People with diabetes or high alcohol intake after hepatitis
C cure are less likely to experience reductions in liver fibrosis after
hepatitis C cure and remained at higher risk of severe liver fibrosis while high coffee consumption was associated with a lower risk
of severe liver fibrosis, a review of the French HEPATHER cohort has found.
The study looked at factors associated with severe liver fibrosis before and after hepatitis C cure. French researchers wanted to identify whether any social or behavioural factors put people at higher risk of severe liver fibrosis and the characteristics of those likely to be at higher risk of severe liver fibrosis after hepatitis C cure. People at higher risk of severe fibrosis after being cured need regular monitoring for progression of liver disease and hepatocellular carcinoma (liver cancer).
The HEPATHER cohort is a French national prospective cohort
of people with hepatitis C. This study excluded people with HIV co-infection and
people already receiving hepatitis C treatment. Cohort members were eligible for
inclusion in the analysis if they had at least one FIB-4 assessment for liver
fibrosis and had provided data on alcohol and coffee consumption, employment,
and education level at enrolment to the cohort.
The analysis included 9692 people who attended a median of
two visits during four years of follow-up. The median age of participants was
56 years, 44% were female and 57% were unemployed. Fifty-nine per cent received
direct-acting antiviral treatment during follow-up and 96% of those treated had
been cured of hepatitis C.
Unhealthy alcohol use was more common in men (6% vs 2%).
Thirty per cent of participants reported drinking at least three cups of coffee
Twenty-six per cent had severe liver fibrosis, 40% had
indeterminate fibrosis stage and 34% had low-grade fibrosis at enrolment.
At the last follow-up visit, 17% had severe fibrosis, 41%
had indeterminate-stage fibrosis and 42% had low-grade fibrosis.
Multivariable analysis showed that greater coffee
consumption was associated with a substantial reduction in the risk of severe
fibrosis, before and after hepatitis C cure. One cup a day reduced the risk by
53% while 4 cups or more a day reduced the risk by 96%. Each additional cup of
coffee reduced the risk of severe fibrosis by 58%. The protective effect of
coffee consumption against severe liver disease is consistent with previous
Hepatitis C cure reduced the risk of severe fibrosis after
cure by 90%.
The risk of severe fibrosis both before and after hepatitis
C cure was four-and-a-half times higher in people with unhealthy alcohol use
compared to people who abstained from alcohol use and was three-and-a-half
times higher in people who were abstinent at enrolment but had a history of
unhealthy alcohol use.
The risk of severe fibrosis was four times higher in people
with diabetes compared to those without diabetes, before and after hepatitis C
cure. Diabetes is known to accelerate the progression of fibrosis.
Compared to genotype 1 infection, genotype 3 infection was
associated with a sevenfold higher risk of severe fibrosis, before and after
cure, while genotype 2 infection was associated with a 45% lower risk of severe
fibrosis compared to genotype 1 before and after cure.
Unemployment raised the risk of severe fibrosis by 69% and
incomplete secondary education raised the risk by 50%.
The researchers also calculated the population-attributable
fraction of each variable, to determine which variables contributed most to the
burden of severe liver fibrosis in people with hepatitis C.
Unemployment (29%) and low educational level (21%) made the
greatest contribution to the burden of fibrosis, followed by diabetes (17%) and
a history of unhealthy alcohol use (15%). The relationship between social
conditions and severe fibrosis is likely to represent the effect of missed
opportunities for diagnosis and delayed treatment, as well as being a proxy for
poor nutrition, obesity and other conditions associated with poverty.
The study investigators say that regular follow-up after
hepatitis C cure is especially important for people with a history of unhealthy
alcohol use or diabetes. Liver disease status should also be monitored
carefully after hepatitis C cure in people with lower socioeconomic status, and
coffee consumption should be promoted after hepatitis C cure for anyone with a
history of unhealthy alcohol use or diabetes, say the study investigators.