Racial Differences in the Progression to Cirrhosis and... : Official journal of the American College of Gastroenterology | ACG (original) (raw)

ORIGINAL CONTRIBUTIONS

Racial Differences in the Progression to Cirrhosis and Hepatocellular Carcinoma in HCV-Infected Veterans

Effect of race on cirrhosis and HCC risk

El-Serag, Hashem B MD, MSHS1,2; Kramer, Jennifer PhD1,3; Duan, Zhigang MS1,3; Kanwal, Fasiha MD, MSHS1,2

1Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

2Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

3Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

Correspondence: El-Serag, MD, MSHS, Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd. (152), Houston, Texas 77030, USA. E-mail: [email protected]

Received 17 January 2014; accepted 16 June 2014

Guarantor of the article: Hashem B. El-Serag, MD, MSHS.

Specific author contributions: Hashem El-Serag conceived the research idea, obtained funding for the study, supervised the analyses, and wrote the paper; Duan Zhigang was involved in data-set cleaning, variable definition, and statistical analyses, as well as in the final approval of the manuscript; Fasiha Kanwal participated in the study design, analysis of data, and writing of the paper and approved the final manuscript; Jennifer Kramer participated in the study design, analysis of data, and writing of the paper and approved the final manuscript.

Financial support: This work is funded in part by National Institutes of Health (NIH) grant from the National Cancer Institute R01 116845, the Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety (IQuESt) (#CIN 13-413), and the Texas Digestive Disease Center NIH DK58338. Dr El-Serag is also supported by National Institute of Diabetes and Digestive and Kidney Diseases K24-04-107.

Potential competing interests: Drs El-Serag and Kanwal each received research grant funding from investigator-initiated studies from Gilead; neither pertained to this paper. The views expressed in this article are those of the author(s) and do not necessarily represent the views of the Department of Veterans Affairs.

Abstract

OBJECTIVES:

The race of patients infected with hepatitis C virus (HCV) in the United States may be associated with the risk for cirrhosis and hepatocellular carcinoma (HCC). However, previous studies are too small to provide convincing data regarding the effect of race on cirrhosis and HCC risk after accounting for demographic, clinical, and virological factors.

METHODS:

We used the Veterans Administration (VA) HCV Clinical Case Registry to identify patients with confirmed viremia between 2000 and 2009 and with at least 1 year of follow-up in the VA. We identified cirrhosis and HCC cases through early 2010. Cox proportional hazard regression models were performed to examine the effect of race on the risk for cirrhosis and HCC while adjusting for patients’ age, gender, period of service (World War I/II, Vietnam era, post-Vietnam era), HIV coinfection, HBV coinfection, alcohol abuse, diabetes, body mass index, and antiviral treatment receipt and response.

RESULTS:

There were 149,407 patients with active HCV viremia. Of them, 56.3% were non-Hispanic White (NHW), 36.1% were African American (AA), 6.0% were Hispanic, and 1.6% belonged to other racial groups. After an average follow-up of 5.2 years, 13,099 patients were seen to have a recorded diagnosis of cirrhosis and 3,551 had HCC. Hispanics had the highest annual incidence rates of cirrhosis and HCC (28.8 and 7.8%, respectively), whereas AAs had the lowest rates (13.3% and 3.9%, respectively) compared with NHWs (21.6 and 4.7%, respectively). There were differences among NHW, AA, and Hispanic patients in the rates of HIV infection (2.1, 2.5, and 6.0%, respectively), HCV genotype 1 (50.0, 50.6, and 64.2%, respectively), obesity (28.0, 25.4, and 30.9%, respectively), diabetes (8.7, 16.1, and 16.1%, respectively), and absence of antiviral treatment (81.1, 89.6, and 82.1%, respectively). However, adjusting for differences in demographic and clinical factors did not change the magnitude or direction of the race effect. Compared with NHWs, Hispanic patients had a higher risk of having cirrhosis recorded (adjusted hazard ratio (HR)=1.28, 95% confidence interval (CI)=1.21–1.37) and HCC (1.61, 95% CI=1.44–1.80). In contrast, AAs had a lower risk of cirrhosis (HR=0.58, 95% CI=0.55–0.60) and HCC (0.77, 95% CI=0.71–0.83) compared with NHWs.

CONCLUSIONS:

Hispanics with HCV are at a significantly higher risk, whereas AAs are at a considerably lower risk of developing cirrhosis and HCC than are NHWs. These associations persisted even after adjusting for a range of factors including HCV genotype, HCV treatment, diabetes, and body mass index.