Background

Hepatitis C virus (HCV) infection is one of the major causes of liver cirrhosis worldwide [1]. The number of individuals with chronic HCV all over the world is approximately 185 million [2].

In the last few years, antiviral therapy for HCV has been rapidly evolving with the introduction and proliferation of direct-acting antiviral (DAA) therapies. They revolutionized the therapy of HCV infection with higher efficacy and sustained virological response (SVR) rates, shortened and simplified regimens, and minimal adverse effects [3]. However, achieving sustained SVR does not instantly reverse HCV-related hepatic fibrosis or cirrhosis.

Reversion of hepatic fibrosis has been an important point of exploration and study among liver diseases experts for several decades. Previous studies on the impact of interferon-based HCV therapy on hepatic fibrosis have shown regression of fibrosis over periods of up to 48 months in some patients after therapy [4,5,6].

Nowadays, liver stiffness assessment using vibration-controlled transient elastography (VCTE) has superseded liver biopsy as a favored non-invasive modality7. Moreover, the value of TE has been assessed in checking the progression of fibrosis in the set of HCV relapses after liver transplantation [7].

Numerous noninvasive laboratory scores such as APRI, FIB-4, and FIB-5 have been verified to be precise in chronic liver disease staging before antiviral treatment and assessing hepatic fibrosis in HCV patients. Furthermore, they have been useful for follow-up of patients with chronic HCV and to evaluate the impact of DAA therapy [8, 9].

The aim of the current study was to assess the impact of SVR following DAAs on liver fibrosis in chronic HCV patients.

Methods

Study design

This is a prospective study that was conducted on patients attending to the Hepatology Clinics, Specialized Medical Hospital, Mansoura University,, Egypt, for follow-up of chronic HCV infection during the period from January 2019 to January 2021.

Patients

Our study was conducted on 1380 chronic HCV patients; 1230 patients received DAAs and 150 patients did not receive treatment on their request (control group). We included patients who are 16 years or older with HCV who are a candidate for DAAs. Patients with radiologically suspected focal lesions either malignant or not, coinfection with other viruses, presence of decompensated liver cirrhosis (Child-Pugh more than 7), and organ failure were excluded from the study. Chronic HCV infection was diagnosed by positive RT-PCR RNA HCV ± abnormal liver function tests and the presence of stigmata of chronic liver disease. HCV RNA was quantified by real-time PCR assay (COBAS AmpliPrep/COBAS TaqMan 48, Roche Molecular Diagnostics). HCV genotype was detected by Versant HCV genotype 2.0 assay (LiPA-Siemens, Erlangen, Germany).

Patients evaluation

Before the start of antiviral treatment, all patients were subjected to full history and clinical assessment.

Laboratory assessment

Laboratory tests were done as complete blood count, liver enzymes aspartate aminotransferase, alanine aminotransferase (ALT, AST), serum bilirubin, serum creatinine, α fetoprotein, and INR.

Transient elastography

The liver stiffness of the patients was assessed via Fibroscan (Echosens, Paris, France). For staging, the subsequent cutoff values were used: were F1 (>4.8 kPa), F2 (>8.3 kPa), F3 (>10.1 kPa), and F4 (>13.4 kPa) [10]. Liver stiffness was considered as the median of all valid measurements. For high BMI (≥30 kg/m2), examination with the XL probe, with two experienced operators, was done. Transient elastography was done before and immediately after treatment and after 48 weeks.

FIB-4 was calculated [age (years) × AST (IU/l)/(platelet count (109/l)× √ALT (IU/l))] for all patients. Fibrosis is considered to be significant if ≥ F3 and non-significant fibrosis if ≤ F2. If fibrosis decreases by only one stage it is considered as fibrosis regression and stationary fibrosis if there is no change in the fibrosis stage.

All patients were evaluated by all the previous parameters before treatment and immediately after treatment, then after 12–48 weeks.

Definitions

Fibrosis regression: decrease liver fibrosis by one or more stages as F4 to < F3.

Fibrosis progression: increase liver fibrosis by one or more stages as F3 to > F4.

Stationary course: No change in liver fibrosis stage.

Treatment protocols

At the Virology unit, Specialized Medical Hospital, Mansoura University, Egypt, all patients were evaluated for anti-HCV treatment. The DAAs regimens were used according to the guidelines of the National Committee for Control of Viral Hepatitis (NCCVH) in Egypt. We treated the patients with the following combinations: SOF plus DCV, SOF/DCV/RBV, SOF/RBV, LDV/SOF, and interferon-based.

Statistical analysis and data interpretation

Data were fed to the computer and analyzed using IBM SPSS Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. Qualitative data were described using numbers and percentages. Quantitative data were described using median (minimum and maximum) and interquartile range for non-parametric data and mean, standard deviation for parametric data after testing normality using Kolmogorov-Smirnov test. Significance of the obtained results was judged at the 0.05 level. Chi-square test, Fisher’s exact test, and Monte Carlo test were used for comparison of 2 or more groups for qualitative variables. Stewart–Maxwell test was used to compare follow-up periods for categorical variables with more than 2 categories. Student’s t test was used to compare 2 independent groups, paired t test and repeated measures ANOVA, to compare between studied periods with post hoc Tukey test for parametric variables. Mann-Whitney U test was used to compare 2 independent groups, Wilcoxon signed rank test and Friedman test were used to compare studied periods for non-parametric variables.

Results

The current study was conducted on 1380 chronic HCV patients, with mean age of 56.39 ± 7.81 years, 770 females and 610 males. DM was found in 27.1% and HTN in 13.6% of patients (Table 1). The common regimen used in HCV treatment was SOF/DCV/RBV in 920 patients.

Table 1 Demographic and clinical characteristics of the studied patients
Full size table

There was a significant improvement of FIB-4 (p<0.001) in the improved group after DAAs proved by liver stiffness measurement. Also, there was significant improvement after DAAs as regard AST, s. bilirubin, s. albumin, and creatinine (p<0.001, 0.01, 0.002, and 0.003, respectively) (Table 2).

Table 2 Radiographic and laboratory results pre and post treatment among studied cases
Full size table

Table 3 compares the radiographic and laboratory results between the control group and interventional arm where there was a significant improvement in the radiographic, laboratory, and endoscopic parameters of the treated patients.

Table 3 Comparison of radiographic and laboratory results between control and interventional arm
Full size table

The study included 150 cirrhotic patients (F4 by fibroscan), treated group (1170 F4 and 6 F3). After treatment, 500 of 1170 F4 patients (42.7%) improved and became 190 F3, 90 F2, and 220 F1. Also, 40 of 60 F3 patients improved and became 10 F2 and 30 F1. After treatment 350 of 1230 treated patients (28.4%) transited from significant fibrosis (≥F3) to non-significant fibrosis (≤F2). Moreover, 840 of 1230 treated patients (68.3%) showed a reduction in liver stiffness ≥ 30% from their baseline by fibroscan.

In Table 4, we compared the radiographic and laboratory results between controls, improved, and non-improved cases. We found that non-improved cases were older, with a high incidence of DM, and have lower baseline ALT, AST, serum albumin, platelets, and high bilirubin than the improved cases.

Table 4 Comparison of radiographic and laboratory results between controls, improved and non-improved cases
Full size table

Discussion

HCV is a worldwide prevalent virus and a major cause of death and morbidity. Introduction of DAAs has resulted in a substantial breakthrough in HCV treatments as they can achieve SVR in almost 100% of patients with chronic hepatitis C; however, the ultimate goal of HCV treatments is to prevent cirrhosis development and its sequels [11].

Our study was conducted on 1380 chronic HCV patients with mean age 56.39 ± 7.81 years, 770 females and 610 males. The common regimen used in HCV treatment was SOF/DCV/RBV (920 patients).

In our study, 500 of 1170 F4 treated patients (42.7%) improved and became 190 F3, 90 F2, and 220 F1. Also, 40 of 60 F3 patients improved and became 10 F2 and 30 F1. After treatment 350 of the treated patients (28.4%) transited from significant fibrosis (≥F3) to non-significant fibrosis (≤F2). Also, There was a significant improvement of FIB-4 (p<0.001) in the improved group after DAAs proved by liver stiffness measurement.

Similar results were observed by Pietsch et al. [12] who evaluated liver stiffness changes (for 96 weeks) using transient elastography in only 143 chronic HCV patients with achieved SVR following DAAs. There was a significant overall long-term improvement of liver stiffness values in all patients in their study although they have not clarified the median of transient elastography changes. Interestingly, in another study of 260 patients with chronic HCV, Lledó et al. reported that 40% of patients showed significant fibrosis regression. Furthermore, this fibrosis regression was more obvious in patients who have advanced fibrosis at baseline [13].

Also, a systematic review and meta-analysis by Singh et al revised 11 studies evaluating LSM before and after DAAs demonstrated a rapid regression in liver stiffness during DAAs treatment and a slower but steady regression after treatment as LSM declined by 2.4 kPa at the end of treatment, by 3.1 kPa 4-24 weeks after treatment, by 3.2 kPa 24–48 weeks after treatment, and by 4.1 kPa > 12 months after treatment. The pooled regression in liver fibrosis in these studies may be related to the design of these studies as the majority of those studies were retrospective and included a small number of patients with advanced fibrosis and cirrhosis [14].

The chance for reversion of liver fibrosis is more pronounced in patients with early cirrhosis because the persistence of necro-inflammatory activity in milder forms of chronic liver disease may take up to 15–30 years before achieving real significant degrees of scarring in the liver [15]. Reversion of early fibrosis is easier than older fibrosis, which becomes more stabilized progressively via collagen crosslinking by tissue transglutaminase that makes fibers less sensitive to degrading enzymes [16]. Septal fibrosis in early-stage concomitant with earlier stages of neo-angiogenesis; is more easily broken down due to its lower degree of maturity of the vessels [17].

Moreover, 840 of the treated patients (68.3%) in our study showed a reduction in liver stiffness ≥ 30% from their baseline by fibroscan. Whereas, Chan and colleagues [18] found that only 34 of 70 patients (48.6%) met 30% improvement in liver stiffness measurement score.

Our study also showed that regression of LSM using transient elastography was also evident by improvement of FIB-4 score. Similarly, several previous studies have shown this concordance between the regression of LSM by elastography and improvement of FIB-4 score in chronic HCV patients after DAA therapy [19,20,21]. From these findings, we could conclude that the combination of these non-invasive scores with transient elastography could be a good tool for the assessment of liver fibrosis.

Huang et al. [22] analyzed 40 paired liver biopsies of chronic hepatitis C patients before and after DAAs therapy and demonstrated significant improvement of liver inflammation and fibrosis after SVR. Furthermore, LSM by transient elastography, APRI, and FIB-4 declined significantly after SVR and predicted fibrosis well even after SVR by DAAs.

In our study, we found that non-improved cases were older, with a high incidence of DM, have lower baseline ALT, AST, serum albumin, platelets, and high bilirubin than the improved cases. Liver fibrosis is an active process comprising chronic stimulation of wound healing reaction as a response to repeated liver injury, leading to fibrillar extracellular matrix deposition in the liver and finally, liver cirrhosis if the cause of injury is not removed. Adipokines have been demonstrated to be incorporated in different obesity-related diseases, such as type 2 diabetes, hypertension, and atherosclerosis. Gathering data reveal that insulin resistance and obesity are linked to the more severe and quicker progression of the fibrosis in different chronic liver diseases [23]. In addition to low baseline ALT, AST before treatment indicates a low process of necroinflammation and the presence of significant fibrosis.

Our study may be limited by the lack of concomitant histopathological examination through liver biopsy; however, according to the American Association For Study of Liver Diseases (AASLD), the standard liver biopsy had been replaced by the non-invasive testing for liver fibrosis stages evaluation. Both transient elastography and non-invasive markers showed a high diagnostic value and their combination could be used to diagnose or exclude cirrhosis [24].

Conclusions

We concluded that treatment of chronic HCV with DAAs is associated with regression of liver fibrosis as about 28% of patients improved from significant fibrosis (≥F3) to non-significant fibrosis (≤F2) after treatment and about 68% showed a reduction in LSM ≥ 30% from their baseline.