Hepatitis C Antibodies

Besides a clinical and laboratory evaluation, each subject underwent a liver ultrasonography, an anthropometric assessment and a 7-day diary of food intake (7DD) [1 (link)]. HBsAg and anti-HCV antibodies were assessed and subjects with anti-HCV antibodies underwent an HCV-RNA assessment to confirm HCV infection [1 (link),14 (link)]. ALT, aspartate transaminase (AST), GGT, glucose, triglycerides and cholesterol were measured by standard laboratory methods after 8-hr fasting. Insulin was measured by radio-immuno-assay (ADVIA Insulin Ready Pack 100, Bayer Diagnostics, Milan, Italy), with intra- and inter-assay coefficients of variation < 5%. FL was diagnosed by the same operator at ultrasonography [6 (link)]. Weight, stature, circumferences (waist and hip) and skinfolds (triceps, biceps, subscapular and suprailiac) were measured by two trained dietitians who had been standardized before and during the study according to standard procedures [15 ]. Body mass index (BMI) was calculated as weight (kg)/stature (m)² and the sum of 4 skinfolds by summing triceps, biceps, subscapular and suprailiac skinfolds [16 (link),17 (link)]. The 7DD was administered to the subjects by two trained dietitians, who discussed it with the subject when she/he returned it one week later [18 (link)]. To avoid the confounding effect of seasonality on food intake, the 7DD diary was administered to a similar number of patients with and without SLD each month [19 ]. Mean daily ethanol intake was calculated as the mean value of ethanol intake as assessed by the 7DD [20 ]. The study protocol was approved and supervised by the Scientific Committee of the Fondo per lo Studio delle Malattie del Fegato (Trieste, Italy), and all subjects gave their written informed consent to participate.

The protocol of the Dionysos Nutrition & Liver Study was described in detail elsewhere [1 (link)]. Briefly, of 5780 residents of Campogalliano (Modena, Italy) aged 18 to 75 years, 3345 (58%) agreed to participate to the study; 3329 (99%) of them had all the data required by the Dionysos Project [7 (link),13 (link)] and were considered for further analysis. 497 (15%) of them had suspected liver disease (SLD) according to at least one of the following criteria: 1) alanine transaminase (ALT) > 30 U*L^-1; 2) gamma-glutamyl-transferase (GGT) > 35 U*L^-1; 3) presence of hepatitis B surface antigen (HBsAg); 4) presence of Hepatitis C (HCV) virus ribonucleic acid (RNA) after detection of anti-HCV antibodies. The 497 subjects with SLD were matched with an equal number of subjects of the same age and sex but without SLD, randomly selected among the remaining 2832 subjects. After exclusion of subjects with HBV or HCV infection, the original analysis was performed on 224 subjects with and 287 without SLD [1 (link)]. The present analysis is performed on 216 (96%) subjects with and 280 (97%) without SLD, based on the availability of skinfold measurements.

This study included patients who participated in the Cohort of Non-alcoholic Fatty Liver Disease in Saudis with T2DM (the CORDIAL Study). This prospective cohort study started in 2015 and recruited patients from King Fahad Medical City (KFMC) and affiliated Primary Care Centers in Riyadh, Saudi Arabia. The cohort was approved by the Institutional Review Board at KFMC (study number: 12–344), and all patients provided written, informed consent prior to recruitment. The study was conducted in accordance with the ethical principles for medical research on human subjects adopted by the 18th World Medical Association General Assembly, and the Declaration of Helsinki 1964 and its subsequent amendments. The inclusion criteria included Saudi patients aged 18–60 years who were diagnosed with T2DM and followed up regularly in the diabetes or primary care clinics. Patients were excluded if they tested positive for hepatitis B surface antigen or had antibodies against hepatitis C virus, were diagnosed with other chronic liver diseases (e.g., hemochromatosis, primary biliary cholangitis, or autoimmune hepatitis), known to have pre-existing hepatic or extrahepatic malignancy, or were consuming >20 g of alcohol per day. The patients will be prospectively followed for 10 years and assessed for hepatic, metabolic, renal, and cardiovascular complications.

The number of patients in each step of the care cascade was determined: screening and confirmatory testing, linkage to care, initiation of DAA, SVR. Laboratory results for HCV antibody and HCV viral tests (i.e., ribonucleic acid [RNA] and genotype) were used to determine screening and confirmatory testing, and respectively. This healthcare system has employed reflex testing for HCV RNA since 2012. Although the clinical test for HCV screening is the HCV antibody, this study assumed that anyone with test results for HCV RNA or genotype was previously screened with an HCV antibody test even if 1 was not recorded, accounting for patients who may have had HCV antibody testing before 2014 and then had confirmatory testing during the study period. This criterion also accounted for patients who received HCV screening at outside facilities and entered the healthcare system for follow-up care.
It was determined which screened patients did not have chronic HCV, were lost to follow-up, or needed linkage to care according to results of HCV antibody and viral tests (Fig. 1). HCV RNA test results of < 15 International Units per liter were considered undetectable. Seronegative patients, those with nonreactive HCV antibody tests, did not have HCV and did not need confirmatory testing or HCV care. Seropositive patients had reactive HCV antibody tests. Seropositive patients with undetectable HCV RNA did not need further HCV care, and seropositive patients with missing HCV RNA testing were considered to have incomplete HCV testing. Seropositive patients with detectable HCV RNA had chronic HCV and needed HCV care. If a patient had a recorded HCV genotype but no recorded RNA, it was assumed that the patient had detectable RNA and thus needed HCV care. This study used the HCV genotype test as a proxy for determining linkage to care (i.e., meeting with a medical professional who provides HCV treatment and management). However, if a patient had a record of initiating antiviral treatment without a recorded genotype, it was assumed that the patient was linked to care.
Initiation of antiviral treatment was defined as the presence of any of the following in the patient’s medication history: boceprevir, daclatasvir, dasabuvir, elbasvir, glecaprevir, grazoprevir, interferon alfacon-1, interferon alpha-2a, interferon alpha-2b, ledipasvir, ombitasvir, paritaprevir, pegylated interferon, pegylated interferon alpha-2b, pibrentasvir, ribavirin, ritonavir, simeprevir, sofosbuvir, telaprevir, velpatasvir, and voxilaprevir. Date of initiation of antiviral treatment was considered the first date that any of the medications were recorded. While treatment durations can vary from 8 to 24 weeks, this study defined SVR as the presence of undetectable HCV RNA at least 20 weeks after initiation of antiviral treatment and on any subsequent test.
Differences in the number of patients between steps indicated drop-offs between steps. For instance, patients who had been linked to care but did not initiate antiviral treatment were considered to have dropped off in the care cascade after the linkage to care step. Additionally, recorded deaths in the EHR were considered in determining progress through the care cascade.

Sera samples were tested for anti-HCV using automated CMIA (Lai Bo Biotechnology, Inc. Jinan, China). The samples were considered positive when the results exceeded the cutoff (s/co) value of 1.00 (according to the manufacturer’s recommendations). The positive samples were subsequently tested for HCV core antigen (HCV cAg; Lai Bo Biotechnology, Inc. Jinan, China), hepatitis B surface antigen (HBsAg, SYSMEX CORPORATION, Janpan), HIV antigen + antibody (Ag + Ab; SYSMEX CORPORATION, Janpan), syphilis antibody (anti-TP; Lai Bo Biotechnology, Inc. Jinan, China), anti-hepatitis A virus (HAV) IgM, and anti-hepatitis E virus (HEV) IgM (Xiamen Innodx Biotech Co., Ltd., Xiamen, China).