Impact of diabetes mellitus and hepatitis B virus coinfection on
patients with chronic hepatitis C: A territory-wide cohort study
Shreenidhi Subramaniam,* Vincent Wai-Sun Wong,
Terry Cheuk-Fung Yip,
Henry Lik-Yuen Chan
and Grace Lai-Hung Wong
*Faculty of Medicine,
Institute of Digestive Disease,
Department of Medicine and Therapeutics,
State Key Laboratory of Digestive Disease, and
Department of Statistics, The Chinese University of Hong Kong, Shatin, Hong Kong
antiviral treatment, chronic viral hepatitis,
cirrhosis, death, diabetes mellitus.
Accepted for publication 18 September 2017.
Grace Lai-Hung Wong, Department of Medicine
and Therapeutics, The Chinese University of
Hong Kong, 9/F Prince of Wales Hospital, 30–32
Ngan Shing Street, Shatin, Hong Kong.
Declaration of conflict of interest:GraceWong
has served as an advisory committee member for
Otsuka and Gilead. She has also served as a
speaker for Abbott, Abbvie, Bristol-Myers Squibb,
Echosens, Furui, Gilead, Janssen, Otsuka, and
Henry Chan is a consultant for Bristol-Myers
Squibb, Gilead, Merck, Novartis, and Roche; has
received honorarium for lecture for Abbott,
Abbvie, Bristol-Myers Squibb, Echosens, Gilead,
Glaxo-Smith-Kline, Merck, Novartis, and Roche;
and has received an unrestricted grant from
Roche for hepatitis B research.
Vincent Wong has served as an advisory
committee member for Abbvie, Roche, Novartis,
Gilead, and Otsuka. He has also served as a
speaker for Abbvie, Bristol-Myers Squibb, Roche,
Novartis, Abbott Diagnostics, and Echosens.
The other authors declare that they have no
Author contribution: Shreenidhi Subramaniam,
Vincent Wong, Henry Chan, and Grace Wong
were responsible for the study concept and
Background and Aim: Studies have demonstrated a higher prevalence of diabetes mellitus
(DM) in patients with chronic hepatitis C (CHC). Furthermore, coinfection with hepatitis B
virus (HBV) is common because of its endemicity in Asian–Paciﬁc regions. The aim of the
present study was to investigate the impact of DM and HBV coinfection on the clinical
outcomes in Chinese CHC patients.
Methods: A territory-wide cohort study was conducted using the database from Hospital
Authority, the sole public medical service provider in Hong Kong. CHC patients were
identiﬁed by the International Classiﬁcation of Diseases, Ninth Revision, Clinical Modiﬁ-
cation diagnosis codes, diagnosed between 2000 and 2012. The primary outcome was
Results: A total of 7149 CHC patients were included. Seven hundred twenty-two (10.1%)
patients were coinfected with HBV. Their mean age was 56 years; 69.0% were men. The
prevalence of DM was similar in mono-infection and coinfection cohorts (22.3% and
21.3%, respectively). Multivariable analysis identiﬁed DM as an independent risk factor
for death and antiviral treatment for hepatitis C virus (HCV) as an independent protective
factor against death. The 5-year survival of CHC patients with mono-infection was better
than that of HBV coinfected patients (62.5% vs 57.0%; P = 0.001). The 5-year survival
of patients who did or did not receive antiviral treatment for HCV was 94.7% and
55.2%, respectively (P < 0.001).
Conclusions: Hepatitis B virus coinfection and DM were independent risk factors for death
in Hong Kong CHC patients. Antiviral treatment for HCV but not HBV was a protective
factor against death.
design. All authors were responsible for the
acquisition, analysis, or interpretation of data.
Shreenidhi Subramaniam, Yee-Kit Tse, Vincent
Wong, Henry Chan, and Grace Wong were
responsible for the drafting of the manuscript. All
authors were responsible for the critical revision of
the manuscript for important intellectual content.
Globally, around 71 million people are chronic hepatitis C (CHC)
These infections often become chronic, progressing to
cirrhosis, end-stage liver disease, and hepatocellular carcinoma
CHC is one of the leading causes of liver transplantation.
Chronic hepatitis C patients have been shown to have a higher
prevalence of type 2 diabetes mellitus (DM).
However, the exact
Ethical approval: The study protocol was approved by the Joint Chinese University of Hong Kong–New
Territories East Cluster Clinical Research Ethics Committee.
Informed consent: Informed consent was exempted in view of the retrospective nature of the study.
Financial support: This work was supported by the Research Fund for the Control of Infectious Dis-
eases from the Food and Health Bureau of the Hong Kong Government (Reference no: CU-14-01-09).
Guarantor of the article: Shreenidhi Subramaniam, Yee-Kit Tse, and Terry Yip had full access to all of
the data in the study and take responsibility for the integrity of the data and the accuracy of the data
Journal of Gastroenterology and Hepatology 33 (2018) 934–941
© 2017 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd