Metabolic management after sustained virologic response in elderly patients with hepatitis C virus: A multicenter study

<jats:title>Abstract</jats:title><jats:sec><jats:title>Aims</jats:title><jats:p>Hepatocellular carcinoma (HCC) develops even in patients with hepatitis C virus (HCV) eradication by direct‐acting antiviral agents. Fatty liver and metabolic dysfunction are becoming major etiologies of HCC. We aimed to evaluate the impact of metabolic dysfunction‐associated steatotic liver disease (MASLD), a new definition of steatotic liver disease, on the development of HCC after HCV eradication.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>We enrolled 1280 elderly patients with HCV eradication and no history of HCC. We evaluated α‐fetoprotein (AFP), Fibrosis‐4 index and MASLD after 24 weeks of sustained virological response. Decision tree analysis was used to investigate factors associated with HCC development after HCV eradication.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>A total of 86 patients (6.7%) developed HCC during the follow‐up period (35.8 ± 23.7 months). On multivariate analysis, serum AFP level (HR 1.08, CI 1.04–1.11, <jats:italic>P</jats:italic> = 0.0008), Fibrosis‐4 index (HR 1.17, CI 1.08–1.26, <jats:italic>P</jats:italic> = 0.0007), and MASLD (HR 3.04, CI 1.40–6.58, <jats:italic>P</jats:italic> = 0.0125) at 24 weeks of sustained virological response were independent factors associated with HCC development. In decision tree analysis, the initial classifier for HCC development was AFP ≥7 ng/mL. However, in patients with AFP <7 ng/mL, MASLD, rather than Fibrosis‐4 index, was the classifier for HCC development. No significant difference was observed in the cumulative incidence of HCC between patients with AFP ≥7 ng/mL and patients with AFP <7 ng/mL and MASLD.</jats:p></jats:sec><jats:sec><jats:title>Conclusion</jats:title><jats:p>MASLD at 24 weeks of sustained virological response is a risk factor for HCC development in elderly patients with HCV eradication. Additionally, decision tree analysis revealed that MASLD was associated with HCC development, even in patients with serum AFP levels <7 ng/mL.</jats:p></jats:sec>