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DR. DAVIDE RIBALDONE (Orcid ID : 0000-0002-9421-3087) DR. MARCO SACCO (Orcid ID : 0000-0003-0975-5584) PROF. GIORGIO MARIA SARACCO (Orcid ID : 0000-0001-5310-4143)

Article type

: Original Articles

Handling editor: Jian Sun LONG-TERM FOLLOW-UP OF DIABETIC AND NON-DIABETIC PATIENTS WITH CHRONIC HEPATITIS C SUCCESSFULLY TREATED WITH DIRECT ACTING ANTIVIRAL AGENTS Running title: Influence of HCV clearance on type 2 diabetes mellitus

Alessia Ciancio (1), Davide Giuseppe Ribaldone (1), Anna Dotta (1), Chiara Giordanino (1), Marco Sacco (1), Sharmila Fagoonee (2), Rinaldo Pellicano (1), Giorgio Maria Saracco (1).

(1) Gastro-hepatoloy Unit, Department of Medical Sciences, University of Turin, Turin, Italy (2) Institute of Biostructure and Bioimaging (CNR) c/o Molecular Biotechnology Center, Turin, Italy.

Corresponding author : Giorgio Maria Saracco, MD Gastro-hepatology Unit Molinette Hospital, University of Turin Corso Bramante 88 10126 Torino, Italy This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/LIV.14676 This article is protected by copyright. All rights reserved

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tel.: 39-011-6336397 e-mail: [email protected] ORCID: http://orcid.org/0000-0001-5310-4143 Word count (only text): 4264 words. Tables number: 6 Figures number: 2

Abbreviation list: HCV, hepatitis C virus; DM, diabetes mellitus; LRE, liver-related events; DAAs, direct-acting antiviral agents; FPG, fasting plasma glucose; HbA1c, glycated haemoglobin; HCC, hepatocellular carcinoma; SVR, sustained virologic response; CHC, chronic hepatitis C; PCR; polymerase chain reaction; TE, transient elastography; APRI, aspartate aminotransferase to platelet ratio; OLT, orthotopic liver transplantation; mRECIST, modified Response Evaluation Criteria in Solid Tumours; HIV, Human Immunodeficiency Virus; AIFA, Italian Agency of the Drug; EASL, European Association for the Study of the Liver; BMI, body mass index; WC, waist circumference; DM, type 2 diabetes mellitus; ALT, alanine aminotransferase; APH, alkaline phosphatase; GGT, gamma glutamyltranspeptidase; INR, international normalized ratio; HDL, high-density lipoprotein; US, abdominal ultrasound; MELD, model for end-stage liver diseases; SD, standard deviation; CI, confidence interval; OR, odds ratio; HR, hazard ratio; RBV, ribavirin; IFN, interferon.

Potential competing interests: all authors declare no potential conflicts of interest. Financial support: this study was unsupported. Ethics approval: obtained Patient consent: obtained

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ABSTRACT Background and aims: Clearance of Hepatitis C Virus (HCV) is associated with improved glycometabolic control in patients with diabetes mellitus (DM) but whether this effect is maintained over the long-term with a reduction of liver-related events (LRE) is still debated. To address these issues, we conducted a long-term prospective study on diabetic and non-diabetic patients with chronic hepatitis C cured by Direct Antiviral Agents (DAAs). Methods: Among 893 recruited patients, 15.7% were diabetic (Group 1) and 84.3% non-diabetic (Group 2); changes in fasting glucose (FG) and glycated haemoglobin (HbA1c) levels were assessed in Group 1 while the incidence of LRE was established in the whole cohort. Differences between groups were evaluated and independent predictors of unfavourable clinical outcome were established. Results: After a mean follow-up of 44.5 months, a significant reduction in FG and HbA1c values was found in Group 1. Death was reported in 5.7% of patients in Group 1 vs 1.6% in Group 2 (p = 0.003), hepatocellular carcinoma (HCC)-free survival was significantly lower in Group 2 (p= 0.015) as well as LRE-free survival in Group 1 cirrhotic patients (p= 0.0006). After adjustment for baseline variables, cirrhosis and albumin levels emerged as independent predictors of LRE; low albumin levels, DM and central obesity were associated to HCC risk in cirrhotic patients while insulin therapy emerged as unfavourable predictor among diabetics. Conclusions: SVR achieved by DAAs is associated with long-term improvement of

glycometabolic control in diabetic patients but among cirrhotics DM still exerts a detrimental effect on the liver.

Key words: Hepatitis C Virus, chronic hepatitis C, insulin resistance, diabetes mellitus, direct acting antiviral agents, cirrhosis

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Lay Summary -

Long-term improvement in glycometabolic control among diabetic patients with chronic hepatitis C (CHC) achieving sustained virologic response (SVR) by direct acting antiviral agents (DAA) is still debated.

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Whether diabetes mellitus (DM) maintains its unfavourable influence on liver.related events (LRE) in patients successfully treated by DAA is largely unknown.

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In this study, we showed that Hepatitis C Virus (HCV) eradication by DAA leads to a long-term amelioration in glucose and glycated haemoglobin (HbA1c) levels in diabetic patients but – among cirrhotic patients – DM still plays a negative role by favouring Hepatocellular Carcinoma (HCC) incidence.

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INTRODUCTION Type 2 diabetes mellitus (DM) is considered an extrahepatic manifestation of Chronic Hepatitis C (CHC) (1-3), even though the mechanisms whereby Hepatitis C Virus (HCV) infection causes DM have not been completely clarified. Some studies (4-5) have shown that the virus can interfere with insulin signalling, eventually inducing alterations in glucose homeostasis.

In

particular, recent reports (6,7) have suggested the role of viral replication in inducing death of pancreatic beta cells and upregulation of several hepatokines known to cause insulin resistance (IR).

Thus, it is reasonable to hypothesize that viral clearance might be accompanied by an

improvement in glucose abnormalities.

Two recent reviews (8,9) reported that the majority of

the studies published so far found a significant glycemic amelioration after achievement of Sustained Virologic Response (SVR) by Direct Acting Antiviral Agents (DAAs); however, some studies (10-13) failed to observe any significant glycometabolic changes. The issue of the longterm beneficial effect of SVR on glycemic control in diabetic patients was addressed by few reports (10,12,14-19) showing conflicting and contradictory results. Despite the fact that most of the studies reporting improvement in glycemic parameters showed de-escalation/withdrawal of antidiabetic therapy in a consistent number of patients (8-9), data regarding classes and dosages of drugs are often incomplete and discrepant. Moreover, due to the lack of prospective studies with long-term follow-up, the clinical outcome of diabetic patients with SVR remains largely unknown. In order to address these issues, we conducted a prospective study on HCV-positive patients with or without DM successfully treated by DAAs aiming at monitoring potential long-term glycometabolic improvement as well as its impact on liver-related clinical outcome.

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PATIENTS AND METHODS All consecutive patients with CHC treated by DAAs in the Gastrohepatologic Clinic of Molinette Hospital, Turin, Italy from January 1, 2015 to December 31, 2016, were considered. Patients were included into the present study if they fulfilled the following criteria at baseline: age > 18 years; positive HCV-RNA by polymerase chain reaction (PCR); chronic liver disease assessed by transient elastography (TE) and aspartate aminotransferase to platelet ratio (APRI) score or liver biopsy. Exclusion criteria were: lack of written informed consent, patients on waiting list for orthotopic liver transplant (OLT), post-OLT patients, presence of hepatocellular carcinoma (HCC) not referred to or not responding to curative treatment confirmed by the modified Response Evaluation Criteria in Solid Tumours (mRECIST) (20), presence of ascites, concomitant liver diseases such as haemochromatosis, Wilson's disease, drug-related liver disease, autoimmune hepatitis, HBsAg carriership, Human immunodeficiency Virus (HIV) infection, primary biliary cholangitis, alpha-1-antitrypsin deficiency. In accordance with the policy of the Italian Agency of the Drug (AIFA) of that period, only patients with F3-F4 fibrosis level according to METAVIR Score (21) or with severe extrahepatic diseases linked to HCV infection were treated with DAAs for 12-24 weeks according to the European Association for the Study of the Liver (EASL) guidelines (22). Out of 1016 treated patients fulfilling the above mentioned criteria, 928 (91.3%) agreed to participate: 145 (15.6%) showed DM at baseline, 783 (84.4%) were non-diabetic. Two of 145 (1.3%) diabetic patients did not achieve SVR compared with 22 out of 783 (2.8%, p= 0.47) nondiabetics and were excluded from the study; 2/143 (1.4%) diabetic and 9/761 (1.1%) non-diabetic patients with SVR were lost to follow up and not included in the final analysis.

Hence, the

overall analysed cohort was composed of 893 patients, 141 (15.7% ) with DM and 752 (84.3% ) non-diabetics. At baseline, a complete medical history and physical examination was undertaken and the following data were obtained from each patient: age, gender,ethnicity, smoking habits, alcohol intake, body mass index (BMI), waist circumference (WC), duration of HCV infection, relevant co-morbidities and – in diabetic patients - family history for DM, duration of DM, type of antidiabetic medication, presence of macro/ microangiopathic disease. The following data on laboratory parameters were also recorded to define baseline characteristics: complete blood count, routine liver biochemistry (alanine aminotransferase [ALT] and aspartate aminotransferase [AST],

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total bilirubin, albumin, alkaline phosphatase [APH], gamma glutamyltranspeptidase [GGT]) international normalized ratio [INR]), creatinine, fasting plasma glucose [FPG], total cholesterol and HDL, triglycerides, HCV genotype and viral load [AmpliPrep®/COBAS Taqman® HCV test, Roche Diagnostics, Basel, Switzerland].

In diabetic patients, baseline glycated haemoglobin

[HbA1c] value was also registered. Liver fibrosis was determined within 3 months from treatment by invasive (liver biopsy) or noninvasive (AST to platelet ratio [APRI] and TE) methods; patients undergoing TE were stratified according to METAVIR Score (21). An abdominal ultrasound (US) was performed in each patient at baseline and those with cirrhosis underwent oesophagogastroduodenoscopy before starting therapy in order to assess the presence of oesophageal/gastric varices. Cirrhotic patients were stratified according to the Child-Turcotte-Pugh classification and Model for End- Stage Liver Disease [MELD]; all episodes of liver decompensation (variceal bleeding, ascites, encephalopathy) and HCC detection occurred before therapy were recorded.

Definitions

WC was measured at the midpoint between the lower border of the rib cage and the iliac crest. Blood pressure was reported as the average of the last three determinations. Hypertension was defined as a systolic or diastolic blood pressure of 130/80 mmHg or higher or when patients received an anti-hypertensive treatment (23). DM was diagnosed according to the criteria recommended by the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus (24). Diagnosis of metabolic syndrome was made according to the criteria suggested by the International Diabetes Federation (25).

Follow-up

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Control visits were planned at 6-months intervals after achieving SVR and patients were followed until the first occurrence of liver related events [LRE] (ascites, variceal bleeding,

hepatic

encephalopathy, HCC) or until the end of December 2019. Mortality was registered as liverrelated or non-liver related. At each control visit, medical history and physical examination were performed; liver function tests, HCV-RNA assessment and liver US were recorded. According to the EASL Guidelines, patients developing any suspicious liver lesion revealed by liver US were further examined with a complementary imaging method to confirm or exclude HCC (26). In diabetic patients, accurate history regarding lifestyle changes, modifications and adherence to antidiabetic therapy, introduction of other medications potentially affecting glycometabolic control was undertaken, patient’s weight was evaluated and registered.

FPG and HbA1c values were

also collected; a decrease in HbA1c levels of at least 0.5% when compared to baseline values was considered as a significant improvement in the glycemic state (27). The study was performed in accordance with the principles of the 1975 Declaration of Helsinki and approved by our local ethics committee (Comitato Etico Interaziendale Città della Salute e della Scienza di Torino, Turin, Italy); written informed consent was obtained from all patients.

STATISTICAL ANALYSIS Continuous variables were reported as median (standard deviation [SD] and 95% confidence interval [CI]) or geometric mean according to the data distribution. Normality was checked by the D’Agostino‒Pearson test. Categorical variables were reported as number and percentage. Comparison of continuous variables between independent groups was performed by the Mann‒Whitney test or independent samples t-test according to data distribution; comparison between paired measurements was performed by the Wilcoxon test or paired samples t-test according to data distribution. Regarding the dichotomous categorical variable, a Chi-squared test or McNemar test were performed for unpaired or paired analysis, respectively. The analysis of the variance was performed by the Friedman test. The association between variables was assessed by logistic regression analysis for outcomes at the end of the follow-up (improvement in HbA1c levels) and by Cox proportional-hazards regression for outcomes that occurred during the followup (first LRE); the strength of association was reported as odds ratio (O.R.) and 95% CI or hazards

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ratio (H.R.) and 95% CI, accordingly. The rate of diabetic and non-diabetic patients free from LRE and HCC has been presented by using Kaplan-Meier curves and the statistical differences were tested by the Mantel-Cox method. Patients not developing LRE or HCC were censored at last visit or at the date of death. All statistical analyses were performed using MedCalc® v.18.9.1 (MedCalc Software Ltd., Ostend, Belgium), and a p value ≤ 0.05 was considered statistically significant.

RESULTS During the follow-up, neither viral late relapse nor re-infection was observed. On December 31st 2019, the cohort had a mean follow up of 44.5±8.5 months without significant differences between diabetic and non-diabetic patients. Baseline demographic, anthropometric and clinical characteristics of diabetic (Group 1) and nondiabetic patients (Group 2) are reported in Table 1; biochemical, virological and hepatologic features of both groups are described in Table 2. As expected, diabetic patients showed significantly higher BMI (25.2±4.8 vs 24.6±3.8, p= 0.049), obesity rate (18.4% vs 8.6%, p= 7% (OR= 8.75, 95% CI= 1.57-48.64,

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p= 0.01) while the presence of oesophageal varices was associated to reduced chance of glycometabolic amelioration (OR= 0.21, 95% CI= 0.06-0.68, p= 0.01). Mortality and incidence of LRE At the end of the follow-up, the overall mortality rate was significantly higher in Group 1 compared to Group 2 (5.7% vs 1.6%, p = 0.003); in detail, 4/8 diabetic patients (50%) died from relapsing HCC or “de novo” HCC, 2/8 (25%) from liver failure and 2/8 (25%) from extra-hepatic neoplasms. Death occurred in 12 non-diabetic patients, due to HCC in 50% of cases, liver failure in 17% and extra-hepatic neoplasms in the remaining 33%. Other 3 patients (1 diabetic, 2 nondiabetics, p = 0.36) were referred to OLT. The cumulative incidence of HCC and LRE in the two groups of patients by Kaplan –Meier curves is shown in Figure 2 and differences regarding both HCC and LRE rate were statistically significant (Mantel-Cox test, p= 0.015 and p= 0.0006 respectively).. Overall, 11/141 (7.8%) patients in Group 1 developed HCC during follow-up compared to 31/752 (4.1%) in Group 2; specifically, of the 8 diabetic patients with HCC prior to antiviral therapy, 5 (62.5%) had a relapse compared to 16/36 non-diabetics

(44.4%) while "de novo" HCC occurred in 6/133 (4.5%)

diabetic patients accounting for an incidence of 1.28 per 100 patients / year, compared to 15/716 (2.1%) non-diabetics, equivalent to an incidence of 0.6 per 100 patients / year. Among cirrhotics, 16/595 (2.6%) developed portal hypertension-related events, 7/112 (6.2%) in Group 1 and 9/483 (1.8%) in Group 2; in detail, 2 (1.8%) diabetic patients developed ascites compared to 8 (1.7%) non-diabetics, 3 (2.7%) showed episodes of hepatic encephalopathy compared to 1 (0.2%) patient without DM and 2 (1.8%) diabetics bled from oesophageal varices compared to none of non-diabetic patients (0%) . Variables associated with long-term risk of LRE Table 4 shows the unadjusted and adjusted HR for the whole cohort. By univariate analysis, patients who developed LRE during follow-up were older, had DM, higher rate of metabolic syndrome and central obesity, showed baseline cirrhosis, APRI > 1.5, oesophageal varices, low albumin and platelets values.

After adjustment for several confounding factors (age, sex, BMI,

general and central obesity, metabolic syndrome, DM, duration of infection, genotype 3, albumin and platelets levels, presence of oesophageal varices, liver stiffness, APRI > 1.5), the only two

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independent predictors of LRE were the presence of pre-therapy cirrhosis (HR= 3.06, 95% CI 1.16-8.06, p= 0.02) and albumin values below 4 g/dL (HR= 3.21, 95% CI 1.59-6.48, p= 0.001). Amongst cirrhotic patients, due to the low incidence (2.6%) of portal hypertension-related events, we focused on HCC development

(Table 5).

By multivariate Cox regression analysis, we

observed that the effect of albumin levels lower than 4 g/dL was comparable to that found in the whole cohort (HR= 2.83, 95% CI 1.32-6.07, p= 0.008); however, two other baseline factors emerged as negative independent predictors of HCC: the presence of DM before antiviral treatment (HR= 2.69, 95% CI= 1.09-6.67, p= 0.03) and central obesity (HR= 1.12, 95% CI 1.031.22, p= 0.01). Finally, we investigated which baseline variable was independently associated with incident HCC among diabetic patients (Table 6): the role of lower albumin values (HR= 12.84, 95% CI= 2.028.65, p= 0.007) and central obesity (HR= 1.21, 95% CI 1.05-1.26, p= 0.01) was confirmed and insulin therapy emerged as unfavourable predictor (HR= 4.11, 95% CI 1.20-14.13, p= 0.02). Discussion Our data show that DAA-based SVR improves glycometabolic control over the long-term in diabetic patients resulting in a significant decrease in HbA1c values in about 75% of them, despite a concomitant weight gain. The tri-phasic pattern of HbA1c levels observed in our study is similar to that reported by Weidner et al. (19) and Li et al. (16); however, at variance with the results of these studies, the vast majority of our patients, after a mean follow up of 44 months, showed glycemic and HbA1c values significantly lower than those reported at baseline. This discrepancy can be explained by the fact that baseline data were available only for 22/28 diabetic patients in the study by Weidner et al. (19) and of these, only 9 had follow-up till 24 months after the end of therapy.

The retrospective/prospective study design adopted by Li and coll. (16) was rather complex and had some limitations. In the general analysis, patients treated with interferon (IFN) were also included while in the subgroup analysis, the DAA-treated diabetics were only 73 out of 192 with a mean follow-up of 15 months. Moreover, no data regarding possible confounding factors such as changes in lifestyle and adherence to antidiabetic therapy were reported. In our study, patients were strictly monitored for these two variables which apparently did not vary throughout the follow-up period despite the intriguing increase in body weight. This finding was already reported in a previous study (28) and could be due to the awareness of being definetively cured that

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determined a diminished attention on food intake, despite the fact that patients denied a reduced nutritional compliance. Alternative or adjunctive explanation may be based upon the complex interactions between adiponectin levels and metabolic disarrangements observed in cured patients (29).

The long-term beneficial effect of SVR on glycometabolic control was also observed by previous studies (14,15,17,18), with a mean follow-up ranging from 18 to 44 months. On the contrary, Teegen et al. (10) and Chaudhury et al. (12) who followed diabetic patients with SVR for 28-30 months did not confirm these results. The discrepancy may be explained by the low number of recruited patients (32 and 42, respectively) and their baseline characteristics (post-OLT patients [10], prevalently Afro-Americans with high rate of HIV-coinfection and low rate of cirrhosis [12]).

In our study, about 75% of diabetic patients showed a significant improvement in glycometabolic control throughout the follow-up; after adjustment for several baseline variables, the only two independent predictors of glycemic amelioration were high values (>7%) of pre-therapy HbA1c as already reported by Hum et al. (14) and the absence of oesophageal varices, suggesting a major role played by portal hypertension on metabolic derangement. We examined the impact of DM on the incidence of LRE and overall survival amongst patients achieving SVR after DAA-based therapy. We showed that diabetic patients had a higher risk of developing LRE than non-diabetic patients with a significantly lower survival probability; this finding was largely expected due to the unfavourable features of diabetic population at baseline. However, after adjustment for baseline confounding variables, the only two independent risk factors for LRE were cirrhosis and low albumin levels, partially confirming previous observations (30-32).

According to our data, HCC was the most frequent LRE with an incidence similar to that reported by previous studies (30-36); when only cirrhotic patients were considered, albumin level < 4 g/dL, DM and central obesity emerged as unfavourable independent predictive factor for HCC risk at multivariate Cox regression analysis. Compared with the IFN era, data from follow-up studies on patients with SVR after therapy with DAAs (30-44) are conflicting as DM was not found to be an independent predictor of HCC in most of them (30-33,35-42); only three studies (34,43-44) have confirmed the negative effect of DM on the development of HCC after viral clearance. This discrepancy may be explained by the heterogeneity of the patients considered, the study design, the different length of follow-up and the

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variable rates of cirrhotic patients included. According to our data, the detrimental effect of DM occurred only in the population with advanced chronic liver disease, even though – due to our limited sample size - further validation is needed before confirming the impact of baseline DM on HCC incidence amongst cirrhotic patients. Central obesity, indicated by abnormal level of WC, was independently associated to the risk of HCC rather than general obesity among cirrhotic patients with SVR. The importance of central obesity in promoting liver carcinogenesis has already been described (45), but so far no follow-up studies on cured HCV patients have reported this parameter when searching for independent predictors of HCC. Albumin values below 4 g/dL and abdominal adiposity confirmed their association with HCC risk among diabetic patients.

Moreover, in this group, insulin therapy emerged as independent

predictor of HCC, as already reported by previous studies (46-49). A limitation of this study is the lack of a control group composed of untreated HCV-positive diabetic patients in order to assess the real magnitude of glycometabolic and clinical modifications occurring among cured diabetics. Due to ethical and legal issues, all HCV-positive diabetic patients had to be treated in our Unit. However, in the studies published so far (8-9), untreated or non-responding patients used as controls

did not show any significant variations in their

glycometabolic control throughout the follow-up. Conversely, we acknowledge the possibility that untreated or non-responding diabetic patients might show an even worse clinical outcome compared to cured diabetic patients. However, this consideration does not contradict one of the main clinical messages of our study, that is the persisting unfavourable effect of DM on HCC incidence among cirrhotic patients achieving SVR. A second limitation regards our results that - although statistically significant - are issued from a study including a relatively small population of diabetic patients; for this reason, they need to be confirmed by larger studies, In conclusion, our findings show that in diabetic patients with CHC who achieved SVR by DAAs a long term improvement in glycometabolic control is observed, especially in those with high baseline HbA1c levels. Whether this beneficial effect is long lasting is matter of debate; in fact, DM biochemical parameters may be affected not only by viral eradication but also by genetic and lifestyle-related factors, such as dietary habits, physical activity and therapeutic adherence, prone to change over the long-term. Moreover, despite this endocrine benefit, DM still plays a negative

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role in cirrhotic patients by favouring HCC occurrence. This finding stresses the importance of continuing HCC surveillance, particularly in this high risk group.

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Accepted Article

36) Marino Z, Darnell A, Lens S, Sapena V, Diaz A, Belmonte E, Perellò C et al. Time association between hepatitis C therapy and hepatocellular carcinoma emergence in cirrhosis: relevance of non-characterized nodules. J Hepatol 2019 70: 874-884.

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Association of exogenous insulin or

sulphonylurea treatment with an increased incidence of hepatoma in patients with hepatitis C virus infection. Liver Int 2010 30: 479-486

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Accepted Article

47) Giovannucci E, Harlan DM, Archer MC et al. Diabetes and cancer: a consensus report. Diabetes Care 2010 33: 1674-1685

48) Singh S, Singh PP, Singh AG, Murad MH, Sanchez W. Anti-diabetic medications and the risk of hepatocellular cancer: a systematic review and meta-analysis Am J Gastroenterol 2013 108: 881-891

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Int J Environ Res Public Health 2019, 16, 2097;

doi:10.3390/ijerph16122097

Table 1. Baseline epidemiological and clinical characteristics of 893 patients included. DM

No DM

(141 pts)

(752 pts)

63  11.2 [58 - 67]

59  11.6 [58 - 60]

Males (n, %)

86 (61%)

436 (58%)

Females (n, %)

55 (39%)

316 (42%)

140 (99%)

732 (97%)

1 (1%)

20 (3%)

25.2  4.8

24.6  3.8

Age (years, mean  SD [range])

p

0.10

0.50

Ethnicity Caucasian (n, %) African (n, %)

BMI (mean  SD)

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0.16

0.049

Accepted Article

Waist circumference Males (cm, mean  SD)

104  9.4

98  10.1

Females (cm, mean  SD)

99  9.5

91  7.8

Males > 94 cm (n, %)

72 (83.7%)

206 ( 47.2%)

Females > 80 cm (n, %)

43 (78.2%)

146 (46.2%)

26 (18.4%)

65 (8.6%)

Never (n, %)

122 (86.6%)

698 (92.8%)

Past or current smokers (n, %)

19 (13.4%)

54 (7.2%)

No (n, %)

133 (94.3%)

741 (98.5%)

Yes (n, %)

8 (5.7%)

11 (1.5%)

Infection duration (years, mean  SD)

19  16.4

18  9.0

0.9

Metabolic syndrome (n, %)

117 (83%)

73 (9.7%)

7%

4.19 (1.57 – 11.17)

0.004

8.75 (1.57 – 48.64)

0.01

Cirrhosis (yes)

1.74 (0.72 – 4.21)

0.22

2.25 (0.58 – 9.03)

0.24

Liver stiffness > 20 kPa

1.00 (0.97 – 1.03)

0.86

1.01 (0.96 – 1.06)

0.68

MELD score >10

1.20 ( 0.41 – 3.52)

0.70

1.51 (0.36 – 6.32)

0.38

APRI > 1.5

1.44 (0.45 – 4.62)

0.54

2.56 (0.35 – 16.65)

0.32

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1.03 (0.20 – 5.35)

0.57

0.61 (0.06.- 5.83)

0.67

Oesophageal varices

0.48 (0.22 – 1.07)

0.07

0.21 (0.06 – 0.68)

0.01

Accepted Article

Previous HCC

*NF: not feasible. OR, Odds ratio; CI, Confidence interval;BMI, Body mass index; DM, diabetes mellitus; HbA1c, glycated hemoglobin; kPa, kiloPascal, MELD, Model for end stage liver diseases; APRI; AST-toplatelet ratio; HCC; Hepatocellular carcinoma.

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Accepted Article

Table 4. Baseline risk factors for the development of liver related events in patients with SVR by univariate and multivariate Cox regression analysis.

Variables

HR (95% CI) Univariate

p

Multivariate

p

Age > 65 years

1.03 (1.00 – 1.05)

0.02

1.01 (0.98 – 1.04)

0.59

Gender female

0.98 (0.57 – 1.70)

0.95

0.83 (0.47 – 1.49)

0.54

Cirrhosis (yes)

4.78 (1.91 – 11.95)

0.0009

3.06 (1.16 – 8.06)

0.02

Past/current smoking

1.11 (0.40 – 3.07)

0.84

1.06 (0.36 – 3.13)

0.91

Alcohol abuse

N.F.*

N.F.*

Metabolic syndrome (yes)

1.98 (1.13 – 3.48)

0.02

1.10 (0.44 – 2.75)

0.84

Abnormal waist circumference

1.03 (1.00 – 1.05)

0.02

1.01 (0.98 – 1.04)

0.72

Albumin < 4 g/dL

5.65 (3.14 – 10.15)

25

0.93 (0.54 – 1.58)

0.78

0.75 (0.41 – 1.35)

0.33

Oesophageal varices (yes)

4.10 (2.41 – 7.00)

20 kPa

1.11 (0.82 – 1.68)

0.45

1.02 (0.86 – 2.28)

0.86

Accepted Article

APRI > 1.5

*N.F. = not feasible. HR, Hazard ratio; CI, confidence interval; BMI, body mass index; APRI, AST-to-platelets ratio; kPa, kiloPascal.

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Accepted Article

Table 5. Association between characteristics and risk of incident HCC in cirrhotic patients by multivariate Cox regression analysis.

Characteristics

Adjusted HR (95% CI)

p

Age > 65 years

1.61 (0.86 – 2.55)

0.13

Gender female

0.61 (0.32 – 1.16)

0.14

Past/current smoking

1.02 (0.35 – 2.95)

0.97

Alcohol abuse

N.F.*

BMI > 25

1.26 (0.27 – 5.55)

0.77

Obesity

1.25 (0.52 – 3.21)

0.55

Abnormal waist circumference

1.12 (1.03 – 1.22)

0.01

Metabolic syndrome

0.86 (0.33 – 2.21)

0.75

Diabetes mellitus

2.69 (1.09 – 6.67)

0.03

Duration of infection > 10 years

1.00 (0.97 – 1.03)

0.93

Genotype 3

0.53 (0.13 – 2.26)

0.39

Albumin < 4 g/dL

2.83 (1.32 – 6.07)

0.008

Platelets < 100 x 109/L

1.14 (0.55 – 2.38)

0.73

APRI > 1.5

1.11 (0.53 – 2.30)

0.75

MELD score > 10

1.92 (0.96 – 3.87)

0.07

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Accepted Article

Oesophageal varices

1.44 (0.77 – 2.68)

0.26

*N.F.: not feasible. HR, Hazard ratio; CI, confidence interval; BMI, body mass index; APRI, AST-to-platelets ratio; MELD, Model for end stage liver disease.

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Accepted Article

Table 6. Association between baseline characteristics and risk of incident HCC in diabetic patients by multivariate Cox regression analysis.

Characteristics

Adjusted HR (95% CI)

p

Age > 65 years

0.70 (0.23 – 2.16)

0.54

Gender female

0.36 (0.10 – 1.25)

0.12

BMI > 25

1.26 (0.27 – 5.55)

0.77

Cirrhosis

N.F.*

Past/current smoking

1.89 (0.32 – 11.26)

0.48

Metabolic syndrome

0.62 (0.11 – 3.44)

0.62

Abnormal waist circumference

1.21 (1.05 – 1.26)

0.01

12.84 (2.02 – 81.65)

0.007

Platelets < 100 x 109/L

2.05 (0.53 – 7.86)

0.30

Obesity

0.42 (0.08 – 2.19)

0.30

Oesophageal varices

1.51 (0.47 – 4.86)

0.49

Duration of DM > 10 years

0.92 (0.83 – 1.02)

0.12

Insulin therapy

4.11 (1.20 – 14.13)

0.02

Family history of DM

0.41 (0.10 - 1.65)

0.22

DM improvement (no)

0.68 (0.15 – 3.20)

0.63

Albumin < 4 g/dL

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Accepted Article

APRI > 1.5

0.66 (0.13 – 3.32)

0.62

*N.F.: not feasible. HCC, Hepatocellular carcinoma; HR, Hazard ratio; CI, Confidence interval; BMI, body mass index; DM, Diabetes mellitus; APRI, AST-to-platelet ratio.

LEGENDS Figure 1. Mean FPG (A) and HbA1c (B) values and body weight (C) at 6-month intervals for 48 months post-treatment. FPG= Fasting Plasma Glucose HbA1c= glycated haemoglobin Figure 2. The Kaplan-Meier curves demonstrating liver related events-free survival and hepatocellular carcinoma-free survival in patients according to their glycometabolic status.

(A) Liver related events-free survival among patients with or without diabetes mellitus at baseline (B) Hepatocellular carcinoma-free survival among patients with or without diabetes mellitus at baseline

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Accepted Article DR. DAVIDE RIBALDONE (Orcid ID : 0000-0002-9421-3087) DR. MARCO SACCO (Orcid ID : 0000-0003-0975-5584) PROF. GIORGIO MARIA SARACCO (...
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