = Transient elastography.

In univariate analysis, baseline TE ≥ 13.5 kPa (indicating cirrhosis) showed a trend to be positively associated with the primary outcome with an OR of 2.00 (95% CI 0.92–4.34), however, the P-value was not statistically significant (P = .079).

4. Discussion

Historically, successful Peg-IFN therapy with or without RBV was associated with substantial histological improvements in studies using paired liver biopsies.^[13,25,26] However, owing to the invasive nature of the procedure, a follow-up liver biopsy to assess the extent of liver fibrosis in patients with chronic HCV infection receiving antiviral treatment is not a common clinical practice. TE, which is an appropriate method for monitoring fibrosis changes in treated HCV-infected individuals, is becoming more widely employed, with accumulating data showing improvements in liver stiffness associated with SVR from both Peg-IFN- and DAA-based therapies.^{[18,19,24,27–29]} Similar to our work, these studies have shown that establishing SVR with DAA causes considerable regression in liver stiffness evaluation over 24 weeks posttreatment, implying that there are reductions in inflammation and possible early improvements in liver fibrosis.

This study included 110 chronic HCV patients with preexisting significant liver fibrosis (≥ F2) determined by TE ≥ 7.0 kPa. Of these patients, 42.7% were infected with HCV GT3 and received SOF + Peg-IFN + RBV therapy, and the remaining patients with HCV GT1 or GT4 (57.3%) received SOF + LDV ± RBV therapy. At 24 weeks after obtaining SVR, 52.7% of our cohort had at least 30% improvement in liver stiffness assessment compared to baseline. This was congruent with the findings of the Chan et al study,^[19] which used TE to evaluate liver stiffness changes 48 weeks after treatment in 70 patients with chronic HCV infection who achieved SVR by DAA. There was a significant improvement in liver stiffness values in the trial by Chan et al, which had a longer follow-up than ours, although the proportion of patients who achieved a 30% improvement in liver stiffness measurement (48.6%) was slightly lower than that in our study. In a study of 143 patients with chronic HCV infection who achieved SVR following DAA, Pietsch et al^[30] evaluated liver stiffness using TE over a follow-up period of 96 weeks and found that most patients continued to exhibit improved liver stiffness values over the long-term course after the end of therapy.

Singh et al recently published a systematic review and meta-analysis that included 24 studies (2214 of 2934 patients who achieved SVR) that compared TE before and after DAA therapy. In the SVR patients, liver stiffness decreased significantly, by 2.4 kPa at the end of therapy and by 3.1, 3.2, and 4.1 kPa at 4 to 24, 24 to 48, and ≥48 weeks post-therapy, respectively (median decrease, 28.2%; IQR, 21.8–34.8); however, most of the included studies were retrospective and only had a small number of patients.^[31] Overall, the findings of our prospective study validated the current understanding that curing HCV infection with DAA therapy is correlated with notable short- and long-term reduction in liver stiffness, as evaluated by TE.

The evaluation of liver stiffness by TE is a composite marker of liver inflammation and fibrosis.^[32] Improvement in liver fibrosis is anticipated to be a slow process that begins at the end of treatment in patients who demonstrate HCV elimination as a result of DAA therapy. The early decline in liver stiffness is most likely due to inflammation resolution, whereas the continuing decline may be due to fibrosis regression, as evidenced by paired liver biopsy investigations with Peg-IFN-based therapy.^[13,25,26] No histological data were collected in our investigation; consequently, whether the extent of TE reductions of at least 30% reported in a significant proportion of our study cohort constitutes true regression of liver fibrosis remains debatable.

Numerous liver fibrosis markers, such as APRI and FIB-4 indices, have been developed. The APRI, according to Wai et al,^[7] and the FIB-4 score, according to Vallet-Pichard et al,^[33] are concordant with the liver fibrosis stage as determined by pathological assessment of liver biopsy tissues in patients with chronic HCV infection before antiviral therapy. The overall results of our study for the validated fibrosis scores APRI and FIB-4, which correspond to TE values, decreased significantly from baseline to 24 weeks after obtaining SVR with DAA, which is consistent with previous reports.^{[18,20,29,34]} Huang et al^[35] analyzed 40 paired liver specimens from patients with chronic HCV before and after DAA treatment and reported a significant improvement in liver inflammation (83% of patients) and fibrosis regression (38% of patients) in a short time, with an average of 6 months (range, 5–7 months) after SVR. Similar to our observations, these researchers discovered that liver stiffness, as measured by TE, APRI, and FIB-4 values, decreased significantly after SVR by DAA and correctly predicted liver fibrosis, with no significant differences among the methods. However, before this observed temporal change in noninvasive measurements can be used as a predictor of fibrosis regression, a larger histology-based correlative study with a longer follow-up period is required to precisely assess the predictive values of TE, APRI, and FIB-4 for liver fibrosis status after SVR by DAA.

In our investigation, individuals with higher pretreatment TE levels had a more prominent decline in this measure after SVR, as shown in the multivariate analysis that baseline TE ≥ 9.5 kPa was significantly positively associated with a TE improvement of at least 30% after SVR, with an adjusted OR of 3.04 (95% CI 1.22–7.60). A meta-analysis by Singh et al found the same results: a higher proportion of patients with higher pretreatment TE experienced a greater absolute decline in TE 6 to 12 months after HCV eradication (P = .006). This could be explained by the fact that patients with more advanced fibrosis had a larger gap in achieving a greater degree of improvement in fibrosis stage by successful DAA therapy.

Furthermore, we newly discovered that non-improved cases had a higher baseline ALP than the improved cases and had a statistically negative correlation with obtaining the primary outcome, with an adjusted OR of 0.98 (95% CI 0.97–0.99). Similarly, in patients with chronic hepatitis B and nonalcoholic fatty liver disease, earlier studies identified a causal relationship between elevated ALP levels and worsening liver fibrosis.^[36,37] Our findings expand the significance of this biochemical marker of liver fibrosis in chronic hepatitis C patients. Additionally, previous studies have established that despite fibrosis improvement, cirrhosis often persists in patients who achieve SVR.^[38] We speculate that our group of patients with baseline elevated ALP includes individuals at various stages of liver disease, ranging from advanced fibrosis to cirrhosis (which is resistant to fibrosis regression), and thus shows less TE improvement than those with lower baseline ALP. Our univariate analysis confirmed this understanding. A baseline TE of ≥ 13.5 kPa, which indicates cirrhosis, was not significantly correlated with a TE improvement of at least 30% at 24 weeks posttreatment (OR = 2.00, 95% CI 0.92–4.34) (P = .079).

The strengths of this study include the prospective nature of the investigation to evaluate the impact of SVR by DAA on changes in TE, APRI, and FIB-4 score over 24 weeks posttreatment. However, our study has some limitations. First, since there was no sequential liver biopsy, it was not possible to confirm whether the changes in the TE and other noninvasive liver fibrosis indicators corresponded to a real fibrosis regression after SVR. Second, this study had a small sample size of 110 patients and a relatively short follow-up period. A larger histology-based study with a longer follow-up period is needed to precisely assess the predictive factors for regression in liver fibrosis stages and noninvasive tests after SVR with DAA.

In conclusion, this prospective cohort study showed that among chronic HCV patients with significant liver fibrosis (≥ 7.0 kPa) at the beginning of DAA therapy, those who achieved SVR had significantly decreased liver stiffness, as measured by TE, during the 24 weeks posttreatment. This probably denotes fibrosis regression, although it cannot be excluded that improvement in the inflammatory process in these patients may affect liver stiffness changes. Moreover, regardless of SVR, a considerable proportion of patients (47.3%) failed to attain the expected target outcomes; thus, early detection and treatment of individuals with HCV infection remains crucial to avoid end-stage liver damage, which is difficult to recover.

Acknowledgments

The authors would like to thank Ms. Wannakorn Homsuwan, a research assistant at Rajavithi Hospital, for her assistance with the statistical analysis and all the patients who participated in this study.

Author contributions

Conceptualization: Apichet Sirinawasatien.

Data curation: Paweenuch Supawan.

Formal analysis: Apichet Sirinawasatien, Paweenuch Supawan.

Funding acquisition: Apichet Sirinawasatien.

Investigation: Paweenuch Supawan.

Supervision: Apichet Sirinawasatien.

Validation: Apichet Sirinawasatien.

Writing – original draft: Apichet Sirinawasatien, Paweenuch Supawan.

Writing – review & editing: Apichet Sirinawasatien.