Liver Disease Outcomes after Sustained Virological Response in Patients with Chronic Hepatitis C Infection Treated with Generic Direct-Acting Antivirals

ABSTRACT.

The introduction of generic direct-acting antivirals (DAAs) in Egypt is associated with a superior cure rate of hepatitis C virus (HCV) infection. However, the course of progressive liver damage and developing liver related complications in patients with sustained virologic response (SVR) remain unclear. This study was designed to examine the long-term outcomes of generic DAA-induced virological cure in a real-life cohort of HCV patients with or without comorbid schistosomiasis. We prospectively enrolled a cohort of 506 recently cured HCV patients (437 Child–Pugh class A [Child-A] and 69 Child–Pugh class B [Child-B]). All patients were clinically evaluated at different time points during a 2-year follow-up (November 2018 to February 2021). Over the course of treatment and follow-up, 77 (15.2%) patients (42 [9.6%] Child-A and 35 [50.7%] Child-B) experienced complications at different time points. The overall mortality rate was approximately 1/1,000 person-years. The incidence of hepatic insufficiency was approximately 5.5/1,000 person-years, and that of de novo hepatocellular carcinoma (HCC) was approximately 8.3/1,000 person-years. A sustained improvement in liver indices up to 2 years of follow-up was observed. In the Cox regression model, pretreatment decompensated cirrhosis predicted the occurrence of adverse liver events and HCC after therapy. In conclusion, in HCV patients with advanced cirrhosis or coexisting hepatic schistosomiasis, generic DAA-induced SVR remains robust with favorable clinical outcomes although the risk of hepatocarcinogenesis cannot be eliminated. Surveillance of patients with treated HCV infection is an important aspect of postcure care for early detection and management of liver disease-related adverse events.

INTRODUCTION

Hepatitis C virus (HCV) infection is one of the main causes of chronic liver disease worldwide.¹ The long-term natural history of HCV infection is highly variable. For instance, hepatic injury can range from minimal histological changes to extensive fibrosis and cirrhosis, which may eventually result in hepatocellular carcinoma (HCC).²

The recent introduction of direct-acting antivirals (DAAs) has transformed HCV therapy. Short and well-tolerated combination therapies of oral DAAs have largely replaced parenteral interferon (IFN)-based therapy. The rates of sustained virologic response (SVR) (persistent undetectable viral load in the blood 12 weeks or more after treatment completion) with these combinations exceed 95%.³ There is increasing evidence that viral eradication following DAA therapy is associated with a significant decrease in liver-related morbidity and mortality and adverse extrahepatic sequelae of HCV infection, while being associated with an increase in health-related quality of life.^4–9

In noncirrhotic patients, SVR is coupled with the normalization of liver parameters caused by necroinflammation resolution. The risk of endangering complications remains in patients with advanced liver disease, although liver cirrhosis may eventually recede.⁸ Recent data have highlighted the reduced risk of HCC and liver-related mortality in patients with cirrhosis with viral clearance compared with untreated patients and nonsustained virologic responders. Particular concerns remain in the presence of cofactors of liver morbidity, such as concurrent hepatitis B virus (HBV) infection, schistosomal hepatic fibrosis (SHF), alcohol abuse, and/or metabolic syndrome.^6,10 Accordingly, HCV-infected patients, despite achieving SVR, remain at a higher health risk than the general population, indicating that SVR is a virologic cure but not necessarily a cure from the risk of liver disease.⁴

The national program for treating HCV infection with generic DAAs (supplied by local manufacturers in Egypt) launched in Egypt in 2012 has achieved great success in eliminating the viral infection in numerous patients.¹¹ This nationwide program embarks on a strong political commitment for inclusive mass screening and treatment offered free of charge to all patients. The program extended its goals to follow up treated patients and provide postcure care for early detection and management of liver disease–related adverse events.^12,13

Although a large body of literature has reported improvement in liver fibrosis/function after SVR,^{8–10,14–25} still, little is known about liver disease outcomes, particularly in patients with SHF in Egyptian settings. Accordingly, in this study, we tracked the long-term occurrence of liver-related events in a real-life cohort of patients with chronic HCV infection after achieving SVR. Moreover, the impact SHF might have on the progression of liver disease was evaluated given the high burden of hepatic schistosomiasis in Egypt, which can surpass 80% in some agrarian communities in northern Egypt.^26,27 Clinical studies in Egypt showed that 70–90% of patients with chronic hepatitis, cirrhosis, or HCC are coinfected with schistosomiasis and HCV.^28–30 Indeed, chronic schistosomiasis in patients with HCV infection can have serious effects on liver pathology and increase the mortality rate. Moreover, liver fibrosis and histopathological changes can persist after viral clearance because of an ongoing inflammatory response and immunological reaction to Schistosoma mansoni.^27,31–35

Evaluating the treatment outcomes and early detection of deteriorating liver conditions will prevent health complications, reduce mortality, and help alleviate the economic burden of liver diseases.

METHODS

Study setting, design, and population.

A prospective real-life study was conducted (November 2018 to February 2021) at a liver center and the National Medical Institute in El-Behira Governorate, Egypt. These centers are among the nationwide network of digitally connected viral hepatitis-specialized treatment centers covering the country map¹³ and providing the standard of care for chronic HCV infection according to the international guidelines.^36,37

The target population comprised patients with chronic HCV infection, who achieved SVR in response to generic DAA regimens. Details about patient selection and DAA combination regimens according to the national protocol are described in our previous work.^38–40

A minimal sample of 314 patients with recently cured HCV infection was required to estimate an 8% rate of developing liver insufficiency after achieving SVR in response to DAAs,²¹ using a margin of error of 3% and an alpha error of 0.05, with an expected dropout rate during the follow-up of 10%. To compensate for potential losses to follow-up and ensure that the sample size is large enough to track rare events, we eventually enrolled 506 patients (including 437 with compensated liver diseases [Child–Pugh Class A (Child-A)] and 69 with compensated liver diseases [Child–Pugh Class B (Child-B)]).⁴¹ The sample size was calculated using Epi Info, version 7.

Patient evaluation and follow-up.

Patients were followed up and evaluated every 3 months for 2 years (patients were evaluated in nine visits: an initial visit and eight follow-up visits) following the SVR12 (12 weeks posttreatment). Pretreatment and treatment data were available for all patients since they received their treatment at the same study setting.

All enrolled patients were interviewed to collect sociodemographic data and medical history and subjected to complete medical examination (general and abdominal), including the estimation of the body mass index (BMI) and any features of decompensated liver disease.

Laboratory investigation included liver function tests (i.e., serum aspartate aminotransferase [AST], serum alanine aminotransferase [ALT], prothrombin activity [PA], prothrombin time [PT], international normalized Ratio (INR), serum albumin, and total serum bilirubin [TSB]), kidney function tests (i.e., serum creatinine and blood urea nitrogen), complete blood count, fasting blood glucose (FBG), antischistosomal Ab (indirect hemagglutination test [Fumouze Diagnostics, France]), and HCV RNA quantitation by real-time polymerase chain reaction (PCR) using Cobas Ampli Prep/Cobas TaqMan HCV RNA assay (Roche Diagnostics; Pleasanton, CA) with a threshold of detection of 15 IU/mL. All patients underwent abdominal ultrasound examinations throughout the follow-up period to check for the general condition of the liver and other abdominal organs. Triphasic computed tomography (CT) and magnetic resonance imaging (MRI) were performed if indicated (suspected focal lesion as revealed by liver ultrasound). We inferred the presence of liver fibrosis or cirrhosis from ultrasound coupled with calculating liver fibrosis scores, namely, the Fibrosis-4 (FIB-4) Index for Liver Fibrosis as a noninvasive biomarker (NIBM) for liver fibrosis (scores of less than 1.45 predict F0–F1; scores of 1.45–3.25 predict F2–F3; and scores of more than 3.25 predict > F3).^42–46

Viral and clinical case definitions.

HCV RNA was tested using PCR to confirm HCV infection (HCV RNA above limits of detection [LOD] = 15 mIU/mL).^38,39 The diagnosis of HBV infection was based on positive PCR testing (HBV DNA above LOD = 15 mIU/mL).^38,39 A positive hepatitis B surface antibody test was defined as having a titer of 10 mIU/mL or above. Treatment experience refers to patients who previously underwent anti-HCV therapy (i.e., IFN-based therapy or DAAs). Difficult-to-treat patients included those having FIB-4 scores of more than 3.25, albumin of ≤ 3.5 g/dL, TSB of > 1.2 mg/dL, INR of > 1.2, and platelet count of < 150,000 mm³, regardless of previous treatment history or liver fibrosis state.^37,47,48 SVR was defined as HCV RNA negativity in the circulation (i.e., below the assay’s LOD) 12 weeks after the end of therapy (EOT). Relapse was defined as a confirmed HCV RNA more than LOD during the first 6 months after treatment in patients with viral RNA less than LOD at the EOT. Staging of liver fibrosis/cirrhosis was inferred from the ultrasonographic morphology of the liver and a calculated FIB-4 index.⁴⁰ Cirrhosis was defined as having a cirrhotic liver morphology on imaging (usually by ultrasound or CT scan). Patients with advanced/decompensated cirrhosis had high TSB (> 1.2 mg/dL), low platelet count (< 150 × 109/L), low albumin (< 3.5 g/dL), prolonged prothrombin time (> 13 seconds), INR > 1.2 beside showing clinical features of cirrhosis.⁴⁹ All patients were subjected to serological detection of antischistosomal antibodies to diagnose schistosomiasis, which was also supported by a history of receiving antischistosomal therapy (tarter emetic in the 1950s and 1960s or praziquantel after the 1970s). We assessed the state of SHF by identifying the characteristic periportal echogenic thickening along the portal veins (periportal fibrosis [PPF]) on liver ultrasound (indicates fibrosis of the host’s granulomatous cell-mediated immune response to the soluble egg antigen deposited by the adult worm in the portal tract).^27,33 The pattern of PPF might be masked in advanced cirrhosis and shrunken liver.⁵⁰ Stating comorbidities was based on reviewing the patients’ records of having a confirmed diagnosis of the condition and being on treatment of that condition. Portal hypertension (PHT) was defined as an increased pressure in the portal venous system above 10 mm of Hg and was measured using Doppler ultrasonography. The portal vein diameter was serially monitored before, during, and after HCV treatment. Indeed, PPF and liver cirrhosis can lead to PHT with the usual potential sequelae, including splenomegaly, ascites, esophageal variceal bleeding, and the development of portosystemic collaterals.⁵¹ Liver decompensation (insufficiency or liver failure) is a complex clinical syndrome characterized by coagulopathy and elevated liver biochemistry and described as the presence of any or a combination of these events: portal hypertensive bleeding, hepatic encephalopathy, ascitic decompensation (de novo or worsening ascites), and spontaneous bacterial peritonitis (SBP). Death resulting from hepatic decompensation or HCC progression defined liver-related mortality.^37,47,48

Statistical analysis.

Data were collected, revised for accuracy and completeness, coded, and fed to Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, version 20.0; Armonk, NY: IBM Corp. Released 2011). All statistical analyses were performed using two-tailed tests and an alpha error of 0.05. The significance of the obtained results was judged at the 5% level (P ≤ 0.05). Continuous variables were presented as the mean ±SD. Categorical variables were expressed as numbers with proportions (n [%]). We tested the association between the different categories of two independent samples using Pearson’s χ² test, the Monte Carlo exact test, and Fisher’s exact test, as appropriate. The differences in the means of quantitative variables measured at different time points (effect size) were tested using repeated-measures analysis of variance (ANOVA). Cox regression analysis (or proportional hazards regression) was performed and hazard rate ratios (HR) with 95% CI were calculated to investigate the effects of several variables upon the time a specified event occurs and thus to identify predictors of complications in patients with cured HCV infection. We included all patient variables (i.e., age, sex, residence, occupation, smoking status, BMI, baseline α fetoprotein (AFP) level, the presence of fibrosis/cirrhosis, comorbidities, HBV infection, DM, schistosomiasis, having been subjected to splenectomy, being difficult-to-treat, and being treatment naïve/experienced) and previous and current therapeutic regimens provided in the model. Variables that did not meet the 0.05 significance level were not considered into the final multivariate model. Backward (Wald) stepwise multivariate logistic regression was performed to generate a reduced predictor model of de novo HCC. The Kaplan–Meier analysis was performed to measure the probability of developing complications in patients with HCV infection who achieved SVR. The development of complications in patients with cured HCV defined the “event-of-interest,” and “censored” defined the lack of complications (i.e., patients who did not experience the event-of-interest at the last follow-up because of either dropout, death from unrelated causes, or the absence of an event [improved or stable condition]).

RESULTS

Characteristics of the study population.

We enrolled 506 patients with recently cured chronic HCV infection (including 437 [86.4%] Child-A and 69 [13.6%] Child-B). Most patients live in rural areas (72.3%) and older than 40 years old (96.8%) with an overall mean age of 57.7 ± 8.7 years. The percentage of women was slightly higher than that of men (54.9% versus 45.1%, respectively), and most men were farmers (50.9%), while the highest proportion of women were housewives (85.6%). Other sociodemographic data are detailed in Table 1.

Table 1.

Sociodemographics of the study population

			Total (N = 506)		Group				P
					Child-A (N = 437)		Child-B (N = 69)
			No.	%	No.	%	No.	%
Age (years)	Age group	20–39.9	16	3.2	15	3.4	1	1.4	0.678
		40–9.9	271	53.6	233	53.3	38	55.1
		60–84	219	43.3	189	43.2	30	43.5
	Mean ± SD		57.5 ± 8.7		57.4 ± 8.8		58.1 ± 7.7		t = −0.693 P = 0.490
	Median, IQR		57, 12		57, 12		57, 12
Sex	Male		228	45.1	191	43.7	37	53.6	0.124
	Female		278	54.9	246	56.3	32	46.4
Residence	Urban		140	27.7	124	28.4	16	23.2	0.371
	Rural		366	72.3	313	71.6	53	76.8
Marital status	Single		33	6.5	27	6.2	6	8.7	0.031
	Married		429	84.8	378	86.5	51	73.9
	Widowed		39	7.7	28	6.4	11	15.9
	Divorced		5	1.0	4	0.9	1	1.4
Education	Illiterate		283	55.9	249	57.0	34	49.3	0.138
	Read and write		146	28.9	128	29.3	18	26.1
	Primary education		12	2.4	10	2.3	2	2.9
	Preparatory education		5	1.0	5	1.1	0	0.0
	Secondary education		37	7.3	28	6.4	9	13.0
	University education		23	4.5	17	3.9	6	8.7
Occupation	Not working		23	4.5	21	4.8	2	2.9	0.102
	Farmer		116	22.9	98	22.4	18	26.1
	Employee		110	21.7	92	21.1	18	26.1
	Professional		9	1.8	7	1.6	2	2.9
	HCW		3	0.6	2	0.5	1	1.4
	Housewife		238	47.0	213	48.7	25	36.2
	Clerical		6	1.2	3	0.7	3	4.3
	Student		1	0.2	1	0.2	0	0.0

Child-A = Child-Pugh class A; Child-B = Child-Pugh class B; HCW = healthcare worker; IQR = interquartile range.

Clinical evaluation of the study cohort.

Fifteen (3.2%) patients with HCV infection (11 [2.5%] Child-A versus 5 [7.2%] Child-B) received either IFN-based therapy (N = 15 [3.0%]) or DAAs (N = 4 [0.8%]). Almost one-fifth (19.4%) of patients with chronic HCV infection were free of comorbidities, whereas 69.2% had a degree of PHT [284 (65.0%) Child-A versus 66 (95.7%) Child-B, P = < 0.001], 64.8% had schistosomiasis [272 (62.2%) Child-A versus 56 (81.2%) Child-B, P = 0.002], 21.1% had diabetes [88 (20.2%) Child-A versus 19 (27.5%) Child-B, P = 0.162], and 15.6% had hypertension [65 (14.9%) Child-A versus 14 (20.3%) Child-B, P = 0.249]. All comorbidities were more frequently presented among Child-B patients than among Child-A patients (P < 0.001) (Supplemental Table 1).

Baseline liver ultrasound examination of the enrolled HCV patients revealed dilated portal vein (63.2%), splenomegaly (43.7%), early cirrhotic changes (39.5%), PPF (24.3%), hepatomegaly (19.6%), abnormal echo pattern (18.4%), coarse bright liver (14.2%), and mild to moderate ascites (3.8%). The presence of benign hepatic nodules (0.6%), hepatoma (0.6%), and cholangiocarcinoma (0.6%) was confirmed using triphasic CT and MRI, particularly among Child-B patients (Supplemental Table 2).

Biochemical and hematological changes over the course of treatment and follow-up.

Repeated-measures ANOVA revealed a significant and linear improvement in liver indices over the treatment course and during the follow-up period among Child-A and those with no coexisting schistosomiasis. The differential trending across the groups was mainly quadratic, although some parameters showed linear, cubic, or order 4 trends. Within subjects, the effect size in repeated mean measures of Child–Pugh score, FIB-4, ALT, AST, albumin, bilirubin, PT, PA, INR, and Hb attributed to the time course was significant. However, this effect was qualified by a significant interaction with the effect of patient status/group (Child–Pugh score but not the schistosomiasis status). Between groups (apart from leukocyte count, FBG, and HbA1c in Child-Pugh groups and leukocyte count, FBG, and HbA1c, Hb, and serum creatinine in schistosomiasis groups) the effect size in the hematological and biochemical changes at different time points varied significantly (Supplemental Tables 3 and 4 and Supplemental Figure 1A and B).

Outcomes of liver disease at different time points.

Overall, 77 (15.2%) patients (42 [9.6%] Child-A and 35 [50.7%] Child-B) in our follow-up cohort experienced complications at different time points over the course of treatment and follow-up. The most frequently encountered complications were mild to moderate ascites (12.6%), de novo HCC (6.5%) (incidence rate of 8.3/1,000 person-years, diagnosed, on average, 15.6 ± 6 months [range, 1–24 months] after therapy initiation), progression of liver fibrosis (6.3%), progression of liver cirrhosis (4.9%), hepatic insufficiency (4.3%), hepatic encephalopathy (1.6%), and hematemesis (1.4%).

Four (0.8%) patients (3 [0.7%] Child-A and 1 [1.4%] Child-B) died during the follow-up period (on average, the deaths occurred 15 months after the SVR12). Three of the four deceased patients (75.0%) had cirrhosis and comorbid schistosomiasis. The causes of death were stroke, HCC and liver insufficiency, SBP, and hepatorenal syndrome.

By the end of follow-up, the condition of liver fibrosis/cirrhosis improved in 37.5% of the patients with cured HCV infection but remained unchanged in 47.2% of those patients (Table 2).

Table 2.

Outcome of liver disease at different timepoints among cured HCV patients in relation to their Child-Pugh class

Outcome	Child-Pugh class	Pretreatment	Treatment phase			Follow-up period (2 Years)								Group total	Grand total
			Week 4	Week 12	Week 24	Visit 1 (12 weeks post-treatment)	Visit 2	Visit 3	Visit 4	Visit 5	Visit 6	Visit 7	Visit 8
			(N = 506)	(N = 455)	(N = 51)	SVR 12	6 months	9 months	12 months	15 months	18 months	21 months	24 months
		No. (%)
Progression of liver fibrosis	Child-A (N = 437)	65 (14.9)							2 (0.5)	3 (0.7)	5 (1.1)	3 (0.7)	4 (0.9)	17 (3.9)	32 (6.3)
	Child-B (N = 69)	66 (95.7)						2 (2.9)	1 (1.4)		2 (2.9)	4 (5.8)	6 (8.7)	15 (21.7)
Progression of liver cirrhosis	Child-A (N = 437)	143 (32.8)						3 (0.7)		3 (0.7)	2 (0.5)	5 (1.1)	2 (0.5)	15 (3.4)	25 (4.9)
	Child-B (N = 69)	62 (89.6)								2 (2.9)		2 (2.9)	6 (8.7)	10 (14.5)
Decompensated liver disease	Child-A (N = 437)											5 (1.1)	6 (1.4)	11 (2.5)	22 (4.3)
	Child-B (N = 69)										3 (4.3)	3 (4.3)	5 (7.2)	11 (16.0)
Ascites (mild to moderate)	Child-A (N = 437)	1 (0.2)	3 (0.7)	2 (0.5)	2 (0.5)		1 (0.2)	2 (0.5)	1 (0.2)		1 (0.2)	1 (0.2)	3 (0.7)	16 (3.7)	64 (12.6)
	Child-B (N = 69)	18 (26.1)	2 (2.9)	2 (2.9)	6 (8.7)	1 (1.4)	2 (2.9)	4 (5.8)	3 (4.3)	5 (7.2)	8 (11.6)	6 (8.7)	9 (13.0)	48 (69.6)
Splenomegaly	Child-A (N = 437)	164 (37.5)		1 (0.2)	1 (0.2)									2 (0.5)	3 (0.6)
	Child-B (N = 69)	57 (82.5)											1 (1.4)	1 (1.4)
Hepatomegaly	Child-A (N = 437)	98 (22.4)		1 (0.2)							2 (0.5)			3 (0.7)	3 (0.6)
	Child-B (N = 69)	1 (1.4)
Collaterals (splenic and portal)	Child-A (N = 437)	6 (1.3)													2 (0.4)
	Child-B (N = 69)	6 (8.7)							1 (1.4)	1 (1.4)				2 (2.9)
De novo HCC (Focal)	Child-A (N = 437)										2 (0.5)	1 (0.2)	1 (0.2)	4 (0.9)	19 (3.8)
	Child-B (N = 69)	2 (2.9)	2 (2.9)	3 (4.3)	2 (2.9)			1 (1.4)	1 (1.4)		1 (1.4)	3 (4.3)	2 (2.9)	15 (21.7)
De novo HCC (Multicentric)	Child-A (N = 437)							1 (0.2)		1 (0.2)	3 (0.7)	2 (0.5)	1 (0.2)	8 (1.8)	14 (2.8)
	Child-B (N = 69)	1 (1.4)									2 (2.9)	1 (1.4)	3 (4.3)	6 (8.7)
Recurrent HCC	Child-A (N = 437)														2 (0.4)
	Child-B (N = 69)									1 (1.4)		1 (1.4)		2 (2.9)
Cholangiocarcinoma	Child-A (N = 437)	1 (0.2)													1 (0.2)
	Child-B (N = 69)	2 (2.9)								1 (1.4)				1 (1.4)
Hematemesis∼	Child-A (N = 437)	8 (1.8)			1 (0.2)		1 (0.2)		1 (0.2)		1 (0.2)		2 (0.5)	2 (0.5)	7 (1.4)
	Child-B (N = 69)	7 (10.1)	1 (1.4)		1 (1.4)		2 (2.9)		1 (1.4)		3 (4.3)	3 (4.3)	5 (7.2)	7 (10.1)
Hepatic encephalopathy∼	Child-A (N = 437)														8 (1.6)
	Child-B (N = 69)							2 (2.9)	2 (2.9)	1 (1.4)	4 (5.8)	3 (4.3)	8 (11.6)	9 (13.0)
Chronic calcular cholecystitis	Child-A (N = 437)	21 (4.8)		1 (0.2)							2 (0.5)			3 (0.7)	4 (0.8)
	Child-B (N = 69)	6 (8.7)						1 (1.4)						1 (1.4)
Portal vein thrombosis	Child-A (N = 437)	2 (0.5)						1 (0.2)			1 (0.2)			2 (0.5)	3 (0.6)
	Child-B (N = 69)	3 (0.7)											1 (1.4)	1 (1.4)
Hepatic nodule (benign lesion)	Child-A (N = 437)	1 (0.2)													3 (0.6)
	Child-B (N = 69)	2 (2.9)									1 (1.4)	1 (1.4)	1 (1.4)	3 (4.3)
DM	Child-A (N = 437)	88 (20.2)													1 (0.2)
	Child-B (N = 69)	19 (27.5)									1 (1.4)			1 (1.4)
Pancreatitis	Child-A (N = 437)														1 (0.2)
	Child-B (N = 69)												1 (1.4)	1 (1.4)
Stable (unchanged)	Child-A (N = 437)													243 (55.6)	239 (47.2)
	Child-B (N = 69)													14 (20.3)
Improved condition of liver fibrosis/cirrhosis	Child-A (N = 437)													172 (39.4)	190 (37.5)
	Child-B (N = 69)													23 (33.3)
Developed complications	Child-A (N = 437)													42 (9.6)	77 (15.2)
	Child-B (N = 69)													35 (50.7)
Mortality	Child-A (N = 437)								1 (0.2)	1 (0.2)		1 (0.2)		3 (0.7)	4 (0.8)
	Child-B (N = 69)										1 (1.4)			1 (1.4)

Child-A = Child-Pugh class A; Child-B = Child-Pugh class B; DM = diabetes mellitus, HCC = hepatocellular carcinoma. The causes of death were stroke, HCC and liver insufficiency, spontaneous bacterial peritonitis, and hepatorenal syndrome. The grand total does not include pretreatment conditions. Same patients can present with similar attacks.

Predictors of adverse liver events in patients who achieved SVR.

A univariate logistic regression model was developed to determine the association between each examined variable and the occurrence of complications in each patient. In univariate analysis, Child-B (HR, 7.14; 95% CI, 4.55–11.19), smoking (HR, 1.80; 95% CI, 1.10–2.95), comorbidities (HR, 2.17; 95% CI, 1.04–4.51), schistosomiasis (HR, 1.85; 95% CI, 1.09–3.13), being difficult-to-treat (HR, 3.22; 95% CI, 1.83–5.65), and some therapeutic regimens (sofosbuvir [SOF] + daclatasvir [DAC] + ribavirin [RBV], SOF + QUREVO + RBV, and SOF + ledipasvir (LED) + RBV) were associated with complications in our SVR cohort (P < 0.05). Nevertheless, in our Cox regression analysis, only the Child–Pugh score was retained in the final model where the Child-B score increased the risk of complications in patients with cured HCV infection by 5-folds (HR, 4.52; 95% CI, 2.63–7.77) (Table 3).

Table 3.

Cox regression (Backward Wald method) for factors associated with developing complications in cured HCV patients

		Developed complications				Univariate analysis				Multivariate analysis
		Yes (N = 429)		No (N = 77)		Sig.	Exp(B)	95.0% CI for Exp(B)		Sig.	Exp(B)a	95% CI for Exp(B)a
		No.	%	No.	%			Lower limit	Upper limit			Lower	Upper
Group	Child-A	395	92.1	42	54.5
	Child-B	34	7.9	35	45.5	< 0.001	7.14	4.55	11.19	< 0.001	4.52	2.63	7.77
[AQ12]Age group	20–39.9	15	3.5	1	1.3	0.313	ref
	40–59.9	234	54.5	37	48.1	0.433	2.21	0.30	16.12
	60–84 years	180	42.0	39	50.6	0.290	2.92	0.40	21.25
Sex	Male	187	43.6	41	53.2	0.129	1.41	0.90	2.21
	Female	242	56.4	36	46.8
Residence	Urban	123	28.7	17	22.1
	Rural	306	71.3	60	77.9	0.229	1.39	0.81	2.38
BMI	18.5–24.99 (Normal weight)	89	20.7	27	35.1	0.039	ref			0.225	ref
	25–29.99 (Overweight)	187	43.6	32	41.6	0.045	0.59	0.36	0.989	0.828	0.94	0.55	1.62
	30–39.99 (Obese)	147	34.3	18	23.4	0.005	0.43	0.24	0.780	0.113	0.60	0.31	1.13
	40+ (Morbid obesity)	6	1.4	0	0.0	0.964	0.00	0.00	0–0
Smoking	No	352	83.0	55	71.4
	Yes	72	17.0	22	28.6	0.020	1.80	1.10	2.95	0.689	1.11	0.65	1.90
Alcohol	No	422	99.5	77	100.0
	Yes	2	0.5	0	0.0	0.701	0.05	0.00	2x105
Drug abuse	No	420	99.1	77	100.0
	Yes	4	0.9	0	0.0	0.587	0.05	0.00	2565.0
Co-morbidities	No	90	21.0	8	10.4
	Yes	339	79.0	69	89.6	0.038	2.17	1.04	4.51	0.306	1.58	0.66	3.78
Diabetes mellitus	No	340	79.3	60	77.9
	Yes	89	20.7	17	22.1	0.772	1.08	0.63	1.86
Schistosomiasis	No	160	37.3	18	23.4
	Yes	269	62.7	59	76.6	0.023	1.85	1.09	3.13	0.914	1.04	0.54	1.97
Splenectomy	No	424	98.8	75	97.4
	Yes	5	1.2	2	2.6	0.294	2.12	0.52	8.64
Difficult-to treat	No	196	45.7	15	19.5
	Yes	233	54.3	62	80.5	< 0.001	3.22	1.83	5.65
Previous HCV treatment	Treatment naïve	415	96.7	75	97.4
	Treatment experienced	14	3.3	2	2.6	0.756	0.80	0.20	3.26
Current drug regimen given	SOF+DAC	102	23.8	7	9.1	0.000	ref			0.710	ref
	SOF+RBV	47	11.0	3	3.9	0.957	0.96	0.25	3.73	0.908	1.18	0.07	18.79
	SOF+DAC+RBV	176	41.0	51	66.2	0.001	3.82	1.74	8.43	0.407	3.23	0.20	51.93
	SOF+SIM	43	10.0	4	5.2	0.636	1.35	0.39	4.60	0.519	1.50	0.44	5.16
	SOF+RBV+INF	50	11.7	4	5.2	0.803	1.17	0.34	3.99	0.731	1.24	0.36	4.28
	SOF+QUREVO+RBV	1	0.2	1	1.3	0.015	13.64	1.68	110.93	0.325	5.55	0.18	168.49
	SOF+LED+RBV	10	2.3	7	9.1	0.000	8.38	2.94	23.91	0.378	3.63	0.21	64.01
Duration of DAAs regimen	12 weeks	382	89.0	73	94.8
	24 weeks	47	11.0	4	5.2	0.156	0.48	0.18	1.32	0.784	0.68	0.04	10.94

a = corresponds to hazard ratio; Child-A = Child-Pugh class A; Child-B = Child-Pugh class B; DAAs = direct acting antivirals; DAC = daclatasvir; INF = interferon; LED = ledipasvir; RBV = ribavirin; SIM = simeprevir; Ref = reference value; Sig = significant; SOF = sofosbuvir.

Likewise, in a univariate analysis, Child-B (HR, 7.14; 95% CI, 4.55–11.19), male gender (HR, 3.11; 95% CI, 1.37–7.06), baseline AFP level (HR, 1.05; 95% CI, 1.03–1.07), schistosomiasis (HR, 3.30; 95% CI, 1.15–9.52), splenectomy (HR, 6.32; 95% CI, 1.50–26.65), being difficult-to-treat (HR, 9.64; 95% CI, 2.23–40.62), and some therapeutic regimens (i.e., SOF + DAC + RBV, SOF + QUREVO + RBV, and SOF + LED + RBV) were associated with de novo HCC in our SVR cohort (P < 0.05). However, in our Cox regression analysis, only Child-B (HR, 4.80; 95% CI, 1.97–11.71), male gender (HR, 4.09; 95% CI, 1.64–10.19), and baseline AFP level (HR, 1.05; 95% CI, 1.03–1.07) were retained in the final model as predictors of de novo HCC in patients who achieved SVR (data not shown).

The probability of developing complications in patients with HCV who achieved SVR.

The Kaplan–Meier analysis revealed that the probabilities of complications at 24 months of follow-up in Child-A patients who achieved SVR were low (0.096 in Child-A versus 0.920 in Child-B). A high probability (0.844) of having complications in Child-B patients who achieved SVR appeared as early as week 4 of treatment. The log-rank, Breslow, and Tarone–Ware tests of equality of having complications demonstrated statistically significant differences in relation to Child–Pugh status among patients with cured HCV infection (P < 0.05) (Supplemental Table 5 and Figure 1A).

Figure 1.

Liver-related adverse events and survival over the course of treatment and follow-up in relation to (A) Child-Pugh class and (B) schistosomiasis. This figure appears in color at www.ajtmh.org.

Similarly, the probabilities of having complications throughout the follow up period was slightly higher and appeared earlier among cured HCV patients with coexisting schistosomiasis (P < 0.05) (Supplemental Table 6 and Figure 1B).

DISCUSSION

So far, this represents the first national study on the long-term follow-up of a real-life cohort of patients with chronic HCV infection after generic DAA-induced SVR. In 2014, generic DAA regimens were successfully introduced as part of the national HCV treatment program in Egypt and demonstrated exceptional efficacy, safety, and tolerability profiles.^11,38,39 As a part of the nationwide HCV elimination program, patients with HCV-related fibrosis or cirrhosis are maintained in surveillance following SVR for early detection and management of HCC and other liver disease-related complications.

The patients included in our cohort did not show significant variations in their sociodemographic characteristics and comorbidities. Note that given the parental antischistosomal therapy campaigns in the 1950s and 1960s,⁵² a significant portion of our cohort has a history of schistosomiasis and SHF, which may have affected the progression of liver disease outcome after virological cure. We assumed that most patients are infected with genotype 4, the predominating HCV strain in Egypt.^53–56 The spectrum of candidates for HCV treatment has been expanded given the high SVR rates (exceeding 95%) following DAA regimens. However, the underrepresentation of Child-B/C patients in our cohort at baseline might have limited the interpretation of our findings.

Direct-acting antivirals therapy has significant prognostic and survival benefits.^25,57 Consistent with other reports, the overall liver-related mortality rates were low in our cohort, emphasizing the favorable outcome of liver disease after DAA-induced SVR.^{9,10,24,58–60} Moreover, deaths occurred among both Child-A and Child-B patients. However, the event rate in Child-B patients might have not been reached because of the relatively small number of this category of patients at baseline. Likewise, liver-related complications occurred at 19/1,000 person-years. Most patients had cirrhosis and schistosomiasis as a concomitant factor for liver injury, aspects that appeared to be significantly associated with the occurrence of liver-related adverse events and mortality after HCV cure.

After the introduction of DAA therapy, data from paired biopsies assessing fibrosis regression are limit.²⁵ Transient elastography and liver ultrasound are the most common imaging modalities used in evaluating patients who achieved SVR. Our cohort lacked systematic data on posttreatment transient elastography. In fact, most liver disease centers in Egypt rely on liver ultrasound and the FIB-4 as an NIBM for providing diagnostic and prognostic information and detecting complications, such as PHT and HCC. Nevertheless, ultrasonography does not provide sufficient clues for diagnosing liver fibrosis owing to its suboptimal accuracy.^61,62 Thus, patients in this cohort with detected abnormal echo pattern or coarse bright liver may have a degree of fibrosis that cannot be judged using conventional ultrasonography. Moreover, the NIBMs of liver fibrosis are affected by the increased platelet count and the normalization of ALT and AST levels. Several studies have evaluated the dynamics of fibrosis-related parameters during and after DAAbased therapy using NIBM panels, which demonstrated promising results.^{14,15,40,63,64}

Apparently, SVR plays a recognized role in improving the liver fibrosis status although the resolution of established fibrosis/cirrhosis might take a long time to ensue.¹⁸ Although the state of liver fibrosis or cirrhosis showed continuous improvement in several patients with cured HCV infection in this cohort, approximately one-third of Child-A6 or Child-B7–9 patients with no co-morbid schistosomiasis have evolved to Child-A5 and Child-A6/Child-B7–8, respectively, by the end of follow-up. In concordance, several studies have demonstrated that the sustained conversion rates to Child-A can reach 50% in patients with chronic HCV infection following SVR.^{19,20,22,24,57} The sustained increase in serum albumin levels and platelet counts in our study cohort corroborates a significant recompensation and progressive improvement in the degree of liver fibrosis/cirrhosis after DAA-induced SVR.^17,64 However, this may be a consequence of a declined necroinflammatory activity after viral clearance, which may lead to the overestimation of fibrosis regression,^16,64,65 a speculation demonstrated by matched elastography–biopsy comparison.⁶⁶ Likewise, several studies have demonstrated decreasing liver stiffness with DAA therapy (²⁵ and references therein). Indeed, the initial decrease might partly be attributed to the resolution of inflammation, whereas the subsequent and consistent decrease from the EOT up to the 1-year follow-up could pertain to fibrosis regression.⁶⁷ However, guided by data from the IFN era, the process of fibrosis resolution gradually ensues over the years.²⁵ Thus, 2 years of follow-up remains relatively short to conclude changes in liver fibrosis after DAA therapy.

Hepatocarcinogenesis is a risk in patients with chronic HCV infection because of long-standing associated cirrhosis^68–70 or is directly induced by HCV core proteins.^71,72 The debate concerning HCC risk in the DAA era remains intense.^25,73,74 Many hospital-based studies^25,75 have reported increasing incidence of HCC. However, as more data have appeared, DAA therapy seemed not to increase the risk of HCC although the risk remains high in patients with advanced fibrosis and cirrhosis.^{8,23,58,76–84} Note that the increased awareness of HCV-related hepatocarcinogenesis and improved patient surveillance and screening methods upon the introduction of DAAs might have contributed to the rising trend of HCC. Importantly, pervious IFN-based therapies might have added advantage in preventing the development of HCC as an immune modulator. Moreover, IFN-based antivirals were used primarily on patients without cirrhosis, whereas the candidates for DAAs include those with advanced fibrosis and cirrhosis who are at a high risk of HCC.⁸⁵

The prevalence of HCC in patients with chronic HCV infection in Egypt can reach 40–50%.^86–89 In our study cohort, the incidence rate of de novo HCC was comparable to the annual number and proportion of HCC among patients with chronic HCV infection⁸⁶ and lower than what was demonstrated in other real-world studies.^{24,73,90–94} In our study cohort, HCC was detected in Child-B patients as early as 4 weeks after treatment initiation, suggesting the likely prior existence of undetectable dysplastic micronodules.²⁰ In Child-A patients, HCC tended to appear later in the follow-up. A retrospective multicenter study from Spain has reported a short-term HCC incidence of 3.73 HCC/100 patient-years in patients with HCV infection with cirrhosis, within few months after initiating DAA therapy.⁹⁵

Moreover, concerns have been raised that HCCs that occurred after DAA therapy were more aggressive, with a high occurrence of multifocal and advanced lesions.^96,97 Nevertheless, focal and multicenter HCC lesions were detected in our patients with effectively cured HCV infection at a comparable frequency. This highlights the careful follow-up and screening adopted for earlier detection of small HCC lesions.

Hepatocellular carcinoma recurrence after DAA-induced SVR remains controversial.^11,98 Purported mechanisms focused on reduced immune surveillance and anti-HCC cytokine effects because of the clearance of HCV-specific T cells from the liver.^79,99–101 Recurrent HCC was observed in two of our Child-B patients at 15 and 18 months of follow-up, respectively. Data from large distinct cohorts in France and North America have found no association between DAA therapy and HCC recurrence among patients who achieved SVR compared with untreated individuals.^78,91,94,102

The analysis of HCC risk factors in patients with chronic HCV infection has been addressed in several studies.^{73,79,80,89,91,94,103,104} For instance, cirrhosis is the most important clinical risk factor for hepatocarcinogenesis,^{69,79,84,91,104–106} although some HCCs do arise in the absence of cirrhosis.¹⁰⁷ Patients with HCV-related cirrhosis had a 3-fold higher adjusted risk of HCC than those with cirrhosis from other etiologies, suggesting that the virus has direct carcinogenic effects.^85,108 This holds true in our cohort, where Child-B and baseline AFP as markers of cirrhosis were strong predictors of de novo HCC in patients who achieved SVR, although cirrhosis per se was not retained in the final multivariate model. In their study, Kanwal et al. have shown that the risk of HCC after DAAs with SVR remained for up to 3.6 years of follow-up, and it was particularly high in patients with cirrhosis.⁹⁴

The AFP is a widely used tumor marker and can detect HCC at values > 400 ng/mL, which is considered diagnostic in the proper clinical context, including appropriate radiological findings.^109,110 In this study, the rise in serum AFP levels strongly correlated with the presence of HCC. Likewise, liver ultrasound, the most common imaging modality used in the surveillance of HCC in Egypt, could detect focal lesions in most cases of HCC. This emphasizes the leading screening role of ultrasound, although its sensitivity can be enhanced by combining it with the AFP assay in the surveillance of HCC in cirrhotic patients with cured HCV infection.

Although patients with schistosomiasis are at a higher risk of HCC, probably because of immunosuppression and subsequent persistent viremia,^31,111,112 our results in this regard did not reach a statistical significance, which could refute a direct causal effect. In this regard, the available literature implies that Schistosoma mansoni, in the presence of HBV and HCV infections, likely acts as a cofactor for accelerating hepatic injury and oncogenesis.¹¹³ In our study cohort, HCV patients with hepatic schistosomiasis were more likely develop liver related complications and death. However, the changes revealed in our quantitative data was mainly attributed to the effect of time since most of these patients showed improved or stationary condition by the end of follow-up. It is noteworthy that HCV patients with comorbid or past history of schistosomiasis received oral antischistosomal treatment^38,39 before starting the DAA therapy, which might have contributed to the resolution of Schistosoma-induced PPF and pathology.

Hepatitis B virus is a major risk factor for HCC, and coinfection with HCV is associated with more rapid tumor progression.¹¹⁴ However, the wider use of HBV vaccination has decreased the role of HBV infection in the pathogenesis of HCC. In Egypt, there has been a decline in the prevalence of HBV infection over the last 30 years because of a successful nationwide vaccination strategy, which has been launched in the early 1990s.¹¹⁵ Interestingly, all HCV/HBV coinfected patients in our study cohort did not have this malignancy. Indeed, the supra-additive effect for HCC risk remains controversial, although data from meta-analyses suggest the lack of synergism between HBV and HCV in hepatocarcinogenesis.^116,117

Consistent with other reports,^{86,88,118,119} male predominance was obvious in our HCC population with a male-to-female ratio of 2.5:1. This may be at least in part explained by differences in exposure to risk factors, including other environmental carcinogens. The role of sex hormones, X-linked genetic factors, and different DNA synthetic activities might be equally important in modulating hepatocarcinogenesis.^120,121 Together, these can suggest an increased risk of HCC among HCV-infected men. Such patients should be attentively followed up and screened for the early detection of HCC.

Smoking increases the risk of HCC in patients with viral hepatitis, given the carcinogenic potential of numerous tobacco components processed in the liver. Moreover, smoking is associated with a reduction in p53, a tumor suppressor gene, and the accumulation of excess iron in hepatocytes, which induces fibrosis and favors the development of HCC.^122,123 Studies have highlighted a 2-fold increased risk of HCC in smokers compared with nonsmokers.^124–126 In this study, although a significant difference in the percentage of smokers was observed between the two groups, this factor was not retained in our HCC predictive model. This agreed with other studies,^127,128 which concluded that tobacco smoking was unrelated to the overall risk of HCC.

In conclusion, HCV clearance by DAA therapy is durable and accompanied by favorable long-term clinical outcomes in terms of survival, recompensation, and improvement of liver function, even in patients with advanced fibrosis/cirrhosis or comorbid schistosomiasis. Yet, the risk of de novo HCC and its recurrence in successfully treated patients remain a concern and warrant further investigation. Furthermore, the risk of liver-related complications after the EOT relates to pretreatment history of decompensation. Accordingly, regular surveillance of patients with cured HCV infection is highly recommended even after clinical stabilization and improvement. Further studies are needed to assess the impact of treatment on survival and quality of life in the long term.

Given the major burden of HCV and HCC in Egypt, the current national HCC surveillance program for cirrhotic patients with HCV infection launched in 2018 could yield important prospective insights on the real effect of DAA agents on HCC risk. Such data would help define the magnitude and complex etiology of HCC, thus enabling policymakers to create targeted and more efficient screening and prevention programs.

STUDY LIMITATIONS

This study represents a large real-world cohort with a long duration of follow-up. However, it has several limitations. Longer follow-up periods are needed to draw accurate conclusions regarding the longitudinal changes in liver function parameters, particularly in patients with more advanced liver disease. We did not include a group of non-SVR or a group of patients with untreated chronic HCV infection to compare the incidence of HCC and other liver disease-related complications. Although the sample size was powered for the primary outcome, it was too small to allow risk stratification and subgroup outcome comparisons. Moreover, the clustering effect of the outcome between observation points should have been addressed as a longitudinal statistical analysis technique to deliver a more robust conclusion.

Note: Supplemental tables and figures appear at www.ajtmh.org.