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Okumura T, Joshita S, Sugiura A, Ota M, Umemura T. Quantitative changes of lipoprotein(a) in chronic hepatitis C patients achieving a sustained virological response by direct-acting antivirals. Clin Res Hepatol Gastroenterol 2022; 46:102011. [PMID: 36031100 DOI: 10.1016/j.clinre.2022.102011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/16/2022] [Accepted: 08/24/2022] [Indexed: 02/04/2023]
Affiliation(s)
- Taiki Okumura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan; Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan.
| | - Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Masao Ota
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan; Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan; Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan; Department of Advanced Therapeutic Endoscopy, Shinshu University School of Medicine, Matsumoto, Japan; Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
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Ando W, Kaneko F, Shimamoto S, Igarashi K, Otori K, Yokomori H. Long-term prediction of hepatocellular carcinoma using serum autotaxin levels after antiviral therapy for hepatitis C. Ann Hepatol 2022; 27:100660. [PMID: 35007770 DOI: 10.1016/j.aohep.2022.100660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/31/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Continuous monitoring for hepatocellular carcinoma is necessary following treatment with direct-acting antivirals in patients with hepatitis C virus infection. We investigated whether the long-term follow-up of serum autotaxin levels could predict the development of hepatocellular carcinoma. PATIENTS AND METHODS This prospective observational study enrolled adult patients with chronic hepatitis C virus infection who presented to the study center from January 2016 to March 2021. Among the patients who achieved a sustained viral response, the relationship between the development of hepatocellular carcinoma and serum autotaxin levels was assessed before treatment with direct-acting antivirals; at the end of therapy; at 12 and 24 weeks; and at 12, 24, 36, and 48 months after treatment. RESULTS Data were analyzed for 139 patients. Thirteen patients developed hepatocellular carcinoma 48 months after treatment. The cut-off serum autotaxin values that predicted hepatocellular carcinoma after 24 weeks were 1.22 (men) and 1.92 (women) mg/L. The area under the curve for serum autotaxin was 0.83 (95% confidence interval [CI]:0.71-0.95) in men and 0.90 (95% CI: 0.82-0.99) in women. The positive predictive value of serum autotaxin was 0.208 (95% CI: 0.139-0.248), and the negative predictive value was 0.971 (95% CI: 0.939-0.990). The cumulative incidence of hepatocellular carcinoma was significantly higher when serum autotaxin levels were above the cut-off value after 24 weeks (p < 0.0001). CONCLUSIONS Serum autotaxin is a candidate biomarker for predicting hepatocellular carcinoma during the long-term follow-up of patients with a sustained viral response following treatment with direct-acting antivirals.
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Affiliation(s)
- Wataru Ando
- Department of Clinical Pharmacy, Center for Clinical Pharmacy and Sciences, School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8641, Japan.
| | - Fumihiko Kaneko
- Department of Gastroenterology and Hepatology, Saitama City Hospital, 2460 Mimuro, Midori-ku, Saitama 336-8522, Japan
| | - Satoshi Shimamoto
- Bioscience Division, Tosoh Corporation, 2743-1 Hayakawa, Ayase-shi, Kanagawa 252-1123, Japan
| | - Koji Igarashi
- Bioscience Division, Tosoh Corporation, 2743-1 Hayakawa, Ayase-shi, Kanagawa 252-1123, Japan
| | - Katsuya Otori
- Department of Clinical Pharmacy, Center for Clinical Pharmacy and Sciences, School of Pharmacy, Kitasato University, 5-9-1 Shirokane, Minato-ku, Tokyo 108-8641, Japan
| | - Hiroaki Yokomori
- Department of Internal Medicine, Kitasato University Medical Center, 6-100 Arai, Kitamoto-shi, Saitama 364-8641, Japan
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Mori Y, Matsuda S, Sato M, Muraoka M, Suzuki Y, Tatsumi A, Nakayama Y, Inoue T, Maekawa S, Enomoto N. The Impact of Antiviral Therapy for Hepatitis C Virus on the Survival of Patients after Hepatocellular Carcinoma Treatment. Intern Med 2022; 61:2721-2729. [PMID: 36104175 PMCID: PMC9556239 DOI: 10.2169/internalmedicine.8456-21] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Owing to advances in direct-acting antiviral (DAA) therapy, a considerable number of patients with hepatitis C virus (HCV)-positive hepatocellular carcinoma (HCC) are now able to achieve a sustained viral response (SVR) after curative treatment of HCC. However, the beneficial effect of a DAA-SVR on the survival remains unclear. Methods A total of 205 patients with HCC who were HCV-positive with Child-Pugh A at the onset from 2008 to 2018 were categorized into 2 groups: 140 patients untreated for HCV throughout the entire course after HCC development (untreated group) and 65 patients treated for HCV with DAAs following HCC treatment who achieved an SVR (SVR group). After propensity score matching, 63 patients from each group were selected. Using these patients, the survival and maintenance of Child-Pugh A after HCC treatment were compared between the untreated group and SVR group. Results There was a significant difference in the overall survival (p<0.001) and the rate of maintaining Child-Pugh A (p<0.001) between the groups. The 5-year survival rates were 96% (SVR group) and 60% (untreated group), and the proportions of patients with Child-Pugh A at 5 years after HCC treatment were 96% (SVR group) and 38% (untreated group). Conclusion In patients with HCV-positive HCC, achieving a DAA-SVR after HCC treatment significantly improved the overall survival rate compared with HCV-untreated patients. The contribution of DAA-SVR during the course of HCC treatment to a longer survival is mainly due to the prevention of the progression of Child-Pugh A to B/C. Further research is needed to determine whether aggressive antiviral therapy is also effective for HCC patients with Child-Pugh B/C.
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Affiliation(s)
- Yuki Mori
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Shuya Matsuda
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Mitsuaki Sato
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Masaru Muraoka
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Yuichiro Suzuki
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Akihisa Tatsumi
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Yasuhiro Nakayama
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Taisuke Inoue
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Shinya Maekawa
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
| | - Nobuyuki Enomoto
- First Department of Internal Medicine, Faculty of Medicine, University of Yamanashi, Japan
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Miyasaka A, Yoshida Y, Suzuki A, Sawara K, Takikawa Y. A Novel Standard for Hepatocellular Carcinoma Screening Intensity After Hepatitis C Elimination. Int J Gen Med 2021; 14:8935-8943. [PMID: 34866934 PMCID: PMC8636695 DOI: 10.2147/ijgm.s344492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/12/2021] [Indexed: 12/22/2022] Open
Abstract
Purpose To investigate long-term incidence of hepatocellular carcinoma (HCC) and the factors associated with HCC occurrence after achieving sustained virological response (SVR) by direct-acting antiviral agent (DAA) treatment for hepatitis C virus (HCV). Methods A total of 476 patients (male 227, female 249; median age 68) with chronic HCV infection who were treated with DAAs and achieved SVR were analyzed. The incidence of HCC and factors related to the development of HCC after HCV elimination were evaluated. Results The median observation period was 46.4 months. During this period, 40 patients developed HCC. The incidence rates of HCC were 3.7%, 6.0%, 7.1%, 9.3%, and 10.6% at 1, 2, 3, 4, and 5 years post-SVR12, respectively. Multivariate analysis with pre-treatment factors revealed that platelet count, α-fetoprotein, fibrosis-4 (Fib-4) index, and previous HCC history were independent factors that contributed to development of HCC post-SVR following DAA treatment. Of these factors, previous HCC history was the most significant, followed by Fib-4 index. Using these two factors, a novel scoring system was established. The presence of previous HCC history was scored as 2, and then, the absence of previous HCC history was stratified by Fib-4 index (≥3.07, 1; <3.07, 0). The HCC occurrence rate at 5 years was 0.4% in the 0-point group, 6.8% in the 1-point group, and 55.6% in the 2-point group, respectively. Conclusion Fib-4 index and previous HCC history were independent predictors for development of HCC after DAA treatment. Patients with these risk factors require careful observation.
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Affiliation(s)
- Akio Miyasaka
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Shiwa-gun, Iwate, Japan.,Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Iwate, Japan
| | - Yuichi Yoshida
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Shiwa-gun, Iwate, Japan.,Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Ninohe, Iwate, Japan
| | - Akiko Suzuki
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Shiwa-gun, Iwate, Japan
| | - Kei Sawara
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Shiwa-gun, Iwate, Japan.,Department of Gastroenterology, Iwate Prefectural Kamaishi Hospital, Kamaishi, Iwate, Japan
| | - Yasuhiro Takikawa
- Division of Hepatology, Department of Internal Medicine, Iwate Medical University School of Medicine, Shiwa-gun, Iwate, Japan
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5
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Yamana Y, Kanda T, Matsumoto N, Honda M, Kumagawa M, Sasaki R, Kanezawa S, Mizutani T, Yamagami H, Masuzaki R, Ishii T, Nirei K, Moriyama M. Efficacy of Glecaprevir/Pibrentasvir for Real-World HCV Infected Patients in the Northern Part of Tokyo, Japan. J Clin Med 2021; 10:5529. [PMID: 34884231 DOI: 10.3390/jcm10235529] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/26/2022] Open
Abstract
Hepatis virus C (HCV) infection causes liver cirrhosis and hepatocellular carcinoma (HCC) worldwide. The objective of our study was to examine the effects of the HCV nonstructural protein (NS) 3/4A inhibitor glecaprevir/NS5A inhibitor pibrentasvir on real-world HCV patients in the northern part of Tokyo, Japan. Although 106 patients were consecutively included, a total of 102 HCV-infected patients with chronic hepatitis or compensated cirrhosis, who received 8- or 12-week combination treatment with glecaprevir/pibrentasvir and were followed up to week 12 after the end of treatment were analyzed retrospectively. Only three patients discontinued treatment due to adverse events; however, they achieved a sustained virologic response at 12 weeks (SVR12). Finally, SVR rates were 99.0% (101/102). Only one patient without liver cirrhosis was a treatment relapser who received hepatic resection for HCC approximately two years after commencement of the 8-week combination treatment with glecaprevir/pibrentasvir. After the exclusion of patients with HCV genotype 1b and P32 deletion in the HCV NS5A region, a 12-week combination of glecaprevir/pibrentasvir led to SVR12 in all nine direct-acting antiviral-experienced patients. Glecaprevir/pibrentasvir had a high efficacy and an acceptable safety profile for real-world HCV patients in a single hospital in Japan.
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Yamashita Y, Joshita S, Sugiura A, Yamazaki T, Kobayashi H, Wakabayashi SI, Yamada Y, Shibata S, Kunimoto H, Iwadare T, Matsumura M, Miyabayashi C, Okumura T, Ozawa S, Nozawa Y, Kobayashi N, Komatsu M, Fujimori N, Saito H, Umemura T. aMAP score prediction of hepatocellular carcinoma occurrence and incidence-free rate after a sustained virologic response in chronic hepatitis C. Hepatol Res 2021; 51:933-942. [PMID: 34216422 DOI: 10.1111/hepr.13689] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/14/2021] [Accepted: 06/25/2021] [Indexed: 02/08/2023]
Abstract
AIMS Hepatocellular carcinoma (HCC) can still occur in hepatitis C virus (HCV) patients who have achieved a sustained virologic response (SVR), which remains an important clinical issue in the direct-acting antivirals era. The current study investigated the clinical utility of the aMAP score (consisting of age, male, albumin-bilirubin, and platelets) for predicting HCC occurrence in HCV patients achieving an SVR by direct-acting antivirals. METHODS A total of 1113 HCV patients without HCC history, all of whom achieved an SVR, were enrolled for clinical comparisons. RESULTS Hepatocellular carcinoma was recorded in 50 patients during a median follow-up period of 3.7 years. The aMAP score was significantly higher in the HCC occurrence group than in the HCC-free group (53 vs. 47, p < 0.001). According to risk stratification based on aMAP score, the cumulative incidence of HCC occurrence for the low-, medium-, and high-risk groups was 0.14%, 4.49%, and 9.89%, respectively, at 1 year and 1.56%, 6.87%, and 16.17%, respectively, at 3 years (low vs. medium, low vs. high, and medium vs. high: all p < 0.01). Cox proportional hazard analysis confirmed aMAP ≥ 50 (hazard ratio [HR]: 2.78, p = 0.014), age≥ 70 years (HR: 2.41, p = 0.028), ALT ≥ 17 U/L (HR: 2.14, p < 0.001), and AFP ≥ 10 ng/mL (HR: 2.89, p = 0.005) as independent risk factors of HCC occurrence. Interestingly, all but one patient (99.5%) with aMAP less than 40 was HCC-free following an SVR. CONCLUSION The aMAP score could have clinical utility for predicting HCC occurrence in HCV patients achieving an SVR.
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Affiliation(s)
- Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoo Yamazaki
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroyuki Kobayashi
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shun-Ichi Wakabayashi
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yosuke Yamada
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Soichiro Shibata
- Department of Gastroenterology, Japanese Red Cross Society Nagano Hospital, Nagano, Japan
| | - Hideo Kunimoto
- Department of Gastroenterology, Nagano Municipal Hospital, Nagano, Japan
| | - Takanobu Iwadare
- Department of Gastroenterology, Nagano Municipal Hospital, Nagano, Japan
| | - Makiko Matsumura
- Department of Gastroenterology, Nagano Chuo Hospital, Nagano, Japan
| | | | - Taiki Okumura
- Department of Gastroenterology, NHO Matsumoto Medical Center, Matsumoto, Japan
| | - Sachie Ozawa
- Department of Internal Medicine, Nagano Prefectural Kiso Hospital, Kiso, Japan
| | - Yuichi Nozawa
- Department of Gastroenterology, Ina Central Hospital, Ina, Japan
| | | | - Michiharu Komatsu
- Department of Gastroenterology, Japanese Red Cross Society Suwa Hospital, Suwa, Japan
| | - Naoyuki Fujimori
- Department of Gastroenterology, NHO Shinshu Ueda Medical Center, Ueda, Japan
| | - Hiromi Saito
- Department of Gastroenterology, Aizawa Hospital, Matsumoto, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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Kobayashi H, Joshita S, Akahane Y, Matsuzaki K, Yamada H, Aomura D, Joshita N, Midorikawa H, Suyama K, Ota M, Wakabayashi SI, Yamashita Y, Sugiura A, Yamazaki T, Misawa H, Umemura T. Protocol: Prospective observational study aiming for micro-elimination of hepatitis C virus in Nagawa town: The Nagawa Project. PLoS One 2021; 16:e0256711. [PMID: 34437651 PMCID: PMC8389441 DOI: 10.1371/journal.pone.0256711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 08/10/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The World Health Organization has set a goal of hepatitis C virus (HCV) elimination by the year 2030. However, no regions in Japan have succeeded in eradicating HCV. Micro-elimination is an approach to attain hepatitis C eradication in which national eradication goals are applied to specific populations so that viral treatment and control efforts can move forward quickly and efficiently. In order to eradicate HCV from Japan, this study aims to achieve HCV micro-elimination in the town of Nagawa. METHODS AND DESIGN The Nagawa Project is an ongoing, prospective, multiple-institution, observational study running from April 1, 2021, to March 31, 2024. All residents of Nagawa town, excluding those under 20 years of age, not consenting to the study, or unable to undergo health check-ups due to nursing care needs, will be included. If found to be HCV antibody-positive, the participant will be recommended to see a doctor in consideration of MAC-2 binding protein glycosylation isomer values. Then, the participant will undergo serum HCV RNA measurement with the real-time polymerase chain reaction by an attending physician. If the participant is HCV RNA-positive, he or she will be referred to a hepatologist for further evaluation. In the case of a definitive diagnosis of chronic hepatitis C, direct acting antiviral treatment will be initiated. Through this process, HCV will be systematically micro-eliminated from the region. DISCUSSION The Nagawa Project will reveal the prevalence of chronic HCV in addition to the HCV eradication rate in Nagawa town towards achieving HCV micro-elimination. TRIAL REGISTRATION This study is performed by Shinshu University School of Medicine and was registered as UMIN 000044114 on May 6, 2021.
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Affiliation(s)
- Hiroyuki Kobayashi
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Satoru Joshita
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- * E-mail:
| | - Yuki Akahane
- Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Hiromi Yamada
- Department of Clinical Laboratory, Yodakubo Hospital, Nagawa, Japan
| | - Daiki Aomura
- Department of Nephrology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nao Joshita
- Health Care Center, Yodakubo Hospital, Nagawa, Japan
| | | | - Kazuhiro Suyama
- Department of Internal Medicine, Yodakubo Hospital, Nagawa, Japan
| | - Masao Ota
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shun-ichi Wakabayashi
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuki Yamashita
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Ayumi Sugiura
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoo Yamazaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | | | - Takeji Umemura
- Division of Gastroenterology and Hepatology, Department of Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Department of Health Promotion Medicine, Shinshu University School of Medicine, Matsumoto, Japan
- Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto, Japan
- Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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Joshita S, Yamashita Y, Okamoto T, Usami Y, Sugiura A, Yamazaki T, Kakino A, Ota M, Sawamura T, Umemura T. Quantitative and qualitative lipid improvement with chronic hepatitis C virus eradication using direct-acting antivirals. Hepatol Res 2021; 51:758-766. [PMID: 33982310 DOI: 10.1111/hepr.13666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 02/08/2023]
Abstract
AIM Direct-acting antivirals have revolutionized hepatitis C virus (HCV) therapy by providing a high sustained virological response (SVR) rate and subsequent favorable lipid increases. Proprotein convertase subtilisin-kexin like-9 (PCSK9) plays an important role in regulating quantitative lipid levels. This study examined the interactions between quantitative PCSK9 and lipid changes, as well as qualitative lipid changes in terms of lectin-like oxidized low-density lipoprotein (LDL) receptor-1 ligand containing apolipoprotein B (LAB) and high-density lipoprotein (HDL) cholesterol uptake capacity (HDL-CUC). METHODS Patients with chronic HCV infection (N = 231) who achieved an SVR by direct-acting antivirals without lipid-lowering therapy were included for comparisons of PCSK9, LAB, HDL-CUC, and other clinical indices between pretreatment and SVR12 time points. RESULTS LDL (LDL) cholesterol and HDL cholesterol levels were quantitatively increased at SVR12, along with higher PCSK9 (all p < 0.0001). PCSK9 was significantly correlated with LDL cholesterol (r = 0.244, p = 0.0003) and apolipoprotein B (r = 0.222, p = 0.0009) at SVR12. Regarding qualitative LDL changes, LAB was significantly decreased and LAB/LDL cholesterol and LAB/apolipoprotein B proportions were improved at SVR12 (all p < 0.0001). In terms of qualitative HDL changes, HDL-CUC was significantly ameliorated, along with HDL-CUC/HDL cholesterol, HDL-CUC/ apolipoprotein A1, and HDL-CUC/ apolipoprotein A2 at SVR12 (all p < 0.0001). CONCLUSIONS HCV eradication by direct-acting antivirals may produce quantitative lipid profile changes, along with PCSK9 production recovery in addition to qualitative lipid improvement, which possibly confers the additional secondary benefits of atherosclerosis improvement and cardiovascular disease event reduction.
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Affiliation(s)
- Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Toru Okamoto
- Institute for Advanced Co-Creation Studies Research, Institute for Microbial Diseases, Osaka University, Osaka, Japan
| | - Yoko Usami
- Department of Laboratory Medicine, Shinshu University Hospital, Matsumoto, Japan
| | - Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tomoo Yamazaki
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Akemi Kakino
- Department of Molecular Pathophysiology, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Masao Ota
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tatsuya Sawamura
- Department of Molecular Pathophysiology, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto, Japan.,Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, Matsumoto, Japan
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9
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Totsuka M, Honda M, Kanda T, Ishii T, Matsumoto N, Yamana Y, Kaneko T, Mizutani T, Takahashi H, Kumagawa M, Sasaki R, Masuzaki R, Kanezawa S, Nirei K, Yamagami H, Matsuoka S, Ohnishi H, Okamoto H, Moriyama M. Japanese Man with HCV Genotype 4 Infection and Cirrhosis Who Was Successfully Treated by the Combination of Glecaprevir and Pibrentasvir. Intern Med 2021; 60:2061-2066. [PMID: 33518580 PMCID: PMC8313908 DOI: 10.2169/internalmedicine.6728-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
A 74-year-old man with a history of transfusion at 35 years old in Egypt was referred to our hospital. He was infected with hepatitis C virus (HCV) genotype 4 (GT4), which is a rare HCV GT in Japan, and was also diagnosed with hepatic compensated cirrhosis. We safely treated the patient for 12 weeks with the combination of glecaprevir and pibrentasvir, and a sustained virologic response (SVR) was achieved. This is the first report of HCV GT4 infection in a treatment-naïve Japanese patient with cirrhosis in whom SVR was achieved with the combination treatment of glecaprevir and pibrentasvir.
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Affiliation(s)
- Mai Totsuka
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Masayuki Honda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Tatsuo Kanda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Tomotaka Ishii
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Naoki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Yoichiro Yamana
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Tomohiro Kaneko
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Taku Mizutani
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hiroshi Takahashi
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Mariko Kumagawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Reina Sasaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Ryota Masuzaki
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Shini Kanezawa
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Kazushige Nirei
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hiroaki Yamagami
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Shunichi Matsuoka
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
| | - Hiroshi Ohnishi
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Japan
| | - Hiroaki Okamoto
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Japan
| | - Mitsuhiko Moriyama
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Japan
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10
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Umemura T, Joshita S, Saito H, Wakabayashi SI, Kobayashi H, Yamashita Y, Sugiura A, Yamazaki T, Ota M. Investigation of the Effect of KIR-HLA Pairs on Hepatocellular Carcinoma in Hepatitis C Virus Cirrhotic Patients. Cancers (Basel) 2021; 13:cancers13133267. [PMID: 34209910 PMCID: PMC8267716 DOI: 10.3390/cancers13133267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/21/2021] [Accepted: 06/25/2021] [Indexed: 11/21/2022] Open
Abstract
Simple Summary Natural killer (NK) cells normally respond to tumor cells and virally infected cells by killing them via the innate immune system. However, the functional impairment of NK cells has been observed in hepatocellular carcinoma. The NK-cell phenotype is partially mediated through the binding of killer cell immunoglobulin-like receptors (KIR) with human leukocyte antigen (HLA) class I ligands. This study evaluated the involvement of KIR–HLA pairs in hepatocellular carcinoma development in 211 patients with hepatitis C virus-associated cirrhosis. HLA-Bw4 and the KIR3DL1+HLA-Bw4 pair were significantly associated with hepatocellular carcinoma onset during a median follow-up of 6.6 years, which suggested that functional interactions between KIR and HLA or HLA-Bw4 may influence the risk of cancer development. Abstract Natural killer cells are partially mediated through the binding of killer cell immunoglobulin-like receptors (KIR) with human leukocyte antigen (HLA) class I ligands. This investigation examined the risk of hepatocellular carcinoma (HCC) in relation to KIR–HLA pairs in patients with compensated hepatitis C virus (HCV)-associated cirrhosis. A total of 211 Japanese compensated HCV cirrhotic cases were retrospectively enrolled. After KIR, HLA-A, HLA-Bw, and HLA-C typing, associations between HLA, KIR, and KIR–HLA combinations and HCC development were evaluated using the Cox proportional hazards model with the stepwise method. During a median follow-up period of 6.6 years, 69.7% of patients exhibited HCC. The proportions of HLA-Bw4 and the KIR3DL1 + HLA-Bw4 pair were significantly higher in patients with HCC than in those without (78.9% vs. 64.1%; odds ratio (OR)—2.10, 95% confidence interval (CI)—1.10–4.01; p = 0.023 and 76.2% vs. 60.9%, odds ratio—2.05, p = 0.024, respectively). Multivariate analysis revealed the factors of male gender (hazard ratio (HR)—1.56, 95% CI—1.12–2.17; p = 0.009), α-fetoprotein > 5.6 ng/mL (HR—1.56, 95% CI—1.10–2.10; p = 0.011), and KIR3DL1 + HLA-Bw4 (HR—1.69, 95% CI—1.15–2.48; p = 0.007) as independent risk factors for developing HCC. Furthermore, the cumulative incidence of HCC was significantly higher in patients with KIR3DL1 + HLA-Bw4 than in those without (log-rank test; p = 0.013). The above findings suggest KIR3DL1 + HLA-Bw4, in addition to HLA-Bw4, as a novel KIR–HLA pair possibly associated with HCC development in HCV cirrhosis. HCV-associated cirrhotic patients with the risk factors of male gender, α-fetoprotein > 5.6 ng/mL, and KIR3DL1 + HLA-Bw4 may require careful surveillance for HCC onset.
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Affiliation(s)
- Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
- Consultation Center for Liver Diseases, Shinshu University Hospital, Matsumoto 390-8621, Nagano, Japan
- Department of Life Innovation, Shinshu University, Matsumoto 390-8621, Nagano, Japan
- Correspondence: ; Tel.: +81-263-37-2634; Fax: +81-263-32-9412
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Hiromi Saito
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Shun-ichi Wakabayashi
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Hiroyuki Kobayashi
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Tomoo Yamazaki
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
| | - Masao Ota
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, Matsumoto 390-8621, Nagano, Japan; (S.J.); (H.S.); (S.-i.W.); (H.K.); (Y.Y.); (A.S.); (T.Y.); (M.O.)
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11
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Hsieh YC, Lin CL, Hung CH, Chen CH, Tung SY, Lin CY, Hu TH, Lu SN, Chien RN, Sheen IS. Real-world experience of elbasvir/grazoprevir in Taiwan: This study was focused on liver and renal adverse effects. J Viral Hepat 2020; 27:505-513. [PMID: 32039536 DOI: 10.1111/jvh.13262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Revised: 11/14/2019] [Accepted: 12/19/2019] [Indexed: 01/03/2023]
Abstract
Elbasvir/grazoprevir with or without ribavirin has excellent efficacy and safety for the treatment of hepatitis C virus (HCV) genotype 1 and 4 patients. The real-world experience has been reported but the detailed analysis of liver and renal adverse effects is lacking. This study evaluated the real-world experience relating to the effectiveness and liver/renal safety of elbasvir/grazoprevir in HCV genotype 1 patients with compensated liver disease. In the four medical centres of Chang Gung Medical System, 350 HCV genotype 1 patients with compensated liver disease who were treated with elbasvir/grazoprevir were enrolled. Clinical characteristics and laboratory data were collected. The effectiveness (sustained virologic response 12 weeks after end of treatment, SVR12) and safety were assessed. A consecutive series of 350 patients with a mean age of 68.8 ± 10.0 years old were enrolled. The majority were treatment-naïve (72.3%), genotype 1b (97.7%) and advanced fibrosis/cirrhosis (94.3%). Seventy-nine (22.6%) had hepatocellular carcinoma and 23 (6.6%) had coinfection with hepatitis B. The effectiveness of SVR12 was 94.6% (95% CI: 92.2%-97.0%) in the full analysis set and 99.1% (95% CI: 98.1%-100.1%) in the per-protocol set. There were two relapses and one nonresponder. Seven (2.0%) patients had adverse events resulting in premature discontinuation of treatment. Five of them were considered drug-related. One was due to autoimmune hepatitis. Contrary to previous reports, around 49% of ALT elevation was observed after 8 weeks, and in two patients was due to hepatitis B flares. As to the renal function during the course of therapy, a minor deterioration of eGFR was observed in patients with baseline eGFR ≥60 mL/min/1.73 m2 , but not in those with baseline eGFR <60, <60-30 or <30 mL/min/1.73 m2 . In this real-world data, elbasvir/grazoprevir was effective with few liver/renal adverse effects. One patient developed autoimmune hepatitis.
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Affiliation(s)
- Yi-Chung Hsieh
- Division of Hepatogastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Lang Lin
- Division of Hepatogastroenterology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chao-Hung Hung
- Division of Hepatogastroenterology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chen
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Hepatogastroenterology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Shui-Yi Tung
- Division of Hepatogastroenterology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Yen Lin
- Division of Hepatogastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Tsung-Hui Hu
- College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Hepatogastroenterology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Sheng-Nan Lu
- Division of Hepatogastroenterology, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Rong-Nan Chien
- Division of Hepatogastroenterology, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - I-Shyan Sheen
- Division of Hepatogastroenterology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
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12
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Sugiura A, Joshita S, Yamashita Y, Yamazaki T, Fujimori N, Kimura T, Matsumoto A, Wada S, Mori H, Shibata S, Yoshizawa K, Morita S, Furuta K, Kamijo A, Iijima A, Kako S, Maruyama A, Kobayashi M, Komatsu M, Matsumura M, Miyabayashi C, Ichijo T, Takeuchi A, Koike Y, Gibo Y, Tsukadaira T, Inada H, Nakano Y, Usuda S, Kiyosawa K, Tanaka E, Umemura T. Effectiveness of Glecaprevir/Pibrentasvir for Hepatitis C: Real-World Experience and Clinical Features of Retreatment Cases. Biomedicines 2020; 8:biomedicines8040074. [PMID: 32260271 PMCID: PMC7235710 DOI: 10.3390/biomedicines8040074] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 12/15/2022] Open
Abstract
Glecaprevir/pibrentasvir (G/P) are direct-acting antivirals (DAAs) that achieve a high sustained virological response (SVR) rate for hepatitis C virus (HCV) infection. We investigated G/P effectiveness for HCV patients based on real-world experience and the clinical features of retreatment cases. HCV patients (n = 182) were compared for clinical features and outcomes between first treatment (n = 159) and retreatment (n = 23) G/P groups. Overall, 77 patients (42.3%) were male, the median age was 68 years, and 86/66/1/4 cases had genotype 1/2/1 + 2/3, respectively. An SVR was achieved in 97.8% (178/182) of cases by intention-to-treat analysis and 99.4% (178/179) of cases by per-protocol analysis. There were no remarkable differences between the first treatment and retreatment groups for male (42.8% vs. 39.1%, p = 0.70), median age (68 vs. 68 years, p = 0.36), prior hepatocellular carcinoma (5.8% vs. 8.7%, p = 0.59), or the fibrosis markers AST-to-platelet ratio index (APRI) (0.5 vs. 0.5, p = 0.80) and fibrosis-4 (FIB-4) index (2.2 vs. 2.6, p = 0.59). The retreatment group had a significantly more frequent history of interferon treatment (12.3% vs. 52.2%, p < 0.01) and the Y93H mutation (25.0% vs. 64.7%, p = 0.02). The number of retreatment patients who had experienced 3, 2, and 1 DAA treatment failures was 1, 3, and 19, respectively, all of whom ultimately achieved an SVR by G/P treatment. In conclusion, G/P was effective and safe for both HCV first treatment and retreatment cases despite the retreatment group having specific resistance mutations for other prior DAAs. As G/P treatment failure has been reported for P32 deletions, clinicians should consider resistance mutations during DAA selection.
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Affiliation(s)
- Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Yuki Yamashita
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Tomoo Yamazaki
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Naoyuki Fujimori
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Takefumi Kimura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Akihiro Matsumoto
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
- Consultation Centers for Hepatic Diseases, Shinshu University Hospital, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Shuichi Wada
- Department of Gastroenterology, Japanese Red Cross Society Nagano Hospital, 22-1 Wakasato, Nagano, Nagano 380-0928, Japan
| | - Hiromitsu Mori
- Department of Gastroenterology, Japanese Red Cross Society Nagano Hospital, 22-1 Wakasato, Nagano, Nagano 380-0928, Japan
| | - Soichiro Shibata
- Department of Gastroenterology, Japanese Red Cross Society Nagano Hospital, 22-1 Wakasato, Nagano, Nagano 380-0928, Japan
| | - Kaname Yoshizawa
- Department of Gastroenterology, National Hospital Organization, Shinshu Ueda Medical Center, 27-21 Midorigaoka, Ueda, Nagano 386-8610, Japan
| | - Susumu Morita
- Department of Gastroenterology, National Hospital Organization, Shinshu Ueda Medical Center, 27-21 Midorigaoka, Ueda, Nagano 386-8610, Japan
| | - Kiyoshi Furuta
- Department of Gastroenterology, National Hospital Organization, Matsumoto Medical Center, 20-30 Muraimachiminami, Matsumoto, Nagano 399-8701, Japan
| | - Atsushi Kamijo
- Department of Gastroenterology, National Hospital Organization, Matsumoto Medical Center, 20-30 Muraimachiminami, Matsumoto, Nagano 399-8701, Japan
| | - Akihiro Iijima
- Department of Internal Medicine, Nagano Prefectural Kiso Hospital, 6613-4 Fukushima, Kiso-town, Kiso, Nagano 397-8555, Japan
| | - Satoko Kako
- Department of Internal Medicine, Nagano Prefectural Kiso Hospital, 6613-4 Fukushima, Kiso-town, Kiso, Nagano 397-8555, Japan
| | - Atsushi Maruyama
- Department of Gastroenterology, Ina Central Hospital, 1313-1 Koshiroukubo, Ina, Nagano 396-8555, Japan
| | - Masakazu Kobayashi
- Department of Gastroenterology, Japanese Red Cross Society Suwa Hospital, 5-11-50 Kogandori, Suwa, Nagano 392-8510, Japan
| | - Michiharu Komatsu
- Department of Gastroenterology, Japanese Red Cross Society Suwa Hospital, 5-11-50 Kogandori, Suwa, Nagano 392-8510, Japan
| | - Makiko Matsumura
- Department of Gastroenterology, Nagano Chuo Hospital, 1570 Tsuruga-Nishitsurugamachi, Nagano, Nagano 380-0814, Japan
| | - Chiharu Miyabayashi
- Department of Gastroenterology, Chikuma Central Hospital, 58 Kuiseshita, Chikuma, Nagano 387-0011, Japan
| | - Tetsuya Ichijo
- Department of Gastroenterology, Japanese Red Cross Society Azumino Hospital, 5685 Toyoshina, Azumino, Nagano 399-8205, Japan
| | - Aki Takeuchi
- Aki Naika Clinic, 236-1 Nozawa, Saku, Nagano 385-0053, Japan
| | - Yuriko Koike
- Kawanakajima Clinic, 1942-25 Kawanagajima-machi, Nagano, Nagano 381-2221, Japan
| | - Yukio Gibo
- Gibo Hepatology Clinic, 1-34-20 Muraimachiminami, Matsumoto, Nagano 399-0036, Japan
| | - Toshihisa Tsukadaira
- Department of Gastroenterology, Kenwakai Hospital, 1936 Kanaenakadaira, Iida, Nagano 395-8522, Japan
| | - Hiroyuki Inada
- Kanebako Internal Medicine Clinic, 320-2 Kanebako, Nagano, Nagano 381-0007, Japan
| | - Yoshiyuki Nakano
- Nakano Gastroenterology Clinic, 4-13-5 Muraimachiminami, Matsumoto, Nagano 399-0036, Japan
| | - Seiichi Usuda
- Gastroenterology Center, Aizawa Hospital, 2-5-1 Honjo, Matsumoto, Nagano 390-0814, Japan
| | - Kendo Kiyosawa
- Gastroenterology Center, Aizawa Hospital, 2-5-1 Honjo, Matsumoto, Nagano 390-0814, Japan
| | - Eiji Tanaka
- Department of Community Medicine Promotion, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
- Department of Life Innovation, Institute for Biomedical Sciences, Shinshu University, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
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13
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Cieciura T, Urbanowicz A, Foroncewicz B, Hryniewiecka E, Pączek L, Ciszek M. Hepatocellular Carcinoma Is a Negative Predictor of Sustained Viral Response in Liver Transplant Recipients With Hepatitis C Treated With Direct-Acting Antivirals. Transplant Proc 2020; 52:2450-2453. [PMID: 32241637 DOI: 10.1016/j.transproceed.2020.01.098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 01/26/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Treatment with direct-acting antivirals (DAA) for hepatitis C (HCV) in liver transplant (LTX) recipients is very effective, but some studies showed that the treatment effectiveness might be impaired in patients with hepatocellular carcinoma (HCC). The study aimed to evaluate the predictors of DAA treatment failure in LTX recipients. METHODS Liver biopsy was done before the treatment in 107 of the 120 patients included. All patients had an abdominal ultrasound and liver elastography performed before and after the therapy. Blood HCV polymerase chain reaction was done before; during; and at 4, 12, and 24 weeks after the treatment. RESULTS Overall sustained viral response 24 weeks after treatment (SVR24) was 96%. There were 2 patients with HCC at the start of the DAA treatment and 3 cases of HCC recurrence during a 1-year follow-up. Treatment failure was observed in 1/115 (0.9%) patients without HCC and 4/5 (80%) with active HCC (P = .0001). Liver fibrosis and previous interferon treatment had no impact on treatment efficacy. Time to viremia elimination on treatment was shorter in the responder versus nonresponder group (28 vs 58 days, P = .03). CONCLUSIONS HCC is a negative predictor of DAA therapy success in LTX recipients.
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Affiliation(s)
- Tomasz Cieciura
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Arkadiusz Urbanowicz
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Foroncewicz
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Ewa Hryniewiecka
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Leszek Pączek
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland; Department of Bioinformatics, Institute of Biochemistry and Biophysics, Polish Academy of Sciences, Warsaw, Poland
| | - Michał Ciszek
- Department of Immunology, Transplant Medicine, and Internal Diseases, Medical University of Warsaw, Warsaw, Poland.
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14
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He S, Lockart I, Alavi M, Danta M, Hajarizadeh B, Dore GJ. Systematic review with meta-analysis: effectiveness of direct-acting antiviral treatment for hepatitis C in patients with hepatocellular carcinoma. Aliment Pharmacol Ther 2020; 51:34-52. [PMID: 31808566 DOI: 10.1111/apt.15598] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/25/2019] [Accepted: 11/06/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection is highly curative and tolerable. Among patients with hepatocellular carcinoma (HCC), optimal timing of DAA therapy remains unclear. Data on efficacy of DAA therapy in patients with HCC would inform this decision-making. AIM To evaluate response to DAA therapy among patients diagnosed with HCV infection and HCC. METHODS Bibliographic databases and conference abstracts were searched. Meta-analysis was conducted to pool sustained virologic response (SVR) estimates. RESULTS Fifty-six studies with 5522 patients with HCV and HCC were included. Overall SVR was 88.3% (95% CI 86.1-90.4). Twenty-seven studies included patients with prior or present HCC (n = 3126) and patients without HCC (n = 49 138), in which SVR was 88.2% (95% CI 85.0-91.4) and 92.4% (95% CI 91.1-93.7) among patients with and without HCC, respectively (odds ratio: 0.54, 95% CI 0.43-0.68, P < .001). In the subgroup analyses, higher SVR was seen in patients who received curative HCC management (SVR 90.4%, 95% CI 88.3-92.4), or treated with sofosbuvir + NS5A inhibitor DAAs (SVR 96.9%, 95% CI 94.3-99.4), or in patients with HCV genotype 1 infection (SVR 92.0%, 95% CI 88.1-95.6). CONCLUSION Response to DAA therapy was lower in patients with HCC compared to those without HCC, regardless of cirrhosis status. Among HCC patients, there was an impact of proportion with curative HCC management on DAA therapy response.
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Affiliation(s)
- Sichan He
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Ian Lockart
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,St Vincent's Hospital, Sydney, NSW, Australia
| | - Maryam Alavi
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Mark Danta
- St Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.,St Vincent's Hospital, Sydney, NSW, Australia
| | | | - Gregory J Dore
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia.,St Vincent's Hospital, Sydney, NSW, Australia
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15
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Joshita S, Sugiura A, Umemura T, Yamazaki T, Fujimori N, Matsumoto A, Usami Y, Tanaka E. Clinical impact of normal alanine aminotransferase on direct-acting antiviral outcome in patients with chronic hepatitis C virus infection. JGH Open 2019; 4:574-581. [PMID: 32782941 PMCID: PMC7411565 DOI: 10.1002/jgh3.12296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/12/2019] [Accepted: 12/01/2019] [Indexed: 12/27/2022]
Abstract
Background and Aims This study aimed to clarify the clinical picture of hepatitis C virus (HCV) carriers with normal alanine aminotransferase (CNALT) and those with ALT elevation (non‐CNALT) under direct‐acting antivirals (DAAs). Methods We enrolled 1002 patients with HCV (427 men, median age: 69 years) who had received DAAs for comparisons between CNALT (ALT ≤33 U/L in males and ≤25 U/L in females; n = 374) and non‐CNALT (n = 628) groups. Results CNALT patients displayed a higher platelet count (PLT) (170 000 vs 146 000/μL, P < 0.0001) and albumin (4.1 vs 4.1 g/dL, P = 0.0006) but lower AST (25 vs 51 U/L, P < 0.0001), alpha fetoprotein (3.2 vs 5.4 ng/mL, P < 0.0001), and liver fibrosis marker scores (all P < 0.0001). The sustained virologic response rate was comparable between the CNALT and non‐CNALT groups (97.8 vs 95.3%, P = 0.106). The cumulative incidence of hepatocellular carcinoma (HCC) after DAA treatment was comparable between the CNALT and non‐CNALT groups (P = 0.117, log‐rank test). In CNALT patients with HCC history, PLT ≥150 000/μL was an independent risk factor of HCC recurrence (P = 0.019). In non‐CNALT patients without HCC history, male gender (P = 0.021) and albumin <4.0 g/dL (P = 0.007) were independent risk factors, while PLT < 150 000/μL (P = 0.081) was a marginal risk factor of HCC occurrence. Conclusion CNALT patients displayed a milder degree of liver fibrosis. Combinations of CNALT and PLT status might be useful as markers for HCC occurrence or recurrence surveillance.
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Affiliation(s)
- Satoru Joshita
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan
| | - Ayumi Sugiura
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan
| | - Takeji Umemura
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan.,Department of Life Innovation, Institute for Biomedical Sciences Shinshu University Matsumoto Japan
| | - Tomoo Yamazaki
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan
| | - Naoyuki Fujimori
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan
| | - Akihiro Matsumoto
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan.,Consultation Centers for Hepatic Diseases Shinshu University Hospital Matsumoto Japan
| | - Yoko Usami
- Department of Laboratory Medicine Shinshu University Hospital Matsumoto Japan
| | - Eiji Tanaka
- Department of Medicine, Division of Gastroenterology and Hepatology Shinshu University School of Medicine Matsumoto Japan
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Yen YH, Chen CH, Hung CH, Wang JH, Lu SN, Kee KM, Hu TH. Active hepatocellular carcinoma is an independent risk factor of direct-acting antiviral treatment failure: A retrospective study with prospectively collected data. PLoS One 2019; 14:e0222605. [PMID: 31581209 DOI: 10.1371/journal.pone.0222605] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 09/03/2019] [Indexed: 12/14/2022] Open
Abstract
Background & aims Previous studies from western countries have reported that active hepatocellular carcinoma (HCC) was associated with direct-acting antiviral (DAA) treatment failure. We sought to examine this issue in an Asian cohort. Methods A retrospective cohort study was conducted on hepatitis C virus (HCV)-infected patients with advanced fibrosis who were treated with DAAs at our hospital between January 2017 and June 2018. Results We treated 1021 HCV-infected patients during this period. A total of 976 of those patients were enrolled in a per-protocol analysis, including 556 (57.2%) who had genotype 1b infections, and 314 (32.3%) who had genotype 2 infections. The mean age of all 976 patients was 65.5 years, and 44.5% were male. 781 of the patients had no HCC, 172 had inactive HCC, and 23 had active HCC. Non-sustained virologic response (SVR) was noted in 10 (1.3%) patients without HCC, 5 (2.9%) patients with inactive HCC, and 4 (13.0%) patients with active HCC. After adjustment for confounders, active HCC (versus inactive HCC and non-HCC) was associated with non-SVR (adjusted odds ratio [AOR] = 24.5 (95% confidence interval [CI] = 4.4–136.9), P<0.001). Next, we excluded the 23 patients with active HCC from the multivariate analysis. After adjustment for confounders, inactive HCC (versus non-HCC) was not associated with non-SVR (AOR = 3.1 (95% CI = 0.94–9.95), P = 0.06). Conclusion Active HCC was associated with non-SVR, while inactive HCC was not. We thus suggest the deferral of DAA treatment until after the complete radiological response of HCCs to treatment.
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17
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Sanduzzi-Zamparelli M, Boix L, Leal C, Reig M. Hepatocellular Carcinoma Recurrence in HCV Patients Treated with Direct Antiviral Agents. Viruses 2019; 11:E406. [PMID: 31052463 PMCID: PMC6563506 DOI: 10.3390/v11050406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 04/23/2019] [Accepted: 04/25/2019] [Indexed: 02/06/2023] Open
Abstract
The risk of hepatocellular carcinoma recurrence is universal regardless of the treatment modality applied, and secondary prevention is still an unmet issue even though the elimination of hepatitis C (HCV) with direct antiviral agents (DAAs) was expected to be one of the new options. Unfortunately, the impact of DAAs on hepatocellular carcinoma (HCC) development (de novo and recurrence) is still controversial. Since the first publication on the subject in 2016, almost all groups worldwide have carried out research in this field with hundreds of publications now available. This revision is focused on the impact of DAAs on HCC recurrence and aims to discuss the potential underlying mechanisms and host factors pointing out the time association phenomenon between DAA treatment and HCC recurrence. Moreover, we comment on the methodological issues that could affect the different interpretations of the published results. In conclusion, this is an area of research with potential in the understanding of the impact of factors not previously considered, and may also help change hepatocarcinogenesis tenets, such as the belief that the elimination of HCV should be used as a second prevention treatment.
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Affiliation(s)
- Marco Sanduzzi-Zamparelli
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - Loreto Boix
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
- Centro de Investigación Médica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain.
| | - Cassia Leal
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
| | - María Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Unit, Hospital Clínic Barcelona, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain.
- Centro de Investigación Médica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, 28029 Madrid, Spain.
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18
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Itokawa N, Atsukawa M, Tsubota A, Ikegami T, Shimada N, Kato K, Abe H, Okubo T, Arai T, Iwashita AN, Kondo C, Mikami S, Asano T, Matsuzaki Y, Toyoda H, Kumada T, Iio E, Tanaka Y, Iwakiri K. Efficacy of direct-acting antiviral treatment in patients with compensated liver cirrhosis: A multicenter study. Hepatol Res 2019; 49:125-135. [PMID: 30307682 DOI: 10.1111/hepr.13256] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 09/16/2018] [Accepted: 09/30/2018] [Indexed: 12/16/2022]
Abstract
AIM Although the development of new direct-acting antivirals (DAAs) for the treatment of chronic hepatitis C virus (HCV) infection has markedly advanced, the effects of cirrhosis on DAA treatment remain unclear. We aimed to clarify the impact of cirrhosis on DAA treatment of patients infected with HCV. METHODS This large-scale, multicenter, retrospective study consisted of 2130 HCV genotype 1b-infected patients who were treated with one of the following DAA combination therapies: asunaprevir/daclatasvir (ASV/DCV), ledipasvir/sofosbuvir (LDV/SOF), or paritaprevir/ombitasvir/ritonavir (PTV/OBV/r). Ninety-two patients (4.3%) previously received DAA-based treatment. Seven hundred and forty-five patients (34.9%) had cirrhosis. RESULTS Overall, the sustained virologic response (SVR) rate was 93.0%. The SVR rates in patients who received ASV/DCV, LDV/SOF, or PTV/OBV/r were 90.0%, 96.9%, and 97.6%, respectively. The SVR rate in patients with cirrhosis (89.1%) was significantly lower than that in patients without cirrhosis (95.1%, P = 6.94 × 10-7 ). In the multivariate analysis for the overall cohort, absence of cirrhosis (P = 1.26 × 10-3 ), no previous DAA-based treatment (P = 2.54 × 10-14 ), low HCV-RNA levels (P = 1.64 × 10-6 ), wild-type non-structural protein 5A L31/Y93 (P = 7.33 × 10-13 ), and DAA regimen (LDV/SOF or PTV/OBV/r) (P = 1.92 × 10-14 ) were independent factors contributing to SVR. Except for patients with DAA-based treatment history, absence of cirrhosis (P = 2.15 × 10-3 ; odds ratio, 2.51) was an independent factor contributing to SVR in 2038 DAA-naïve patients. CONCLUSION This study suggests that the presence of cirrhosis reduces the SVR rate of DAA treatment, regardless of the type of DAA treatment.
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Affiliation(s)
- Norio Itokawa
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Masanori Atsukawa
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan.,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| | - Akihito Tsubota
- Core Research Facilities for Basic Science, The Jikei University School of Medicine, Tokyo, Japan
| | - Tadashi Ikegami
- Department of Internal Medicine, Division of Hepatology and Gastroenterology, Tokyo Medical University, Ibaraki Medical Center, Ibaraki, Japan
| | - Noritomo Shimada
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Otakanomori Hospital, Chiba, Japan
| | - Keizo Kato
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Hiroshi Abe
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Shinmatsudo Central General Hospital, Chiba, Japan
| | - Tomomi Okubo
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Taeang Arai
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Ai-Nakagawa Iwashita
- Department of Internal Medicine, Division of Gastroenterology, Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan
| | - Chisa Kondo
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
| | - Shigeru Mikami
- Department of Internal Medicine, Division of Gastroenterology, Kikkoman General Hospital, Chiba, Japan
| | - Toru Asano
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Yasushi Matsuzaki
- Department of Internal Medicine, Division of Hepatology and Gastroenterology, Tokyo Medical University, Ibaraki Medical Center, Ibaraki, Japan
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan
| | - Takashi Kumada
- Department of Nursing, Ogaki Women's College, Gifu, Japan
| | - Etsuko Iio
- Department of Virology and Liver Unit, Nagoya City University, Graduate School of Medical Sciences, Aichi, Japan
| | - Yasuhito Tanaka
- Department of Virology and Liver Unit, Nagoya City University, Graduate School of Medical Sciences, Aichi, Japan
| | - Katsuhiko Iwakiri
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Nippon Medical School, Tokyo, Japan
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