Autoantibody Positivity in Chronic Hepatitis C Pre- and Post-Direct- Acting Antiviral Therapy: A Prospective Multicenter South Korean Study

Autoantibody Positivity in Chronic Hepatitis C Pre- and Post-Direct- Acting Antiviral Therapy: A Prospective Multicenter South Korean Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Autoantibody Positivity in Chronic Hepatitis C Pre- and Post-Direct- Acting Antiviral Therapy: A Prospective Multicenter South Korean Study Su Hyun Choi, Gwang Hyeon Choi, Eun Sun Jang, Youn Jae Lee, Young Seok Kim, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4427436/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background/Aims: Hepatitis C virus (HCV) infection causes extrahepatic manifestations involving autoantibody production. This study aimed to elucidate the positivity rates of four autoantibodies (ANA, ASM, anti-LKM1, and AMA) in patients with chronic hepatitis C (CHC) before and after direct-acting antiviral (DAA) therapy compared to those in healthy controls. Methods: This study enrolled prospectively collected plasma samples from 201 CHC patients [median age, 62 years; 49.8% women] from eight hospitals before and after DAA therapy and 127 healthy individuals. Results: The ANA positivity at pretreatment was higher in CHC patients than in healthy controls (32.3% vs. 21.3%, p=0.030), which decreased at SVR (32.3% vs. 23.9%, p=0.009). Female sex and higher globulin levels were related to ANA positivity in the control and CHC patient groups, respectively. Patients with ANA positivity at pretreatment and at SVR (n=48) were older and had a higher proportion of advanced liver disease than ANA-negative patients at SVR (n=153). Conclusions: ANA positivity was observed in one-third of CHC patients at pretreatment, which was significantly higher than that in healthy controls, and decreased after SVR. CHC patients with ANA positivity after SVR were older and had more advanced liver disease than those with ANA negativity. Health sciences/Gastroenterology/Hepatology Biological sciences/Immunology hepatitis C virus autoantibody anti-nuclear antibody direct acting antivirals sustained virological response Figures Figure 1 Figure 2 Introduction Hepatitis C virus (HCV) infection is a significant global health problem, with approximately 58 million individuals infected worldwide, and an estimated annual incidence of 1.5 million. 1 In addition to liver disease, HCV infection causes extrahepatic manifestations, including mixed cryoglobulinemia, non-Hodgkin lymphoma, and autoantibody production. 2 – 4 The frequency of circulating autoantibodies, especially rheumatoid factor or anti-nuclear antibody (ANA), is reportedly high among patients with chronic hepatitis C (CHC), suggesting a relationship between HCV and autoimmune processes. However, the prevalence of circulating autoantibodies in patients with CHC is highly variable since ANA, anti-smooth muscle antibody (ASM), and anti-liver kidney microsomal antibody type 1 (LKM-1) positivity are observed in 4–54%, 4–78%, and 0–13% of cases, respectively; moreover, only a few studies have compared their prevalence in patients with CHC with that in healthy controls (6–10%). 5–7 The mechanisms of autoantibody production and its clinical significance in CHC are unknown. Moreover, the alterations in the levels of these autoantibodies after direct-acting antiviral (DAA) therapy and viral eradication are not clear. 8 , 9 This study primarily aimed to compare the positivity rates of four conventional autoantibodies [ANA, ASM, anti-LKM1, and anti-mitochondrial antibody (AMA)] in patients with CHC at pretreatment (PreTx) with those in healthy controls. The secondary aim was to investigate the change in their positivity rates before and after DAA therapy, and explore the clinical factors related to ANA positivity in patients with CHC and healthy controls. Patients and Methods Study population and method of plasma sampling A total of 201 patients with chronic HCV (> 18 years old) who underwent DAA therapy were prospectively enrolled from 8 university hospitals between 2020 and 2022, as part of the Korea HCV Cohort study. 10 , 11 Patients who met any of the following criteria were excluded: concurrent human immunodeficiency virus (HIV) or hepatitis B virus (HBV) coinfection (n = 9), absence of blood samples before and after DAA therapy (n = 0) and presence of active hepatocellular carcinoma (HCC) before DAA therapy (n = 0). A sustained virological response (SVR) was achieved after DAA therapy in all patients. Written informed consent was obtained from each patient before enrollment in the cohort study. This study was approved by the Institutional Review Board (IRB No. B-0706-046-002) and conducted in accordance with the Declaration of Helsinki. The participants’ plasma samples were prospectively collected and stored at -70°C till the analysis. The sampling time was at PreTx and at the time of SVR evaluation (SVR), with a window period of 4 weeks. The control group comprised plasma samples from 127 healthy persons who were randomly selected from a biobank at Seoul National University Bundang Hospital under IRB approval (IRB No. X-2302-810-902) after age and sex adjustment to the general population of South Korea in 2021. Since the control samples from individuals aged > 70 years were limited, we could not match their age to that of the patients with HCV. All healthy controls tested negative for HCV, HBV, and HIV infection, without any active cancer, autoimmune, or major organ diseases and had normal laboratory results on health examination. Measurement of autoantibodies ANA, ASM, anti-LKM1, and AMA were detected using indirect immunofluorescence with cutoff levels of 1:80, 1:10, 1:10, and 1:10, respectively, according to the manufacturer’s protocols, at the Seoul Central Laboratory in South Korea. ANA [detected with the Hep-20-10 EUROPattern (EUROIMMUN, Lübeck, Germany)], ASM [detected with the Hep-2/Mouse Kidney/Stomach COMVI II (Immco Diagnostics, Inc. New York, USA)], AMA [detected with the Hep-2/Mouse KidneyCOMVI I (Immco Diagnostics, Inc. New York, USA)], and anti-LKM1 [detected using the Mouse Liver/Kidney/Stomach Kit (Immco Diagnostics, Inc. New York, USA)] were assayed. Collection of clinical data Clinical data, including the patients’ age, sex, body mass index, alcohol and smoking status, severity of liver disease categorized into chronic hepatitis, liver cirrhosis, and HCC; DAA regimens; comorbidities including autoimmune diseases (thyroid disease, diabetes, rheumatoid arthritis, systemic lupus erythematosus, mixed cryoglobulinemia, lymphoma, kidney disease, etc.); and laboratory results were collected from the medical records before and after DAA treatment at the time of SVR evaluation. The laboratory data included the status of 4 autoantibodies (ANA, ASM, anti-LKM1, and AMA), HCV RNA concentration, HCV genotype, white blood cell count, hemoglobin, platelet count, aspartate transaminase (AST), alanine transaminase (ALT), bilirubin, protein, albumin, calculated globulin derived from difference between the protein and albumin levels, alpha-fetoprotein, prothrombin time (International normalized ratio), creatinine, fasting blood glucose, cholesterol at PreTx and at SVR12 after DAA therapy. Using the collected data, indirect fibrosis markers, including the fibrosis-4 index, aminotransferase-to-platelet ratio index, Child-Pugh score, and Model for End-Stage Liver Disease score, were calculated at PreTx and at the time of SVR12. The results of all abdominal radiology and vibration-controlled transient elastography (Fibroscan®; Echosens, Paris, France), if available, were collected. These data were entered into an established electronic case report form on the authorized website of the Korean Centers for Disease Control Korea HCV cohort study ( http://is.cdc.go.kr/ ) by the research coordinators. All input data were quality-controlled by independent statistical researchers (D.H. Baik and M.R. Ki) at least four times per year. Statistical analysis Continuous variables were analyzed using Student’s t-test for normally distributed data and the Mann-Whitney test for non-normally distributed data. Categorical variables were analyzed using the chi-square test or Fisher's exact test. The McNemar test was conducted for paired data to compare the prevalence of autoantibody positivity before and after DAA treatment. To identify factors related to autoantibody positivity, multivariate logistic analysis was conducted, with adjustment for age, sex, and other clinically relevant and/or statistically significant factors identified by the univariate analysis. Statistical significance was established at p ˂0.05. Data analyses were conducted using SPSS version 22(IBM Corp., Armonk, NY, USA). Results Clinical characteristics of the study population The clinical characteristics of the 201 patients with HCV at PreTx and SVR (median age, 62 years; women, 49.8%) and 127 healthy controls (median age, 55 years; women, 49.6%) are summarized in Table 1 . The proportions of liver cirrhosis and inactive HCC among the patients with HCV infection were 7.5% and 8.0%, respectively. HCV genotype 1 (46.3%) and genotype 2 (52.2%) were present in nearly all patients with CHC (98.5%). Common comorbidities, such as hypertension and diabetes, were present in 48.8% and 26.9% of patients, respectively. The following autoimmune comorbidities were found at PreTx: thyroid disease (4%), rheumatoid arthritis (1.5%), systemic lupus erythematosus (0%), mixed cryoglobulinemia (0%), lymphoma (0.5%), kidney diseases (6.5%), and others (1.5%). The most frequently prescribed DAA regimen was glecaprevir/pibrentasvir in 86.1% of cases, because sofosbuvir/velpatasvir and sofosbuvir/velpatasvir/voxilaprevir were not approved in South Korea during the study period. Vibration-controlled transient elastography was performed in 102 patients (50.7%) at PreTx, which yielded a median liver stiffness value of 7.50 kPa. After SVR, most laboratory results related to liver function improved, including a significant reduction in plasma globulin levels and an increase in the total cholesterol levels (Table 1 ). The median age (55 years) was lower in the healthy control group than that in the HCV group because of the non-availability of samples from normal older individuals, since the controls were age-and sex-matched to the general population of South Korea in 2021. The laboratory results of the control group were within the normal range, without a history of cancer, major cardiovascular or pulmonary, autoimmune, or liver disease (Table 1 ). Table 1 Clinical Characteristics of HCV patients at Pre- and Post-DAA Treatment and Healthy controls. Variable HCV at PreTx (n = 201) Healthy (n = 127) p -value † HCV at Post-DAA p -value ‡ Age, years, median (IQR) 62 (52–70) 55 (42–64) < 0.001 NA NA 20 ~ 29 3 (1.5%) 15 (11.8%) < 0.001 NA NA 30 ~ 39 12 (6.0%) 15 (11.8%) NA NA 40 ~ 49 20 (10.0%) 17 (13.4%) NA NA 50 ~ 59 56 (27.9%) 30 (23.6%) NA NA 60 ~ 69 55 (27.4%) 27 (21.3%) NA NA 70~ 55 (27.4%) 23 (18.1%) NA NA Females, n (%) 100 (49.8%) 63 (49.6%) 1 NA NA BMI (kg/m²) 23.8 ± 4.62 NA NA NA NA History of alcohol use, n (%) 47 (23.4%) NA NA NA NA History of tabacco use, n (%) 105 (52.2%) NA NA NA NA Liver disease status, n (%) (hepatitis/cirrhosis/inactive HCC) 170 (84.6%) / 15 (7.5%) / 16 (8.0%) NA NA NA NA Child-Pugh class, n (%) (A/B/C) 192 (95.5%) / 9 (4.5%) / 0 NA NA NA NA Log HCV-RNA, median (IQR), IU/mL 6.02 (5.29–6.54) NA NA NA NA HCV genotype, n (%) (1/2/others) 93 (46.3%) / 105 (52.2%) / 3 (1.5%) NA NA NA NA DAA regimen, n (%) NA NA NA NA Gleprevir/Pibrentasivir 173 (86.1%) NA NA NA NA Elbasvir/Grazoprevir 11 (5.5%) NA NA NA NA Ledipasvir/Sofosbuvir 13 (6.5%) NA NA NA NA Ledipasvir/Sofosbuvir + ribavirin 3 (1.5%) NA NA NA NA Sofosbuvir + ribavirin 1 (0..5%) NA NA NA NA Type 2 diabetes, n (%) 54 (26.9%) 0 (0%) < 0.001 NA NA Hypertension, n (%) 98 (48.8%) 28 (22.0%) < 0.001 NA NA Thyroid disease 8 (4.0%) 0 (0%) 0.025 NA NA Lab. Findings Hemoglobin (g/dL) 13.79 ± 1.67 14.13 ± 1.36 0.039 13.78 ± 1.7 0.521 WBC (x10³/uL) 5847 ± 1798 5442.13 ± 1492.34 0.035 6338.51 ± 2119.59 < 0.001 Platelet (x10³/uL) 188.00 ± 62.29 258.40 ± 49.01 < 0.001 198.02 ± 63.39 < 0.001 AST (IU/L) 61.36 ± 45.07 30.78 ± 15.70 < 0.001 26.08 ± 16.55 < 0.001 ALT (IU/L) 62.35 ± 62.13 30.04 ± 22.56 < 0.001 20.01 ± 11.44 < 0.001 Bilirubin (mg/dL) 0.80 ± 0.48 0.86 ± 0.32 0.203 0.80 ± 0.60 0.699 Protein (g/dL) 7.42 ± 0.60 7.23 ± 0.34 < 0.001 7.29 ± 0.46 < 0.001 Albumin (g/dL) 4.14 ± 0.45 4.50 ± 0.24 < 0.001 4.33 ± 0.46 < 0.001 Globulin (g/dL) 3.28 ± 0.50 2.74 ± 0.32 < 0.001 2.96 ± 0.44 < 0.001 Prothrombin time (INR) 1.03 ± 0.94 NA NA 1.04 ± 0.10 0.506 Creatinine (mg/dL) 0.87 ± 0.49 0.74 ± 0.16 < 0.001 0.96 ± 0.92 < 0.001 Cholesterol (mg/dL) , 169.04 ± 38.95 188.43 ± 35.49 < 0.001 175.72 ± 41.63 < 0.001 Glucose (mg/dL) 116.13 ± 39.05 93.07 ± 13.52 < 0.001 111.37 ± 32.63 0.016 AFP (ng/mL) 7.99 ± 24.97 NA NA 5.73 ± 29.00 0.421 FIB-4 3.44 ± 3.08 1.25 ± 0.05 < 0.001 2.19 ± 2.18 0.000 APRI 0.88 ± 0.81 0.31 ± 0.18 < 0.001 0.42 ± 0.72 0.000 MELD score 3.28 ± 4.22 0.24 ± 0.29 < 0.001 3.34 ± 3.87 0.118 TE (kPa), median (IQR) (n = 102) 7.50 (5.00-12.15) NA NA NA NA BMI, body mass index; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; DAA, direct acting antiviral; WBC, white blood cell count; AST, aspartate aminotransferase ; ALT, alanine aminotransferase; INR, international normalized ratio; AFP. alpha fetoprotein; FIB-4, Fibrosis-4 index; APRI, AST to Platelet Ratio Index; TE, transient elastography; MELD, Model for End-Stage Liver Disease † The p-value between HCV patients and healthy controls." ‡ The p-value between HCV at Pre-Tx and Post-DAA Continous variables are expressed as mean ± SD, and the categorical variable are indicated as n(%). Positivity rates of four autoantibodies in the HCV and control groups The comparison of the positivity rates of the four autoantibodies between the CHC and healthy controls groups is summarized in Table 2 . In patients with CHC, the ANA, ASM, LKM-1, and AMA positivity rates were 32.3%, 2.0%, 0, and 0%, respectively; thus, the proportion of autoantibody-positive patients was 32.8%. In healthy controls, the ANA, ASM, LKM-1, and AMA positivity rates were 21.3%, 2.4%, 0, and 0.8%, respectively; thus, the proportion of autoantibody-positive patients was 22.8%. One healthy control with AMA positivity showed alkaline phosphatase levels within the normal range. Therefore, the ANA-positivity rate in patients with CHC was significantly higher than that in the healthy controls (p = 0.030). Table 2 Positive rates of autoantibodies in HCV patients at Pre-treatment and Healthy controls Autoantibody HCV at PreTx (n = 201) Healthy (n = 127) p -value ANA, n (%) 65 (32.3%) 27 (21.3%) 0.030 ASM, n (%) 4 (2.0%) 3 (2.4%) 1.000 LKM-1, n (%) 0 (0%) 0 (0%) - AMA, n (%) 0 (0%) 1 (0.79%) 0.387 Any autoantibody positive, n (%) 66 (32.8%) 29 (22.8%) 0.052 ANA, anti-nuclear antibody; ASM, anti-smooth muscle antibody; LKM, anti-liver kidney microsomal antibody, AMA, anti-mitochondrial antibody Factors related to ANA-positivity in healthy controls and patients with HCV at PreTx Among the healthy controls, the proportion of female patients was significantly higher in the ANA-positive subgroup than in the ANA-negative subgroup (66.7% vs. 45.0%, p = 0.046). No other factors were significantly associated with ANA positivity (Supplementary Table 1). In patients with CHC, the ANA-positive subgroup showed a significantly higher serum globulin level (3.43 vs 3.21 g/dL, p = 0.007) than that in the ANA-negative subgroup, while the median age (65 vs. 60 years, p = 0.189) and the proportion of women (44.6% vs. 52.2%, p = 0.314) did not differ between these two subgroups. The plasma HCV RNA levels were lower in the ANA-positive subgroup than in the ANA–negative subgroup (log HCV RNA titer 5.70 vs 6.08 IU/mL, p = 0.057) (Supplementary Table 2). Univariate and multivariate logistic analyses revealed that only high globulin level was an independent factor associated with ANA positivity among patients with HCV (odds ratio: 2.64, confidence interval: 1.40–4.98, p = 0.003) (Table 3 ). Table 3 Univariate & Multivariate analysis for Factors related to ANA positivity in HCV patients Variable Univariate analysis Multivariate analysis † OR (95% Cl) p -value OR (95% Cl) p -value Age, < 40years (vs. ≥40 years) 0.74 (0.23–2.44) 0.63 0.94 (0.28–3.16) 0.93 Sex, Female (vs. Male) 1.36 (0.75–2.46) 0.31 1.17 (0.63–2.17) 0.62 Liver disease, HCC or cirrhosis (vs. hepatitis) 1.03 (0.51–2.07) 0.94 - - Child-Pugh class, B (vs. A) 1.03 (0.51–2.07) 0.94 - - Log HCV-RNA, median, ≥ 6 (vs. <6) 0.70 (0.38–1.26) 0.23 0.78 (0.42–1.44) 0.42 HCV genotype 2 (vs. genotype 1) 0.68 (0.37–1.25) 0.22 - - Globulin, ≥ 3.5 g/dL (vs. < 3.5g/dL) 2.80 (1.50–5.20) 0.001 2.64 (1.40–4.98) 0.003 FIB-4 ≥ 3.25 (vs. <3.25) 1.02 (0.55–1.89) 0.96 - - TE ≥ 11.5 (vs. < 11.5) 1.75 (0.73–4.17) 0.21 - - † Controlled for: age, sex, log HCV-RNA and globulin, OR, odds ratio; CI, confidence interval; HCC, hepatocellular carcinoma; FIB-4, fibrosis-4 index; TE, transient elastography Change in autoantibody positivity after DAA therapy with SVR The positivity rates for the four autoantibodies before and after DAA therapy are summarized in Table 4 . The PreTx ANA positivity (32.3%) decreased significantly at SVR (23.9%, p = 0.009), which was similar to that in healthy controls (21.3%). Among the four patients with ASM positivity at PreTx, one patient achieved ASM negativity at SVR. One anti-LKM-1-negative patient underwent conversion to anti-LKM-1 positivity at SVR. Any autoantibody prevalence at PreTx (32.8%) decreased significantly at SVR (25.4%) (p = 0.028). As shown in Fig. 1 , 57% (37/65) of patients with HCV who were ANA-positive at PreTx maintained ANA positivity at SVR12. Compared to the ANA-negative conversion group, the group that sustained ANA positivity was older (median 67 vs. 59 years, p = 0.013) and had a higher proportion of liver cirrhosis or HCC (27% vs. 17.9%, p = 0.082) (Supplementary Table 3). Meanwhile, 8% (11/136) of ANA-negative patients with HCV at PreTx underwent conversion to ANA positivity at SVR12, while 92% remained in the ANA-negative state (Fig. 1 ). The ANA-positive-conversion group was older (median age: 70 vs. 58 years, p = 0.012), with a higher proportion of patients with liver cirrhosis or HCC (45.5% vs. 21.6%, p = 0.052) and higher globulin levels (3.45 vs 3.19, p = 0.077) than the sustained-ANA-negativity group (Supplementary Table 4). The PreTx ANA titers were significantly lower after SVR, as shown in Supplementary Fig. 1 (p = 0.006). Table 4 Changes of autoantibody positivity in HCV patients receiving DAA therapy Autoantibody Pre-DAA (n = 201) Post-DAA (n = 201) p -value ANA, n (%) 65 (32.3%) 48 (23.9%) 0.009 ASM, n (%) 4 (2.0%) 3 (1.5%) 1.000 LKM-1, n (%) 0 (0%) 1 (0.5%) 1.000 AMA, n (%) 0 (0%) 0 (0%) - Any autoantibody positive, n (%) 66 (32.8%) 51 (25.4%) 0.028 ANA, antinuclear antibody; ASM, anti-smooth muscle antibody; LKM, anti-liver kidney microsomal antibody, AMA, anti-mitochondrial antibody. ANA pattern in patients with HCV at PreTx and SVR The ANA patterns at PreTx and SVR in ANA-positive patients with HCV are indicated in Fig. 2 . The ANA patterns tended to change before and after treatment (p = 0.092). The proportions of the homogenous and speckled patterns were similar (43% vs. 42%) among the ANA-positive patients at PreTx. However, the proportion of the homogenous pattern increased (54%), while that of the speckled pattern decreased (34%) at SVR. In addition, the proportion of cytoplasmic ANA positivity decreased significantly from 18.4% at PreTx to 11.9% at SVR (p = 0.006) (Supplementary Fig. 2). Among the patients with ANA-positive CHC at PreTx, those who maintained ANA positivity at SVR showed a higher frequency of homogenous and cytoplasmic patterns than those who lost ANA positivity at SVR12 (Supplementary Table 5). Discussion In this study, 32% of patients with CHC showed ANA positivity at PreTx, which was significantly higher than that in the healthy-control group (21.3%), and decreased to a rate similar to that in healthy controls at SVR. Female sex was related to ANA positivity in healthy controls, while elevated globulin levels were associated with ANA positivity in patients with CHC, irrespective of age or sex. Thirty-seven (57%) of 65 patients with HCV with ANA-positivity at PreTx maintained this status at SVR, whereas 11 (8%) of the 136 ANA-negative patients at PreTx exhibited positive conversion at SVR. Patients with ANA positivity at SVR were characterized by older age and a higher prevalence of cirrhosis or inactive HCC compared to the ANA-negative patients; at PreTx, the homogenous and speckled ANA patterns showed a similar level of predominance, whereas the proportion of the homogenous pattern increased and that of the speckled pattern decreased at SVR. In addition, the proportion of cytoplasmic ANA positivity at PreTx significantly decreased at SVR. HCV induces damage to the liver, and also causes a range of extrahepatic diseases, of which mixed cryoglobulinemia and non-Hodgkin’s lymphoma are the most recognized diseases involving B-lymphocyte dysregulation. Cluster of Differentiation 81 (CD81), also known as tetraspanin, was the first receptor identified for HCV entry. CD81 is expressed on both liver cells and B lymphocytes. HCV infection may stimulate B cells directly through the binding of HCV E2 envelope glycoprotein to cell surface CD81, leading to the polyclonal expansion of B cells, recruiting immune complexes, and culminating in a wide spectrum of autoimmune and lymphoproliferative disorders. In addition, the molecular mimicry of viral antigens may be a mechanism underlying the development of autoimmune phenomena. 12 ANA, a key biomarker of autoimmune liver disease and systemic rheumatic disease, is a diverse group of autoantibodies that recognize macromolecular components in the cell nucleus (DNA, RNA, proteins, and their complexes). Although ANA-targeting antigens are usually present in the nucleus, they can translocate to the cytoplasm or extracellular space, particularly during cell death (mostly apoptosis). In the extracellular space, nuclear antigens form immune complexes with ANAs that can stimulate an immune response. The immunofluorescence assay is regarded as the gold standard for ANA testing; however, the results vary widely according to the threshold for positivity (initial serum/plasma dilution of 1:40 or 1:80), cell types or reagents used for testing, observer’s interpretation, and factors related to the study sample, including the genetic background of the participants. Therefore, the interpretation of ANA test results requires appropriate controls. 13 However, 4–30% of healthy populations exhibit ANA positivity, depending on the study. 14 – 18 ANA prevalence in the U.S. population aged above 12 years during 1999–2004 was 13.8% at a cutoff of 1:80 using HEp-2 ANA slides, and the prevalence was higher in women than in men. ANA positivity increased with age but not in a linear pattern, such that that peak age in women was 40–49 years, with a declining trend in older age groups. 19 In our study, ANA positivity in healthy adult controls aged above 20 years was 21.3% and higher in women, in line with the results of the U.S. study. Although our sample size was small, to the best of our knowledge, this is the first study to report on ANA positivity in a healthy Korean population. ANA-positivity rates in patients with CHC reportedly range from 20 to 50%, depending on the study. A Swiss HCV cohort study with 235 patients with CHC (median age: 56 years, men: 62%, cirrhosis: 27%) reported that ANA positivity at PreTx (cutoff, 1:80) was 41%, although it lacked data on healthy controls. 20 An Australian study that included 127 diverse patients with CHC (mean age: 41 years, men: 61%, study period: 2005–2012) and 198 retrospectively recruited control samples (mean age: 50 years, men: 52%, study period: 1994) reported that the ANA/extractable nuclear antigen antibody positivity rates were higher in patients with CHC (50%) than in the controls (14%) using Hep2000 cells and a cutoff of > 7 IU. 18 A Taiwanese study that retrospectively enrolled 258 patients with CHC from 2020–2021(mean age: 64 years, men: 44%, cirrhosis: 17%) reported that ANA positivity at PreTx was 28.7% (Hep-20-10 cells, cutoff 1:320), 21 showing that female sex (p = 0.023), older age (p = 0.001), lower HCV RNA titer (p = 0.06), and more advanced fibrosis (p = 0.098) were associated with ANA positivity. An American retrospective study that included 1,556 patients with CHC who underwent autoantibody testing during 1997–2016 reported that 388 patients (21.8%) showed ANA positivity, and that the proportion of women was higher and the rate of SVR was lower among the autoantibody-positive patients, although ANA positivity had no impact on the clinical outcomes. 17 Studies that predominantly included Caucasian patients tended to have a higher prevalence of ANA positivity than the current (32.3%) or previous Taiwan study (28.7%), which may be related to genetic differences. Moreover, higher serum globulin was an independent factor related to ANA positivity in patients with CHC in this study, which has not been commonly reported in other studies. These findings suggest that chronic HCV infection may stimulate B cells, resulting in B-cell proliferation and increased globulin production. Interestingly, our results showed that patients with ANA-positive CHC had lower levels of HCV RNA in the blood, concurrent with the above-mentioned Taiwanese study, although the difference did not attain statistical significance. This may be related to the antiviral role of B lymphocytes, although a widespread and robust T-cell response is a well-known determinant of HCV clearance. 22 In this study, PreTx ANA positivity decreased after SVR to a level similar to that in the healthy controls. A Swiss cohort study reported that ANA positivity at PreTx (41%) decreased to 35.3% at SVR. 20 A retrospective Italian study that included 46 patients with CHC reported that PreTx ANA positivity (85%) decreased to 29% at SVR. 16 Although only a few studies have reported on the change in ANA positivity after DAA therapy, their findings support our result of decreased ANA positivity after SVR. Meanwhile, the current and previous studies consistently reported that more than half of patients with ANA-positive CHC at PreTx remained in an ANA-positive state after SVR and about one in ten ANA-negative patients at PreTx showed conversion to an ANA-positive state after SVR. 20 Interestingly, our results showed that patients with ANA-positive CHC at SVR were older and had more advanced liver disease than the ANA-negative patients. Recent experimental studies have reported that despite virus eradication with DAA therapy, monoclonal B-cell expansion and intraclonal diversification persist in patients with HCV with lymphoproliferative disorders, 23 and HCV-specific memory B cells live for long after HCV clearance. 24 Moreover, B cells in patients who are cured of HCV exhibit persistent perturbations, showing that highly self-reactive immune signatures may contribute to a suboptimal vaccine response with the hepatitis B vaccine. 25 Therefore, our results suggest that possibility of incomplete recovery of the B-cell response with possible self-reactive features even after viral eradication, especially in older patients with advanced liver disease. Although the ANA patterns changed after SVR, as shown in this study, their significance remains unclear. The current study has some limitations. First, the sample size of our study was not large, although this is the largest prospective study of Asian CHC. Although a healthy-control group was appropriately included, age could not be matched because of the unavailability of plasma samples. Second, our study was conducted at a tertiary-care center, which could have potentially resulted in referral bias. However, to date, DAA therapy has mostly been performed at tertiary centers because of the high cost and strict reimbursement policy for DAA therapy in Korea. Third, the long-term outcomes after SVR according to ANA positivity were not observed. In conclusion, ANA positivity was observed in one-third of patients with CHC at PreTx, which was significantly higher than that in healthy controls and decreased after SVR. CHC patients with ANA positivity after SVR were older and had more advanced liver disease compared to those with ANA negativity. This suggests that B-cell dysfunction in patients with HCV may persist after SVR with DAA. Thus, investigation of the long-term outcomes, including the occurrence of HCC and the development of other autoimmune diseases according to ANA positivity, is warranted. Abbreviations HCV, hepatitis C virus; anti-nuclear antibody; ASM, anti-smooth muscle antibody; anti-LKM-1, anti-liver kidney microsomal antibody type 1; AMA, anti-mitochondrial antibody; CHC, chronic hepatitis C; DAA, direct-acting antivirals; HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; SVR, sustained virological response; PreTx, pretreatment; AST, aspartate transaminase; ALT, alanine transaminase; CD81, Cluster of Differentiation 81 Declarations Data availability statement: The datasets used or analysed during the current study available from the corresponding author on reasonable request. Conflict of interest disclosure: The authors have no conflicts to declare. Ethical approval statement: This study was conducted in accordance with the Helsinki Declaration of 1975 (revised in 2000). The study protocol was approved by the Institutional Review Board of each hospital. Patient consent statement: Written informed consent was obtained from each patient before enrollment in the cohort study Funding: This study was supported by a grant from the Chronic Infectious Disease Cohort Study (Korea HCV Cohort Study, 2023-E1901-00) conferred by the Korea Disease Control and Prevention Agency. AUTHORSHIP Guarantor of the article: Sook-Hyang Jeong Author Contributions: SH Choi and GH Choi were responsible for data acquisition, analysis and interpretation, statistical analysis, and manuscript drafting., SH Jeong was responsible for the study concept and design, data acquisition and interpretation, and manuscript writing and finalization. ES Jang, YS Kim, YJ Lee, IH Kim, SB Cho, BS Lee, KA Kim, and WJ Chung assisted with data acquisition and analysis. MR Ki and DH Baik assisted with the data analysis and interpretation. All authors have approved the original draft. Acknowledgement We deeply appreciate the clinical research coordinators (Dong-Eun Lee, Na-Hae Kim, Da-Woon Jeong, Se-Min Na, Hyo-Yong Kang, Ah-Ra Jo, Seung-Hee Han, Eun-Suk Chung, Ha-Yuu Jeong, and Hye-Min Lee) for their dedication to this study and the officials of the Korea Disease Control and Prevention Agency (Myung-Sun Lee, Jae-Hyun Seong, Jung-kyu Lee, Mee-kyung Kee, Hyang-Min Chung, Byeong-Sun Choi, Ki Soon Kim, Chun Kang, Sung Soon Kim, and Young-Mee Jee) for their strong support for this study. We thank Yun-Tae Kim and Hee Jun Kim of the Seoul Central Laboratory for the autoantibody analysis. References World Health Organization. Key facts. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c . (2023) El-Kamary, SamerS, Jhaveri R, Shardell MD. All-cause, liver-related, and non–liver-related mortality among HCV-infected individuals in the general US population. Clin Infect Dis. 53, 150–157 (2011) Marrone A, Ciotti M, Rinaldi L, Adinolfi LE, Ghany M. Hepatitis B and C Virus infection and risk of haematological malignancies. J Viral Hepat. 27, 4–12 (2020) Cacoub P, Saadoun D. Extrahepatic manifestations of chronic HCV infection. N Engl J Med. 384, 1038–1052 (2021) Narciso-Schiavon JL, Schiavon LL. Autoantibodies in chronic hepatitis C: a clinical perspective. World J Hepatol. 7, 1074–1085 (2015) Lenzi, M. et al. Prevalence of non-organ-specific autoantibodies and chronic liver disease in the general population: a nested case-control study of the Dionysos cohort. Gut. 45, 435–441 (1999) Prüßmann, J. et al. Co-occurrence of autoantibodies in healthy blood donors. Exp Dermatol. 23, 519–521 (2014) Banerjee D, Reddy KR. Review article: safety and tolerability of direct-acting anti‐viral agents in the new era of hepatitis C therapy. Aliment Pharmacol Ther. 43, 674–696 (2016) European Association for the Study of the Liver. Electronic address: [email protected] . EASL recommendations on treatment of hepatitis C 2016. J Hepatol. 66, 153–194 (2017) Choi, G. H. et al. Hepatocellular carcinoma, decompensation, and mortality based on hepatitis C treatment: A prospective cohort study. World J Gastroenterol 28, 4182–4200 (2022) Nam, J. Y. et al. Epidemiological and clinical characteristics of hepatitis C virus infection in South Korea from 2007 to 2017: A prospective multicenter cohort study. Gut Liver 14, 207–217 (2020) Priora, M. et al. Autoantibodies and rheumatologic manifestations in hepatitis C virus infection. Biology (Basel). 10, 1071 (2021) Pisetsky DS. Antinuclear antibody testing - misunderstood or misbegotten? Nat Rev Rheumatol 13, 495–502 (2017) Acay A, Demir K, Asik G, Tunay H, Acarturk G. Assessment of the frequency of autoantibodies in chronic viral hepatitis. Pak J Med Sci 31, 150–154 (2015) Emara M, Mohsen E, Shawky RM. Assessment of the prevalence of non-Oirgan-specific autoantibodies in Egyptian patients with HCV. A Journal of Molecular and Cellular Immunology . Immunol Invest. 49, 676–686 (2020) Shahini, E. et al. Clinical relevance of serum non-organ-specific antibodies in patients with HCV infection receiving direct-acting antiviral therapy. Aliment Pharmacol Ther. 48, 1138–1145 (2018) Gilman, A. J. et al. Autoantibodies in chronic hepatitis C virus infection: impact on clinical outcomes and extrahepatic manifestations. BMJ Open Gastroenterol. 5, e000203 (2018) Deshpande, P. et al. Frequent occurrence of low-level positive autoantibodies in chronic hepatitis C. Pathology. 52, 576–583 (2020) Satoh, M. et al. Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum. 64, 2319–2327 (2012) Beretta-Piccoli, B. T. et al. Autoimmune liver serology before and after successful treatment of chronic hepatitis C by direct acting antiviral agents. J Autoimmun. 102, 89–95 (2019) Hsiao S-W. et al. A retrospective study of prevalence and pattern of international consensus on ANA patterns among patients with hepatitis C virus infection. PeerJ. 10, e14200 (2022) Khairy, M. et al. Serum autoantibodies positivity prevalence in patients with chronic HCV and impact on pegylated interferon and ribavirin treatment response. Liver Int. 33, 1504–1509 (2013) Mazzaro, C. et al. Persistence of monoclonal B-cell expansion and intraclonal diversification despite virus eradication in patients affected by hepatitis C virus‐associated lymphoproliferative disorders. Br J Haematol 203, 237–243 (2023) Nishio, A. et al. Serum neutralization activity declines but memory B cells persist after cure of chronic hepatitis C. Nat Commun. 13, 5446 (2022) Zhou, M. J. et al. Cured HCV patients with suboptimal hepatitis B vaccine response exhibit high self-reactive immune signatures. Hepatol Commun. 7, e00197 (2023) Additional Declarations No competing interests reported. Supplementary Files FigureS1.tif FigureS2.tif SupplementaryinformationTablesandFigureLegends.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4427436","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":311317909,"identity":"2d178b55-c25d-4455-8d5e-812c48a00617","order_by":0,"name":"Su Hyun Choi","email":"","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Su","middleName":"Hyun","lastName":"Choi","suffix":""},{"id":311317912,"identity":"185cf0d6-af55-455d-8957-da8485fcf73f","order_by":1,"name":"Gwang Hyeon Choi","email":"","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Gwang","middleName":"Hyeon","lastName":"Choi","suffix":""},{"id":311317913,"identity":"c2bb263a-31b1-44da-a929-745bd333a0c7","order_by":2,"name":"Eun Sun Jang","email":"","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Eun","middleName":"Sun","lastName":"Jang","suffix":""},{"id":311317915,"identity":"54f129ef-606a-4ef1-b2dd-a757a38eb1e0","order_by":3,"name":"Youn Jae Lee","email":"","orcid":"","institution":"Inje University Busan Paik Hospital","correspondingAuthor":false,"prefix":"","firstName":"Youn","middleName":"Jae","lastName":"Lee","suffix":""},{"id":311317921,"identity":"17cb8e3a-5440-4c6d-b9f0-9d70b1fbcdda","order_by":4,"name":"Young Seok Kim","email":"","orcid":"","institution":"Soonchunhyang University Bucheon Hospital","correspondingAuthor":false,"prefix":"","firstName":"Young","middleName":"Seok","lastName":"Kim","suffix":""},{"id":311317923,"identity":"594d302d-fac6-421e-b906-5b516d5d7417","order_by":5,"name":"In Hee Kim","email":"","orcid":"","institution":"Jeonbuk National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"In","middleName":"Hee","lastName":"Kim","suffix":""},{"id":311317926,"identity":"8ec91ee6-dee9-43cd-a7c8-436b6af12332","order_by":6,"name":"Sung Bum Cho","email":"","orcid":"","institution":"Chonnam National University Hwasun Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sung","middleName":"Bum","lastName":"Cho","suffix":""},{"id":311317928,"identity":"032887ae-1e5f-48b9-99ca-35966df34b02","order_by":7,"name":"Byung Seok Lee","email":"","orcid":"","institution":"Chungnam National University 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Policy","correspondingAuthor":false,"prefix":"","firstName":"Dahye","middleName":"","lastName":"Baik","suffix":""},{"id":311317932,"identity":"50df20c5-7c99-4ab5-bb68-1802e270e566","order_by":11,"name":"Moran Ki","email":"","orcid":"","institution":"National Cancer Center Graduate School of Cancer Science and Policy","correspondingAuthor":false,"prefix":"","firstName":"Moran","middleName":"","lastName":"Ki","suffix":""},{"id":311317933,"identity":"b27bc5d8-2ed2-4226-b6be-05a03dac50bd","order_by":12,"name":"Sook-Hyang Jeong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAApklEQVRIiWNgGAWjYBACxgYexgdAOsGAFC3MBqRpYWDgYZMgTQtz/9ljlT93HM4zZ2A+9vELUQ6bkZd2m/fM4WLLBrbk2TLEaeExu83YdjhxwwEeY2YJorT0nzEr/EmaloYcMwZeqBbGD8Q5LMdYmrctvdjgMFsyMzE6GAz7zxh+/NlmnWdwvPkw4w+itDTAWEArmHmI0SKP4kqibBkFo2AUjIIRBwD92DG5D9Y6rwAAAABJRU5ErkJggg==","orcid":"","institution":"Seoul National University Bundang Hospital, Seoul National University College of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sook-Hyang","middleName":"","lastName":"Jeong","suffix":""}],"badges":[],"createdAt":"2024-05-15 22:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4427436/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4427436/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":58315712,"identity":"87e518bf-147b-4438-8fbe-5f2c378c03ef","added_by":"auto","created_at":"2024-06-13 20:58:54","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":238489,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in ANA positivity before and after DAA treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe alluvial plot shows changes in ANA positivity after DAA therapy with SVR. Although ANA positivity at PreTx (32.3%) decreased significantly at SVR (23.9%), 57% (37/65) of patients with ANA-positive HCV at PreTx maintained ANA positivity at SVR12, whereas 43% underwent conversion to ANA-negativity at SVR12. Meanwhile, 8% (11/136) of patients with ANA-negative HCV at PreTx converted to ANA-positivity at SVR12, whereas 92% remained in the ANA-negative state.\u003c/p\u003e\n\u003cp\u003eDAA, direct-acting antivirals, PreRx: pretreatment, SVR: sustained virological response, ANA: anti-nuclear antibody\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/12b9ea1c0ba827c8a4814291.jpg"},{"id":58315711,"identity":"b03fec17-baef-441e-9343-89faca8ec60b","added_by":"auto","created_at":"2024-06-13 20:58:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":377032,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChanges in the ANA pattern in patients with HCV before and after DAA treatment\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis alluvial plot shows the changes in the ANA pattern in patients with HCV before and after DAA therapy. The ANA patterns before treatment tended to change after treatment (p=0.088). Among patients with HCV at PreTx, the prevalence of homogenous and speckled patterns was comparable at 12.4% and 12.9%, respectively. After treatment, 69% retained the homogenous pattern, 4% transitioned to the speckled pattern, and 27% were converted to the ANA-negative state. After treatment, 36% maintained the speckled pattern, 52% shifted to the ANA-negative state, and 12% converted to a homogenous pattern. Notably, among patients initially negative for ANA at PreTx who transitioned to an ANA-positive status, the homogenous pattern was most frequently observed.\u003c/p\u003e\n\u003cp\u003eDAA, direct-acting antiviral, PreRx: pretreatment, HCV: hepatitis C virus, ANA: anti-nuclear antibody\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/e0b98604b2ad6fc2233498dc.jpg"},{"id":58317327,"identity":"839e74d1-5073-4f4b-8562-6b513ee9463b","added_by":"auto","created_at":"2024-06-13 21:22:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1708336,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/00caf3c1-0875-49f9-a572-13528ec543b6.pdf"},{"id":58315709,"identity":"66eed91c-6cf3-4bd4-95a2-73fa1607bdb6","added_by":"auto","created_at":"2024-06-13 20:58:54","extension":"tif","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":549196,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1.tif","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/e42a1ff8e891df4d1d1e480b.tif"},{"id":58316077,"identity":"ee66fe4d-2d3c-4a50-9217-d99ece753df9","added_by":"auto","created_at":"2024-06-13 21:06:54","extension":"tif","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":552680,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS2.tif","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/64b9a43ccd25516b6e9e2549.tif"},{"id":58316078,"identity":"61ebc8c6-7ab3-4117-ae41-772e3d34f2ca","added_by":"auto","created_at":"2024-06-13 21:06:54","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":49094,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryinformationTablesandFigureLegends.docx","url":"https://assets-eu.researchsquare.com/files/rs-4427436/v1/86fd346f6a820fc6029f093c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Autoantibody Positivity in Chronic Hepatitis C Pre- and Post-Direct- Acting Antiviral Therapy: A Prospective Multicenter South Korean Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHepatitis C virus (HCV) infection is a significant global health problem, with approximately 58\u0026nbsp;million individuals infected worldwide, and an estimated annual incidence of 1.5\u0026nbsp;million.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e In addition to liver disease, HCV infection causes extrahepatic manifestations, including mixed cryoglobulinemia, non-Hodgkin lymphoma, and autoantibody production.\u003csup\u003e\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e The frequency of circulating autoantibodies, especially rheumatoid factor or anti-nuclear antibody (ANA), is reportedly high among patients with chronic hepatitis C (CHC), suggesting a relationship between HCV and autoimmune processes.\u003c/p\u003e \u003cp\u003eHowever, the prevalence of circulating autoantibodies in patients with CHC is highly variable since ANA, anti-smooth muscle antibody (ASM), and anti-liver kidney microsomal antibody type 1 (LKM-1) positivity are observed in 4\u0026ndash;54%, 4\u0026ndash;78%, and 0\u0026ndash;13% of cases, respectively; moreover, only a few studies have compared their prevalence in patients with CHC with that in healthy controls (6\u0026ndash;10%).\u003csup\u003e5\u0026ndash;7\u003c/sup\u003e The mechanisms of autoantibody production and its clinical significance in CHC are unknown. Moreover, the alterations in the levels of these autoantibodies after direct-acting antiviral (DAA) therapy and viral eradication are not clear.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThis study primarily aimed to compare the positivity rates of four conventional autoantibodies [ANA, ASM, anti-LKM1, and anti-mitochondrial antibody (AMA)] in patients with CHC at pretreatment (PreTx) with those in healthy controls. The secondary aim was to investigate the change in their positivity rates before and after DAA therapy, and explore the clinical factors related to ANA positivity in patients with CHC and healthy controls.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and method of plasma sampling\u003c/h2\u003e \u003cp\u003eA total of 201 patients with chronic HCV (\u0026gt;\u0026thinsp;18 years old) who underwent DAA therapy were prospectively enrolled from 8 university hospitals between 2020 and 2022, as part of the Korea HCV Cohort study.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e Patients who met any of the following criteria were excluded: concurrent human immunodeficiency virus (HIV) or hepatitis B virus (HBV) coinfection (n\u0026thinsp;=\u0026thinsp;9), absence of blood samples before and after DAA therapy (n\u0026thinsp;=\u0026thinsp;0) and presence of active hepatocellular carcinoma (HCC) before DAA therapy (n\u0026thinsp;=\u0026thinsp;0). A sustained virological response (SVR) was achieved after DAA therapy in all patients. Written informed consent was obtained from each patient before enrollment in the cohort study. This study was approved by the Institutional Review Board (IRB No. B-0706-046-002) and conducted in accordance with the Declaration of Helsinki. The participants\u0026rsquo; plasma samples were prospectively collected and stored at -70\u0026deg;C till the analysis. The sampling time was at PreTx and at the time of SVR evaluation (SVR), with a window period of 4 weeks. The control group comprised plasma samples from 127 healthy persons who were randomly selected from a biobank at Seoul National University Bundang Hospital under IRB approval (IRB No. X-2302-810-902) after age and sex adjustment to the general population of South Korea in 2021. Since the control samples from individuals aged\u0026thinsp;\u0026gt;\u0026thinsp;70 years were limited, we could not match their age to that of the patients with HCV. All healthy controls tested negative for HCV, HBV, and HIV infection, without any active cancer, autoimmune, or major organ diseases and had normal laboratory results on health examination.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eMeasurement of autoantibodies\u003c/h2\u003e \u003cp\u003eANA, ASM, anti-LKM1, and AMA were detected using indirect immunofluorescence with cutoff levels of 1:80, 1:10, 1:10, and 1:10, respectively, according to the manufacturer\u0026rsquo;s protocols, at the Seoul Central Laboratory in South Korea. ANA [detected with the Hep-20-10 EUROPattern (EUROIMMUN, L\u0026uuml;beck, Germany)], ASM [detected with the Hep-2/Mouse Kidney/Stomach COMVI II (Immco Diagnostics, Inc. New York, USA)], AMA [detected with the Hep-2/Mouse KidneyCOMVI I (Immco Diagnostics, Inc. New York, USA)], and anti-LKM1 [detected using the Mouse Liver/Kidney/Stomach Kit (Immco Diagnostics, Inc. New York, USA)] were assayed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eCollection of clinical data\u003c/h2\u003e \u003cp\u003eClinical data, including the patients\u0026rsquo; age, sex, body mass index, alcohol and smoking status, severity of liver disease categorized into chronic hepatitis, liver cirrhosis, and HCC; DAA regimens; comorbidities including autoimmune diseases (thyroid disease, diabetes, rheumatoid arthritis, systemic lupus erythematosus, mixed cryoglobulinemia, lymphoma, kidney disease, etc.); and laboratory results were collected from the medical records before and after DAA treatment at the time of SVR evaluation. The laboratory data included the status of 4 autoantibodies (ANA, ASM, anti-LKM1, and AMA), HCV RNA concentration, HCV genotype, white blood cell count, hemoglobin, platelet count, aspartate transaminase (AST), alanine transaminase (ALT), bilirubin, protein, albumin, calculated globulin derived from difference between the protein and albumin levels, alpha-fetoprotein, prothrombin time (International normalized ratio), creatinine, fasting blood glucose, cholesterol at PreTx and at SVR12 after DAA therapy. Using the collected data, indirect fibrosis markers, including the fibrosis-4 index, aminotransferase-to-platelet ratio index, Child-Pugh score, and Model for End-Stage Liver Disease score, were calculated at PreTx and at the time of SVR12. The results of all abdominal radiology and vibration-controlled transient elastography (Fibroscan\u0026reg;; Echosens, Paris, France), if available, were collected.\u003c/p\u003e \u003cp\u003eThese data were entered into an established electronic case report form on the authorized website of the Korean Centers for Disease Control Korea HCV cohort study (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://is.cdc.go.kr/\u003c/span\u003e\u003cspan address=\"http://is.cdc.go.kr/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) by the research coordinators. All input data were quality-controlled by independent statistical researchers (D.H. Baik and M.R. Ki) at least four times per year.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were analyzed using Student\u0026rsquo;s t-test for normally distributed data and the Mann-Whitney test for non-normally distributed data. Categorical variables were analyzed using the chi-square test or Fisher's exact test. The McNemar test was conducted for paired data to compare the prevalence of autoantibody positivity before and after DAA treatment. To identify factors related to autoantibody positivity, multivariate logistic analysis was conducted, with adjustment for age, sex, and other clinically relevant and/or statistically significant factors identified by the univariate analysis. Statistical significance was established at p ˂0.05. Data analyses were conducted using SPSS version 22(IBM Corp., Armonk, NY, USA).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eClinical characteristics of the study population\u003c/h2\u003e \u003cp\u003eThe clinical characteristics of the 201 patients with HCV at PreTx and SVR (median age, 62 years; women, 49.8%) and 127 healthy controls (median age, 55 years; women, 49.6%) are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe proportions of liver cirrhosis and inactive HCC among the patients with HCV infection were 7.5% and 8.0%, respectively. HCV genotype 1 (46.3%) and genotype 2 (52.2%) were present in nearly all patients with CHC (98.5%). Common comorbidities, such as hypertension and diabetes, were present in 48.8% and 26.9% of patients, respectively. The following autoimmune comorbidities were found at PreTx: thyroid disease (4%), rheumatoid arthritis (1.5%), systemic lupus erythematosus (0%), mixed cryoglobulinemia (0%), lymphoma (0.5%), kidney diseases (6.5%), and others (1.5%). The most frequently prescribed DAA regimen was glecaprevir/pibrentasvir in 86.1% of cases, because sofosbuvir/velpatasvir and sofosbuvir/velpatasvir/voxilaprevir were not approved in South Korea during the study period. Vibration-controlled transient elastography was performed in 102 patients (50.7%) at PreTx, which yielded a median liver stiffness value of 7.50 kPa. After SVR, most laboratory results related to liver function improved, including a significant reduction in plasma globulin levels and an increase in the total cholesterol levels (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe median age (55 years) was lower in the healthy control group than that in the HCV group because of the non-availability of samples from normal older individuals, since the controls were age-and sex-matched to the general population of South Korea in 2021. The laboratory results of the control group were within the normal range, without a history of cancer, major cardiovascular or pulmonary, autoimmune, or liver disease (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical Characteristics of HCV patients at Pre- and Post-DAA Treatment and Healthy controls.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCV at PreTx (n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eHCV at Post-DAA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003csup\u003e\u0026Dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years, median (IQR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (52\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55 (42\u0026ndash;64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e20\u0026thinsp;~\u0026thinsp;29\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e30\u0026thinsp;~\u0026thinsp;39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (11.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e40\u0026thinsp;~\u0026thinsp;49\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (13.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e50\u0026thinsp;~\u0026thinsp;59\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (27.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30 (23.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e60\u0026thinsp;~\u0026thinsp;69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (27.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e70~\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (27.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (18.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFemales, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e100 (49.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (49.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u0026sup2;)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;4.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of alcohol use, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (23.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHistory of tabacco use, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (52.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiver disease status, n (%) \u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e (hepatitis/cirrhosis/inactive HCC)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e170 (84.6%) / 15 (7.5%) / 16 (8.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild-Pugh class, n (%) (A/B/C)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (95.5%) / 9 (4.5%) / 0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLog HCV-RNA, median (IQR), IU/mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.02 (5.29\u0026ndash;6.54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCV genotype, n (%) (1/2/others)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (46.3%) / 105 (52.2%) / 3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDAA regimen, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGleprevir/Pibrentasivir\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173 (86.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eElbasvir/Grazoprevir\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLedipasvir/Sofosbuvir\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (6.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLedipasvir/Sofosbuvir\u0026thinsp;+\u0026thinsp;ribavirin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSofosbuvir\u0026thinsp;+\u0026thinsp;ribavirin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (0..5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eType 2 diabetes, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (26.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypertension, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (48.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (22.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eThyroid disease\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLab. Findings\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHemoglobin (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.79\u0026thinsp;\u0026plusmn;\u0026thinsp;1.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13.78\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWBC (x10\u0026sup3;/uL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5847\u0026thinsp;\u0026plusmn;\u0026thinsp;1798\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5442.13\u0026thinsp;\u0026plusmn;\u0026thinsp;1492.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.035\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6338.51\u0026thinsp;\u0026plusmn;\u0026thinsp;2119.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlatelet (x10\u0026sup3;/uL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e188.00\u0026thinsp;\u0026plusmn;\u0026thinsp;62.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e258.40\u0026thinsp;\u0026plusmn;\u0026thinsp;49.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e198.02\u0026thinsp;\u0026plusmn;\u0026thinsp;63.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAST (IU/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61.36\u0026thinsp;\u0026plusmn;\u0026thinsp;45.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.78\u0026thinsp;\u0026plusmn;\u0026thinsp;15.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26.08\u0026thinsp;\u0026plusmn;\u0026thinsp;16.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eALT (IU/L)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.35\u0026thinsp;\u0026plusmn;\u0026thinsp;62.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e30.04\u0026thinsp;\u0026plusmn;\u0026thinsp;22.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.01\u0026thinsp;\u0026plusmn;\u0026thinsp;11.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBilirubin (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.86\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.203\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.699\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProtein (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.23\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlbumin (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.50\u0026thinsp;\u0026plusmn;\u0026thinsp;0.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlobulin (g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eProthrombin time (INR)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.03\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.04\u0026thinsp;\u0026plusmn;\u0026thinsp;0.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.506\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCreatinine (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.96\u0026thinsp;\u0026plusmn;\u0026thinsp;0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCholesterol (mg/dL)\u003c/b\u003e,\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169.04\u0026thinsp;\u0026plusmn;\u0026thinsp;38.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e188.43\u0026thinsp;\u0026plusmn;\u0026thinsp;35.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e175.72\u0026thinsp;\u0026plusmn;\u0026thinsp;41.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlucose (mg/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116.13\u0026thinsp;\u0026plusmn;\u0026thinsp;39.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.07\u0026thinsp;\u0026plusmn;\u0026thinsp;13.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e111.37\u0026thinsp;\u0026plusmn;\u0026thinsp;32.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.016\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAFP (ng/mL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.99\u0026thinsp;\u0026plusmn;\u0026thinsp;24.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.73\u0026thinsp;\u0026plusmn;\u0026thinsp;29.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFIB-4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.19\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAPRI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.88\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMELD score\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.28\u0026thinsp;\u0026plusmn;\u0026thinsp;4.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.34\u0026thinsp;\u0026plusmn;\u0026thinsp;3.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.118\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTE (kPa), median (IQR) (n\u0026thinsp;=\u0026thinsp;102)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.50 (5.00-12.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI, body mass index; HCC, hepatocellular carcinoma; HCV, hepatitis C virus; DAA, direct acting antiviral; WBC, white blood cell count; AST, aspartate aminotransferase ; ALT, alanine aminotransferase; INR, international normalized ratio; AFP. alpha fetoprotein; FIB-4, Fibrosis-4 index; APRI, AST to Platelet Ratio Index; TE, transient elastography; MELD, Model for End-Stage Liver Disease\u003c/p\u003e \u003cp\u003e \u003csup\u003e\u0026dagger;\u003c/sup\u003eThe p-value between HCV patients and healthy controls.\" \u003csup\u003e\u0026Dagger;\u003c/sup\u003eThe p-value between HCV at Pre-Tx and Post-DAA\u003c/p\u003e \u003cp\u003eContinous variables are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, and the categorical variable are indicated as n(%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003ePositivity rates of four autoantibodies in the HCV and control groups\u003c/h2\u003e \u003cp\u003eThe comparison of the positivity rates of the four autoantibodies between the CHC and healthy controls groups is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. In patients with CHC, the ANA, ASM, LKM-1, and AMA positivity rates were 32.3%, 2.0%, 0, and 0%, respectively; thus, the proportion of autoantibody-positive patients was 32.8%. In healthy controls, the ANA, ASM, LKM-1, and AMA positivity rates were 21.3%, 2.4%, 0, and 0.8%, respectively; thus, the proportion of autoantibody-positive patients was 22.8%. One healthy control with AMA positivity showed alkaline phosphatase levels within the normal range. Therefore, the ANA-positivity rate in patients with CHC was significantly higher than that in the healthy controls (p\u0026thinsp;=\u0026thinsp;0.030).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePositive rates of autoantibodies in HCV patients at Pre-treatment and Healthy controls\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoantibody\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHCV at PreTx (n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHealthy (n\u0026thinsp;=\u0026thinsp;127)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eANA, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (21.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASM, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (2.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLKM-1, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAMA, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.79%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny autoantibody positive, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (22.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eANA, anti-nuclear antibody; ASM, anti-smooth muscle antibody; LKM, anti-liver kidney microsomal antibody, AMA, anti-mitochondrial antibody\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFactors related to ANA-positivity in healthy controls and patients with HCV at PreTx\u003c/h2\u003e \u003cp\u003eAmong the healthy controls, the proportion of female patients was significantly higher in the ANA-positive subgroup than in the ANA-negative subgroup (66.7% vs. 45.0%, p\u0026thinsp;=\u0026thinsp;0.046). No other factors were significantly associated with ANA positivity (Supplementary Table\u0026nbsp;1).\u003c/p\u003e \u003cp\u003eIn patients with CHC, the ANA-positive subgroup showed a significantly higher serum globulin level (3.43 vs 3.21 g/dL, p\u0026thinsp;=\u0026thinsp;0.007) than that in the ANA-negative subgroup, while the median age (65 vs. 60 years, p\u0026thinsp;=\u0026thinsp;0.189) and the proportion of women (44.6% vs. 52.2%, p\u0026thinsp;=\u0026thinsp;0.314) did not differ between these two subgroups. The plasma HCV RNA levels were lower in the ANA-positive subgroup than in the ANA\u0026ndash;negative subgroup (log HCV RNA titer 5.70 vs 6.08 IU/mL, p\u0026thinsp;=\u0026thinsp;0.057) (Supplementary Table\u0026nbsp;2). Univariate and multivariate logistic analyses revealed that only high globulin level was an independent factor associated with ANA positivity among patients with HCV (odds ratio: 2.64, confidence interval: 1.40\u0026ndash;4.98, p\u0026thinsp;=\u0026thinsp;0.003) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eUnivariate \u0026amp; Multivariate analysis for Factors related to ANA positivity in HCV patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eUnivariate analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMultivariate analysis\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR (95% Cl)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOR (95% Cl)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, \u0026lt;\u0026thinsp;40years (vs. \u0026ge;40 years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.74 (0.23\u0026ndash;2.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.94 (0.28\u0026ndash;3.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex, Female (vs. Male)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.36 (0.75\u0026ndash;2.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.17 (0.63\u0026ndash;2.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.62\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLiver disease, HCC or cirrhosis (vs. hepatitis)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.51\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eChild-Pugh class, B (vs. A)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.03 (0.51\u0026ndash;2.07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLog HCV-RNA, median, \u0026ge;\u0026thinsp;6 (vs. \u0026lt;6)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.70 (0.38\u0026ndash;1.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.78 (0.42\u0026ndash;1.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHCV genotype 2 (vs. genotype 1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.68 (0.37\u0026ndash;1.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlobulin, \u0026ge;\u0026thinsp;3.5 g/dL (vs.\u003c/b\u003e \u0026lt;\u003cb\u003e3.5g/dL)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.80 (1.50\u0026ndash;5.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.64 (1.40\u0026ndash;4.98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFIB-4\u0026thinsp;\u0026ge;\u0026thinsp;3.25 (vs. \u0026lt;3.25)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.02 (0.55\u0026ndash;1.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTE\u0026thinsp;\u0026ge;\u0026thinsp;11.5 (vs.\u003c/b\u003e \u0026lt;\u003cb\u003e11.5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.75 (0.73\u0026ndash;4.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003eControlled for: age, sex, log HCV-RNA and globulin,\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOR, odds ratio; CI, confidence interval; HCC, hepatocellular carcinoma; FIB-4, fibrosis-4 index; TE, transient elastography\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eChange in autoantibody positivity after DAA therapy with SVR\u003c/h2\u003e \u003cp\u003eThe positivity rates for the four autoantibodies before and after DAA therapy are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. The PreTx ANA positivity (32.3%) decreased significantly at SVR (23.9%, p\u0026thinsp;=\u0026thinsp;0.009), which was similar to that in healthy controls (21.3%). Among the four patients with ASM positivity at PreTx, one patient achieved ASM negativity at SVR. One anti-LKM-1-negative patient underwent conversion to anti-LKM-1 positivity at SVR. Any autoantibody prevalence at PreTx (32.8%) decreased significantly at SVR (25.4%) (p\u0026thinsp;=\u0026thinsp;0.028).\u003c/p\u003e \u003cp\u003eAs shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, 57% (37/65) of patients with HCV who were ANA-positive at PreTx maintained ANA positivity at SVR12. Compared to the ANA-negative conversion group, the group that sustained ANA positivity was older (median 67 vs. 59 years, p\u0026thinsp;=\u0026thinsp;0.013) and had a higher proportion of liver cirrhosis or HCC (27% vs. 17.9%, p\u0026thinsp;=\u0026thinsp;0.082) (Supplementary Table\u0026nbsp;3). Meanwhile, 8% (11/136) of ANA-negative patients with HCV at PreTx underwent conversion to ANA positivity at SVR12, while 92% remained in the ANA-negative state (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The ANA-positive-conversion group was older (median age: 70 vs. 58 years, p\u0026thinsp;=\u0026thinsp;0.012), with a higher proportion of patients with liver cirrhosis or HCC (45.5% vs. 21.6%, p\u0026thinsp;=\u0026thinsp;0.052) and higher globulin levels (3.45 vs 3.19, p\u0026thinsp;=\u0026thinsp;0.077) than the sustained-ANA-negativity group (Supplementary Table\u0026nbsp;4).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe PreTx ANA titers were significantly lower after SVR, as shown in Supplementary Fig.\u0026nbsp;1 (p\u0026thinsp;=\u0026thinsp;0.006).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChanges of autoantibody positivity in HCV patients receiving DAA therapy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAutoantibody\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-DAA (n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePost-DAA (n\u0026thinsp;=\u0026thinsp;201)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eANA, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (32.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (23.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASM, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (2.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (1.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLKM-1, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (0.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAMA, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAny autoantibody positive, n (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (32.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (25.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eANA, antinuclear antibody; ASM, anti-smooth muscle antibody; LKM, anti-liver kidney microsomal antibody, AMA, anti-mitochondrial antibody.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eANA pattern in patients with HCV at PreTx and SVR\u003c/h2\u003e \u003cp\u003eThe ANA patterns at PreTx and SVR in ANA-positive patients with HCV are indicated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. The ANA patterns tended to change before and after treatment (p\u0026thinsp;=\u0026thinsp;0.092). The proportions of the homogenous and speckled patterns were similar (43% vs. 42%) among the ANA-positive patients at PreTx. However, the proportion of the homogenous pattern increased (54%), while that of the speckled pattern decreased (34%) at SVR. In addition, the proportion of cytoplasmic ANA positivity decreased significantly from 18.4% at PreTx to 11.9% at SVR (p\u0026thinsp;=\u0026thinsp;0.006) (Supplementary Fig.\u0026nbsp;2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmong the patients with ANA-positive CHC at PreTx, those who maintained ANA positivity at SVR showed a higher frequency of homogenous and cytoplasmic patterns than those who lost ANA positivity at SVR12 (Supplementary Table\u0026nbsp;5).\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, 32% of patients with CHC showed ANA positivity at PreTx, which was significantly higher than that in the healthy-control group (21.3%), and decreased to a rate similar to that in healthy controls at SVR. Female sex was related to ANA positivity in healthy controls, while elevated globulin levels were associated with ANA positivity in patients with CHC, irrespective of age or sex. Thirty-seven (57%) of 65 patients with HCV with ANA-positivity at PreTx maintained this status at SVR, whereas 11 (8%) of the 136 ANA-negative patients at PreTx exhibited positive conversion at SVR. Patients with ANA positivity at SVR were characterized by older age and a higher prevalence of cirrhosis or inactive HCC compared to the ANA-negative patients; at PreTx, the homogenous and speckled ANA patterns showed a similar level of predominance, whereas the proportion of the homogenous pattern increased and that of the speckled pattern decreased at SVR. In addition, the proportion of cytoplasmic ANA positivity at PreTx significantly decreased at SVR.\u003c/p\u003e \u003cp\u003eHCV induces damage to the liver, and also causes a range of extrahepatic diseases, of which mixed cryoglobulinemia and non-Hodgkin\u0026rsquo;s lymphoma are the most recognized diseases involving B-lymphocyte dysregulation. Cluster of Differentiation 81 (CD81), also known as tetraspanin, was the first receptor identified for HCV entry. CD81 is expressed on both liver cells and B lymphocytes. HCV infection may stimulate B cells directly through the binding of HCV E2 envelope glycoprotein to cell surface CD81, leading to the polyclonal expansion of B cells, recruiting immune complexes, and culminating in a wide spectrum of autoimmune and lymphoproliferative disorders. In addition, the molecular mimicry of viral antigens may be a mechanism underlying the development of autoimmune phenomena.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eANA, a key biomarker of autoimmune liver disease and systemic rheumatic disease, is a diverse group of autoantibodies that recognize macromolecular components in the cell nucleus (DNA, RNA, proteins, and their complexes). Although ANA-targeting antigens are usually present in the nucleus, they can translocate to the cytoplasm or extracellular space, particularly during cell death (mostly apoptosis). In the extracellular space, nuclear antigens form immune complexes with ANAs that can stimulate an immune response. The immunofluorescence assay is regarded as the gold standard for ANA testing; however, the results vary widely according to the threshold for positivity (initial serum/plasma dilution of 1:40 or 1:80), cell types or reagents used for testing, observer\u0026rsquo;s interpretation, and factors related to the study sample, including the genetic background of the participants. Therefore, the interpretation of ANA test results requires appropriate controls.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eHowever, 4\u0026ndash;30% of healthy populations exhibit ANA positivity, depending on the study.\u003csup\u003e\u003cspan additionalcitationids=\"CR15 CR16 CR17\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e ANA prevalence in the U.S. population aged above 12 years during 1999\u0026ndash;2004 was 13.8% at a cutoff of 1:80 using HEp-2 ANA slides, and the prevalence was higher in women than in men. ANA positivity increased with age but not in a linear pattern, such that that peak age in women was 40\u0026ndash;49 years, with a declining trend in older age groups.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e In our study, ANA positivity in healthy adult controls aged above 20 years was 21.3% and higher in women, in line with the results of the U.S. study. Although our sample size was small, to the best of our knowledge, this is the first study to report on ANA positivity in a healthy Korean population.\u003c/p\u003e \u003cp\u003eANA-positivity rates in patients with CHC reportedly range from 20 to 50%, depending on the study. A Swiss HCV cohort study with 235 patients with CHC (median age: 56 years, men: 62%, cirrhosis: 27%) reported that ANA positivity at PreTx (cutoff, 1:80) was 41%, although it lacked data on healthy controls.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e An Australian study that included 127 diverse patients with CHC (mean age: 41 years, men: 61%, study period: 2005\u0026ndash;2012) and 198 retrospectively recruited control samples (mean age: 50 years, men: 52%, study period: 1994) reported that the ANA/extractable nuclear antigen antibody positivity rates were higher in patients with CHC (50%) than in the controls (14%) using Hep2000 cells and a cutoff of \u0026gt;\u0026thinsp;7 IU.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e A Taiwanese study that retrospectively enrolled 258 patients with CHC from 2020\u0026ndash;2021(mean age: 64 years, men: 44%, cirrhosis: 17%) reported that ANA positivity at PreTx was 28.7% (Hep-20-10 cells, cutoff 1:320),\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e showing that female sex (p\u0026thinsp;=\u0026thinsp;0.023), older age (p\u0026thinsp;=\u0026thinsp;0.001), lower HCV RNA titer (p\u0026thinsp;=\u0026thinsp;0.06), and more advanced fibrosis (p\u0026thinsp;=\u0026thinsp;0.098) were associated with ANA positivity. An American retrospective study that included 1,556 patients with CHC who underwent autoantibody testing during 1997\u0026ndash;2016 reported that 388 patients (21.8%) showed ANA positivity, and that the proportion of women was higher and the rate of SVR was lower among the autoantibody-positive patients, although ANA positivity had no impact on the clinical outcomes.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e Studies that predominantly included Caucasian patients tended to have a higher prevalence of ANA positivity than the current (32.3%) or previous Taiwan study (28.7%), which may be related to genetic differences. Moreover, higher serum globulin was an independent factor related to ANA positivity in patients with CHC in this study, which has not been commonly reported in other studies. These findings suggest that chronic HCV infection may stimulate B cells, resulting in B-cell proliferation and increased globulin production. Interestingly, our results showed that patients with ANA-positive CHC had lower levels of HCV RNA in the blood, concurrent with the above-mentioned Taiwanese study, although the difference did not attain statistical significance. This may be related to the antiviral role of B lymphocytes, although a widespread and robust T-cell response is a well-known determinant of HCV clearance.\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, PreTx ANA positivity decreased after SVR to a level similar to that in the healthy controls. A Swiss cohort study reported that ANA positivity at PreTx (41%) decreased to 35.3% at SVR.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e A retrospective Italian study that included 46 patients with CHC reported that PreTx ANA positivity (85%) decreased to 29% at SVR.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Although only a few studies have reported on the change in ANA positivity after DAA therapy, their findings support our result of decreased ANA positivity after SVR.\u003c/p\u003e \u003cp\u003eMeanwhile, the current and previous studies consistently reported that more than half of patients with ANA-positive CHC at PreTx remained in an ANA-positive state after SVR and about one in ten ANA-negative patients at PreTx showed conversion to an ANA-positive state after SVR.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Interestingly, our results showed that patients with ANA-positive CHC at SVR were older and had more advanced liver disease than the ANA-negative patients. Recent experimental studies have reported that despite virus eradication with DAA therapy, monoclonal B-cell expansion and intraclonal diversification persist in patients with HCV with lymphoproliferative disorders,\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e and HCV-specific memory B cells live for long after HCV clearance.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e Moreover, B cells in patients who are cured of HCV exhibit persistent perturbations, showing that highly self-reactive immune signatures may contribute to a suboptimal vaccine response with the hepatitis B vaccine.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Therefore, our results suggest that possibility of incomplete recovery of the B-cell response with possible self-reactive features even after viral eradication, especially in older patients with advanced liver disease. Although the ANA patterns changed after SVR, as shown in this study, their significance remains unclear.\u003c/p\u003e \u003cp\u003eThe current study has some limitations. First, the sample size of our study was not large, although this is the largest prospective study of Asian CHC. Although a healthy-control group was appropriately included, age could not be matched because of the unavailability of plasma samples. Second, our study was conducted at a tertiary-care center, which could have potentially resulted in referral bias. However, to date, DAA therapy has mostly been performed at tertiary centers because of the high cost and strict reimbursement policy for DAA therapy in Korea. Third, the long-term outcomes after SVR according to ANA positivity were not observed.\u003c/p\u003e \u003cp\u003eIn conclusion, ANA positivity was observed in one-third of patients with CHC at PreTx, which was significantly higher than that in healthy controls and decreased after SVR. CHC patients with ANA positivity after SVR were older and had more advanced liver disease compared to those with ANA negativity. This suggests that B-cell dysfunction in patients with HCV may persist after SVR with DAA. Thus, investigation of the long-term outcomes, including the occurrence of HCC and the development of other autoimmune diseases according to ANA positivity, is warranted.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHCV, hepatitis C virus; anti-nuclear antibody; ASM, anti-smooth muscle antibody; anti-LKM-1, anti-liver kidney microsomal antibody type 1; AMA, anti-mitochondrial antibody; CHC, chronic hepatitis C; DAA, direct-acting antivirals; HIV, human immunodeficiency virus; HBV, hepatitis B virus; HCC, hepatocellular carcinoma; SVR, sustained virological response; PreTx, pretreatment; AST, aspartate transaminase; ALT, alanine transaminase; CD81, Cluster of Differentiation 81\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability statement:\u0026nbsp;\u003c/strong\u003eThe datasets used or analysed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest disclosure:\u003c/strong\u003e The authors have no conflicts to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval statement:\u0026nbsp;\u003c/strong\u003eThis study was conducted in accordance with the Helsinki Declaration of 1975 (revised in 2000). The study protocol was approved by the Institutional Review Board of each hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient consent statement:\u003c/strong\u003e Written informed consent was obtained from each patient before enrollment in the cohort study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was supported by a grant from the Chronic Infectious Disease Cohort Study (Korea HCV Cohort Study, 2023-E1901-00) conferred by the Korea Disease Control and Prevention Agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHORSHIP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuarantor of the article:\u003c/strong\u003e Sook-Hyang Jeong\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e SH Choi and GH Choi were responsible for data acquisition, analysis and interpretation, statistical analysis, and manuscript drafting., SH Jeong was responsible for the study concept and design, data acquisition and interpretation, and manuscript writing and finalization. ES Jang, YS Kim, YJ Lee, IH Kim, SB Cho, BS Lee, KA Kim, and WJ Chung assisted with data acquisition and analysis. MR Ki and DH Baik assisted with the data analysis and interpretation. All authors have approved the original draft.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe deeply appreciate the clinical research coordinators (Dong-Eun Lee, Na-Hae Kim, Da-Woon Jeong, Se-Min Na, Hyo-Yong Kang, Ah-Ra Jo, Seung-Hee Han, Eun-Suk Chung, Ha-Yuu Jeong, and Hye-Min Lee) for their dedication to this study and the officials of the Korea Disease Control and Prevention Agency (Myung-Sun Lee, Jae-Hyun Seong, Jung-kyu Lee, Mee-kyung Kee, Hyang-Min Chung, Byeong-Sun Choi, Ki Soon Kim, Chun Kang, Sung Soon Kim, and Young-Mee Jee) for their strong support for this study. We thank Yun-Tae Kim and Hee Jun Kim of the Seoul Central Laboratory for the autoantibody analysis.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. Key facts. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/hepatitis-c\u003c/span\u003e\u003cspan address=\"https://www.who.int/news-room/fact-sheets/detail/hepatitis-c\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. (2023)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl-Kamary, SamerS, Jhaveri R, Shardell MD. All-cause, liver-related, and non\u0026ndash;liver-related mortality among HCV-infected individuals in the general US population. Clin Infect Dis. 53, 150\u0026ndash;157 (2011)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarrone A, Ciotti M, Rinaldi L, Adinolfi LE, Ghany M. Hepatitis B and C Virus infection and risk of haematological malignancies. J Viral Hepat. 27, 4\u0026ndash;12 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCacoub P, Saadoun D. Extrahepatic manifestations of chronic HCV infection. N Engl J Med. 384, 1038\u0026ndash;1052 (2021)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarciso-Schiavon JL, Schiavon LL. Autoantibodies in chronic hepatitis C: a clinical perspective. World J Hepatol. 7, 1074\u0026ndash;1085 (2015)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLenzi, M. \u003cem\u003eet al.\u003c/em\u003e Prevalence of non-organ-specific autoantibodies and chronic liver disease in the general population: a nested case-control study of the Dionysos cohort. Gut. 45, 435\u0026ndash;441 (1999)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePr\u0026uuml;\u0026szlig;mann, J. \u003cem\u003eet al.\u003c/em\u003e Co-occurrence of autoantibodies in healthy blood donors. Exp Dermatol. 23, 519\u0026ndash;521 (2014)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBanerjee D, Reddy KR. Review article: safety and tolerability of direct-acting anti‐viral agents in the new era of hepatitis C therapy. Aliment Pharmacol Ther. 43, 674\u0026ndash;696 (2016)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Association for the Study of the Liver. Electronic address: [email protected]. EASL recommendations on treatment of hepatitis C 2016. J Hepatol. 66, 153\u0026ndash;194 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChoi, G. H. \u003cem\u003eet al.\u003c/em\u003e Hepatocellular carcinoma, decompensation, and mortality based on hepatitis C treatment: A prospective cohort study. World J Gastroenterol 28, 4182\u0026ndash;4200 (2022)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNam, J. Y. \u003cem\u003eet al.\u003c/em\u003e Epidemiological and clinical characteristics of hepatitis C virus infection in South Korea from 2007 to 2017: A prospective multicenter cohort study. Gut Liver 14, 207\u0026ndash;217 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePriora, M. \u003cem\u003eet al.\u003c/em\u003e Autoantibodies and rheumatologic manifestations in hepatitis C virus infection. Biology (Basel). 10, 1071 (2021)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePisetsky DS. Antinuclear antibody testing - misunderstood or misbegotten? Nat Rev Rheumatol 13, 495\u0026ndash;502 (2017)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAcay A, Demir K, Asik G, Tunay H, Acarturk G. Assessment of the frequency of autoantibodies in chronic viral hepatitis. Pak J Med Sci 31, 150\u0026ndash;154 (2015)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEmara M, Mohsen E, Shawky RM. Assessment of the prevalence of non-Oirgan-specific autoantibodies in Egyptian patients with HCV. \u003cem\u003eA Journal of Molecular and Cellular Immunology\u003c/em\u003e. Immunol Invest. 49, 676\u0026ndash;686 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShahini, E. \u003cem\u003eet al.\u003c/em\u003e Clinical relevance of serum non-organ-specific antibodies in patients with HCV infection receiving direct-acting antiviral therapy. Aliment Pharmacol Ther. 48, 1138\u0026ndash;1145 (2018)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilman, A. J. \u003cem\u003eet al.\u003c/em\u003e Autoantibodies in chronic hepatitis C virus infection: impact on clinical outcomes and extrahepatic manifestations. BMJ Open Gastroenterol. 5, e000203 (2018)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDeshpande, P. \u003cem\u003eet al.\u003c/em\u003e Frequent occurrence of low-level positive autoantibodies in chronic hepatitis C. Pathology. 52, 576\u0026ndash;583 (2020)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSatoh, M. \u003cem\u003eet al.\u003c/em\u003e Prevalence and sociodemographic correlates of antinuclear antibodies in the United States. Arthritis Rheum. 64, 2319\u0026ndash;2327 (2012)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBeretta-Piccoli, B. T. \u003cem\u003eet al.\u003c/em\u003e Autoimmune liver serology before and after successful treatment of chronic hepatitis C by direct acting antiviral agents. J Autoimmun. 102, 89\u0026ndash;95 (2019)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsiao S-W. \u003cem\u003eet al.\u003c/em\u003e A retrospective study of prevalence and pattern of international consensus on ANA patterns among patients with hepatitis C virus infection. PeerJ. 10, e14200 (2022)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhairy, M. \u003cem\u003eet al.\u003c/em\u003e Serum autoantibodies positivity prevalence in patients with chronic HCV and impact on pegylated interferon and ribavirin treatment response. Liver Int. 33, 1504\u0026ndash;1509 (2013)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazzaro, C. \u003cem\u003eet al.\u003c/em\u003e Persistence of monoclonal B-cell expansion and intraclonal diversification despite virus eradication in patients affected by hepatitis C virus‐associated lymphoproliferative disorders. Br J Haematol 203, 237\u0026ndash;243 (2023)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNishio, A. \u003cem\u003eet al.\u003c/em\u003e Serum neutralization activity declines but memory B cells persist after cure of chronic hepatitis C. Nat Commun. 13, 5446 (2022)\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhou, M. J. \u003cem\u003eet al.\u003c/em\u003e Cured HCV patients with suboptimal hepatitis B vaccine response exhibit high self-reactive immune signatures. Hepatol Commun. 7, e00197 (2023)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"hepatitis C virus, autoantibody, anti-nuclear antibody, direct acting antivirals, sustained virological response ","lastPublishedDoi":"10.21203/rs.3.rs-4427436/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4427436/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground/Aims: \u003c/strong\u003e\u003c/em\u003eHepatitis C virus (HCV) infection causes extrahepatic manifestations involving autoantibody production. This study aimed to\u003cstrong\u003e \u003c/strong\u003eelucidate the positivity rates of four autoantibodies (ANA, ASM, anti-LKM1, and AMA) in patients with chronic hepatitis C (CHC) before and after direct-acting antiviral (DAA) therapy compared to those in healthy controls.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods: \u003c/strong\u003e\u003c/em\u003eThis study enrolled prospectively collected plasma samples from 201 CHC patients [median age, 62 years; 49.8% women] from eight hospitals before and after DAA therapy and 127 healthy individuals.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u003c/em\u003eThe ANA positivity at pretreatment was higher in CHC patients than in healthy controls (32.3% vs. 21.3%, p=0.030), which decreased at SVR (32.3% vs. 23.9%, p=0.009). Female sex and higher globulin levels were related to ANA positivity in the control and CHC patient groups, respectively. Patients with ANA positivity at pretreatment and at SVR (n=48) were older and had a higher proportion of advanced liver disease than ANA-negative patients at SVR (n=153).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003e\u003c/em\u003eANA positivity was observed in one-third of CHC patients at pretreatment, which was significantly higher than that in healthy controls, and decreased after SVR. CHC patients with ANA positivity after SVR were older and had more advanced liver disease than those with ANA negativity.\u003c/p\u003e","manuscriptTitle":"Autoantibody Positivity in Chronic Hepatitis C Pre- and Post-Direct- Acting Antiviral Therapy: A Prospective Multicenter South Korean Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-13 20:58:47","doi":"10.21203/rs.3.rs-4427436/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bd412b5f-969f-46b0-8fad-f195cbd134ed","owner":[],"postedDate":"June 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":32903644,"name":"Health sciences/Gastroenterology/Hepatology"},{"id":32903645,"name":"Biological sciences/Immunology"}],"tags":[],"updatedAt":"2024-06-13T20:58:49+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-13 20:58:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4427436","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4427436","identity":"rs-4427436","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}