Sustained Virological Response Reduces Incidence of Onset of Type 2 Diabetes in Chronic Hepatitis C

February 27, 2009

Yasuji Arase, Fumitaka Suzuki, Yoshiyuki Suzuki, Norio Akuta, Masahiro Kobayashi, Yusuke Kawamura, Hiromi Yatsuji, Hitomi Sezaki, Tetsuya Hosaka, Miharu Hirakawa, Kenji Ikeda and Hiromitsu Kumada

Diabetes is present in patients with chronic hepatitis C virus infection. The aim of this retrospective cohort study was to assess the cumulative development incidence and predictive factors for type 2 diabetes after the termination of interferon therapy in Japanese patients positive for hepatitis C virus (HCV). A total of 2,842 HCV-positive patients treated with interferon (IFN) monotherapy or combination therapy with IFN and ribavirin were enrolled. The mean observation period was 6.4 years. An overnight (12-hour) fasting blood sample or a casual blood sample was taken for routine analyses during follow-up. The primary goal was the onset of type 2 diabetes.

Evaluation was performed by using the Kaplan-Meier method and Cox proportional hazard analysis. Of 2,842 HCV patients, 143 patients developed type 2 diabetes. The cumulative development rate of type 2 diabetes was 3.6 percent at five years, eight percent at 10 years, and 17 percent at 15 years.

Multivariate Cox proportional hazard analysis revealed type 2 diabetes development after the termination of IFN therapy occurred when histological staging was advanced (hazard ratio 3.30; 95 percent confidence interval [CI] 2.06-5.28; P greater than 0.001), sustained virological response was not achieved (hazard ratio 2.73; 95% CI 1.77-4.20; P less than 0.001), the patient had pre-diabetes (hazard ratio 2.19; 95 percent CI 1.43-3.37; P less than 0.001), and age was more than 50 years (hazard ratio 2.10; 95 percent CI 1.38-3.18; P less than 0.001).

Conclusion: Our results indicate sustained virological response causes a two-thirds reduction in the risk of type 2 diabetes development in HCV-positive patients treated with IFN. (HEPATOLOGY 2009;49:739-744.)

Hepatitis C virus (HCV) is one of the more common causes of chronic liver disease in world. Chronic hepatitis is an insidiously progressive form of liver disease that relentlessly, but silently, progresses to cirrhosis in 20 to 50 percent of cases during a period of 10 to 30 years.1-3 In addition, HCV is a major risk for hepatocellular carcinoma (HCC).4-8 Moreover, chronic HCV infection has been associated with a variety of extrahepatic complications such as essential mixed cryoglobulinemia, porphyria cutanea tarda, membranoproliferative glomerulonephritis, autoimmune thyroiditis, sialadenitis and cardiomyopathy.9-13

Lately, data supporting a link between type 2 diabetes mellitus (T2DM) and chronic hepatitis C infection have been reported.14,15 Although there is growing evidence to support the concept HCV infection is a risk factor for developing T2DM, there have been a few interventional studies confirming the issue. This issue needs to be confirmed with a long-term follow-up of patients with high risk of developing diabetes. Thus, prospective studies including metabolic evaluations are clearly needed to clarify these issues. With this background in mind, the cohort study was initiated to investigate the cumulative incidence and risk factors of T2DM after prolonged follow-up in HCV-infected patients treated with interferon (IFN) monotherapy or combination therapy with IFN and ribavirin. The strengths of the current study are the large numbers of patients included and the long-term follow-up of patients.

Abbreviations:

• CI, confidence interval
• FPG, fasting plasma glucose
• HCC, hepatocellular carcinoma
• HCV, hepatitis C virus
• IFN, interferon
• SVR, sustained virological response
• T2DM, type 2 diabetes mellitus.

From the Department of Hepatology, Toranomon Hospital, Tokyo, Japan.
Received September 25, 2008; accepted October 13, 2008.
Supported in part by grants-in-aid from Okinaka Memorial Institute for Medical Research and the Japanese Ministry of Health, Labor, and Welfare.

Address reprint requests to: Yasuji Arase, M.D., Department of Hepatology,
Toranomon Hospital, 2-2-2, Toranomon, Minato-ku, Tokyo 105-8470, Japan.
E-mail: es9y-ars@asahi-net.or.jp; fax: (81)-3-3582-7068.

Copyright © 2008 by the American Association for the Study of Liver Diseases.
Published online in Wiley InterScience (www.interscience.wiley.com).
DOI 10.1002/hep.22703
Potential conflict of interest: Nothing to report.

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Patients and Methods

Patients

There were 5,890 patients diagnosed with chronic HCV infection and treated with IFN mono-therapy or combination IFN plus ribavirin therapy between September 1990 and March 2007 in the Department of Hepatology, Toranomon Hospital, Tokyo, Japan.

Of these, 2,842 patients satisfied the following criteria:

1. No evidence of diabetes mellitus for three months after the termination of IFN (plasma glucose concentration less than 126 mg/dL [6.9 mmol/L] in the fasting state, less than 200 mg/dL [11.0 mmol/L] in casual state and/or two hours after a 75-g oral glucose load).
2. Features of chronic hepatitis or cirrhosis diagnosed via laparoscopy and/or liver biopsy before the initiation of IFN therapy.
3. Positivity for serumHCVRNAbefore the initiation of IFN therapy.
4. Period of less than or equal to one year of IFN therapy.
5. Negativity for hepatitis B surface antigen (HBsAg), antinuclear antibodies or antimitochondrial antibodies in serum as determined via radioimmunoassay or spot hybridization.
6. No evidence of HCC nodules as shown on ultrasonography and/or computed tomography.
7. No underlying systemic disease, such as systemic lupus erythmatosus or rheumatic arthritis.

Patients who were taking medications known to alter glucose tolerance or had illnesses that could seriously reduce life expectancy or their ability to participate in the trial were excluded from the study. Patients were classified as having normal glucose or pre-diabetes based on fasting plasma glucose (FPG), casual plasma glucose or two-hour plasma glucose. The normal glucose group was regarded as having an FPG of less than 100 mg/dL, casual plasma glucose of less than 140 mg/dL and/or two-hour plasma glucose of less than 140 mg/dL. The pre-diabetes group was regarded as having an FPG of 100-125 mg/dL, casual plasma glucose of 140-200 mg/dL, and/or two-hour plasma glucose of 140-200 mg/dL.16

Next, we assessed predictive factors for T2DM in chronic hepatitis C patients treated with IFN. The physicians in charge explained the purpose and method of this clinical trial to each patient and/or the patient’s family. Informed consent was obtained from all living patients included in the present cohort study. The study was approved by the Institutional Review Board of our hospital.

Outcome Measures

The primary outcome was T2DM, diagnosed by the use of the 2003 criteria of the American Diabetes Association.16 These criteria include:

1. Casual plasma glucose greater than or equal to 200 mg/dL.
2. FPG greater than or equal to 126 mg/dL.
3. Two-hour post-glucose (oral glucose tolerance test) greater than or equal to200 mg/dL.

Laboratory Investigation

Anti-HCV was detected using a second-generation enzyme-linked immunosorbent assay (ELISA II; Abbott Laboratories, North Chicago, IL). HCV-RNA was determined by the Amplicor method (Cobas Amplicor HCV Monitor Test, version 2.0; Roche, Tokyo, Japan). Hepatitis B surface antigen was tested via radioimmunoassay (Abbott Laboratories, Detroit, MI). The used serum samples were stored at negative 80 degrees celsius at the first consultation. Diagnosis of HCV infection was based on detection of serum HCV antibody and positive RNA. Height and weight were recorded at baseline, and the body mass index was calculated as weight (in kg)/height (in m2).

Evaluation of Liver Cirrhosis

Liver status of the 2,842 patients was mainly determined via peritoneoscopy and/or liver biopsy. Liver biopsy specimens were obtained using a modified Vim Silverman needle with an internal diameter of two mm (Tohoku University, Kakinuma Factory, Tokyo, Japan), fixed in 10 percent formalin and stained with hematoxylin-eosin, Masson’s trichrome, silver impregnation and periodic acid-Schiff after diastase digestion. The size of specimens for examination was more than six portal areas.17

Follow-up

The starting time of follow-up was three months after the termination of IFN therapy. After that, patients were followed up monthly to tri-monthly in our hospital. Physical examination and biochemical tests were conducted at each examination together with regular check-up. An overnight (12-hour) fasting blood sample or a casual blood sample was taken for routine analyses. These included aminotransferase activities, total cholesterol, platelet counts and serum HCV RNA level. Three hundred twenty-four patients were lost to follow-up. This was because the appearance of T2DM and death was not identified in these patients, they were considered as censored data in the statistical analysis.18 Moreover, patients retreated with antiviral agents were regarded as withdrawals at the time of starting the retreatment of antiviral agents.

Statistical Analysis

The cumulative appearance rate of T2DM was calculated from three months after the termination of IFN treatment to the appearance of T2DM using the Kaplan-Meier method. Differences in the development of T2DM were tested using the log rank test. Independent factors associated with the incidence rate of T2DM were analyzed by the Cox proportional hazard model. The following variables were analyzed for potential covariates for incidence of T2DM at the time of termination of IFN therapy at our hospital:

• Age
• Sex
• State of liver disease (chronic hepatitis or liver cirrhosis)
• Body mass index
• Glucose level
• Aspartate aminotransferase level
• Alanine aminotransferase level
• Type of IFN
• Total dose of IFN
• Efficacy of IFN therapy
• Hypertension
• Triglyceride level
• Total cholesterol level

A P value of less than 0.05 was considered significant. Data analysis was performed using SPSS 11.5 for Windows (SPSS, Chicago, IL).

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Results

Patient Characteristics

Table 1 shows the characteristics of the 2,842 HCV-positive patients treated with IFN monotherapy or combination therapy with IFN and ribavirin. The sustained virological response (SVR) rate was 36.7 percent (886/2417) in IFN monotherapy and 68 percent (289/425) in IF plus ribavirin therapy. Thus, the number of patients with SVR was 1,175. The mean period after the termination of antiviral drugs was 6.4 years.

Table 1. Patient Characteristics
N	2,842
Sex (male/female)	1,778/1,064
Age (years)	51.8 + 9.0
Height (cm)	163.8 + 9.1
Body weight (kg)	62.7 + 11.7
Body mass index	23.3 + 3.2
Blood pressure (systolic/diastolic, mm Hg)	128 + 18/77 + 12
HCV genotype (1b/2a/2b/other)	744/752/290/56
HCV RNA level (KIU/mL)	593 + 540
Staging (non-LC/LC)	2,649/193
Blood glucose level (normal/prediabetes)	2,601/241
Fasting plasma glucose (mg/dL)	87 + 24
Triglyceride (mg/dL)	166 + 31
Total bilirubin (g/dL)	102 + 56
AST (IU/L)	74 + 63
ALT (IU/L)	116 + 102
IFN monotherapy*/combination therapy†	2,417/425
Efficacy of treatment (SVR/non-SVR)	1,175/1,667
Follow-up period (years)	6.4 + 5.0
Data are expressed as the number of patients or mean + or _standard deviation.

Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; LC, liver cirrhosis; SVR, sustained virological response.

*Outbreak of IFN monotherapy: recombinant IFN-cx2a, 304 cases; recombinant IFN-cx2b, 235 cases; natural IFN-b_, 1,355 cases; natural IFN-_, 522 cases; total dose of IFN _ 598 _ 170 MU.

†Outbreak of combination therapy: recombinant IFN-_2b _ ribavirin, 175 cases; total dose of IFN _ 537 _ 196 MU; total dose of ribavirin _ 182 _ 69 g; pegylated IFN-_2b _ ribavirin, 250 cases; total dose of pegylated IFN _ 4.28 _ 1.17 mg; total dose of ribavirin _ 232 _ 60 g.

Incidence of T2DM in Patients with HCV

A total of 143 patients (102 men and 41 women) developed T2DM during amean observation period of 6.4 years. Of these, 26 were SVR and 117 were non-SVR. The cumulative development rate of T2DM was determined to be 3.6 percent at five years, 8 percent at 10 years, and 17 percent at 15 years using the Kaplan-Meier method (Fig. 1). The factors associated with the incidence ofT2DMin all 2,842 patients treated with IFN therapy are shown in Table 2.

Multivariate Cox proportional hazard analysis revealed type 2 diabetes development after the termination of IFN therapy occurred when histological staging was advanced (hazard ratio 3.30; 95 percent confidence interval [CI] 2.06-5.28; P less than 0.001), sustained virological response was not achieved (hazard ratio 2.73; 95 percent CI 1.77-4.20; P less than 0.001), patient had pre-diabetes (hazard ratio 2.19; 95 percent CI 1.43-3.37; P less than 0.001) and age was 50 years or older, liver cirrhosis and pre-diabetes contribute to a high risk of developing diabetes. The cumulative development rates of T2DM based on difference of age, efficacy of the IFN therapy, histological diagnosis and glucose level at the starting time of follow-up are shown in Fig. 2.

Fig. 3 shows the impact of reduction due to SVR on the incidence of T2DM in patients with 50 years or older, liver cirrhosis or pre-diabetes. When patients with age 50 years or older, liver cirrhosis and pre-diabetes have SVR after IFN therapy, SVR could statistically reduce the onset of T2DM compared with those without SVR.

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Discussion

We have described the development incidence of diabetes after the termination of antiviral therapy in HCV-positive patients treated with IFN therapy in the present study. Diabetes has been reported in less than 0.08 percent of patients treated with IFN19,20. Therefore, patients without diabetes for three months after the termination of IFN were enrolled in the present study. The present study indicates the annual incidence of T2DM for a prolonged follow-up after the termination of IFN therapy among HCV patients is 0.8 to 1.0 percent.

The present study was limited by a retrospective cohort trial. We started the present study in 1991 based on the diabetes mellitus criteria published by Fajans.21 However, after that, diabetes mellitus criteria were revised. We thus rechecked the diagnosis of T2DM based on the diabetes mellitus criteria of 2003 in patients seen prior to 2003.16 Because of rechecking the diagnosis of T2DM on the basis of diabetes mellitus criteria in 2003, the present study was regarded as a retrospective cohort study. However, the patients were prospectively followed. Another limitation of the study was patients were treated with different types of antiviral therapy (IFN monotherapy or combination IFN ribavirin therapy) for different duration (four to 52 weeks). This heterogeneity makes it difficult to interpret the results of the study. On the other hand, the strength of the present study is the long-term follow-up in the large numbers of patients included.

The present study shows several findings with regard to development of T2DM after the termination of antivirus agents for HCV positive patients. First, the T2DM development rate in the non-SVR group was higher than in the SVR group. The SVR caused a two-thirds reduction in the onset of T2DM in the course of posttreatment follow-up. That SVR reduced the onset of diabetes mellitus in HCV patients is in accordance with the data reported by Simo´ et al.22 and Romero-Go´mez et al.23

Though the role of HCV in the pathogenesis of diabetes mellitus remains speculative, the following possible mechanisms have been reported:

1. Patients with HCV have a tendency to attain insulin resistance24.
2. In transgenic mice, the expression of HCV core protein is associated with insulin resistance and T2DM development25.
3. SVR in HCV patients reduces insulin resistance and onset of the incidence of abnormal glucose value.26

Thus, it is accepted clearance of HCV reduces the onset of T2DM.

Second, in addition to persistence of HCV, the present study suggests aging, histological progression and pre-diabetes enhanced the onset of T2DM in patients with HCV infection. However, when HCV was eradicated even in patients with age 50 years or older, pre-diabetes, or liver cirrhosis, the cumulative development rate ofT2DM decreased.

T2DM is increasing dramatically in many Asian nations, including Japan, during the last few decades.27 It is widely accepted seven to eight million people are affected by diabetes mellitus in Japan. Approximately eight to 10 percent of adults in Japan have T2DM. In general, T2DM is associated with a genetic predisposition, but it is also strongly influenced by lifestyle-related factors, such as eating habits and/or physical activity.28-33 The risk factors associated with T2DM include family history, age, sex, obesity, smoking and physical activity. T2DM occurred in elderly patients compared to young patients. Life expectancies are long in Japan. Thus, in the near future, a large number of patients with HCV will be more than 60 years old. Therefore, it is apparent the incidence ofT2DM will increase in HCV-positive patients.

T2DM is a serious, costly disease. Treatment for T2DM may prevent some of its devastating complications, but does not usually restore normoglycemia or eliminate all the adverse consequences.28,29 Moreover, HCV patients with T2DM are at major risk for HCC.34 On the efficacy of IFN therapy, it has been reported T2DM reduces HCV eradication via combination IFN plus ribavirin therapy.26 Thus, it should be considered whether HCV-positive patients should be treated with antiviral drugs in the histological nonprogression stage and at a non-elderly age for prevention of T2DM onset. If SVR obtained via antiviral therapy for HCV cannot only prevent progression to liver cirrhosis or HCC but also prevent the development of diabetes, the potential impact of IFN therapy is quite significant.

In conclusion, this retrospective study suggests the annual incidence of T2DM among patients with HCV is 0.8 to 1 percent. Our results indicate SVR causes a two-thirds reduction of T2DM development in HCV-positive patients treated with antiviral drugs.

Acknowledgment: The authors acknowledge the editorial assistance of Thomas Hughes.

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