The worldwide prevalence of HCV infection approximates 1.6%, affecting approximately 115 million individuals.25 Globally, genotype 1 (G1) is the most common, and accounts for roughly one in two of all HCV infections in adults, followed by the G3, G2, G4, G6 and G5 genotypes.25 The average prevalence of NAFLD in HCV-infected individuals is approximately 55% (40–86%). The prevalence of NAFLD is significantly higher in HCV-infected individuals, when compared to that in non-HCV-infected individuals.26 Furthermore, the incidence of NAFLD is higher in patients infected with other genotypes of HCV, when compared to patients infected with non-genotype 3 HCV.27
Pathogenesis
Recent data has suggested that NAFLD is associated with fibrosis progression, which results from chronic HCV infection, and appears to be induced by insulin resistance and liver fat degeneration. HCV infection induces liver fatty degeneration and insulin resistance, liver fatty degeneration promotes the production of liver inflammation, and insulin resistance and liver inflammation lead to liver stellate cell activation, leading to liver fibrosis.27 Both steatosis and insulin resistance are independently associated with advanced liver fibrosis.28
HCV infection is associated with a variety of metabolic disorders, which are known as, hepatitis C-related metabolic disorder syndrome. This metabolic disorder is characterized by insulin resistance, hypocholesterolemia, hyperuricemia, and altered body fat distribution.29 HCV affects the development of NAFLD in various ways, in which insulin resistance and fat degeneration play an irreplaceable role. Furthermore, various factors can lead to insulin resistance, such as obesity, high BMI,30 and HCV.28 In addition, some inflammatory factors can cause insulin resistance, such as TNF-α and IL6.31 For obese subjects with viral genotype 1, the TNF-α and IL6 inflammation markers increase, and the insulin signaling pathway is reduced by increasing the expression of the suppressors of cytokine signaling (SOCS)-3 gene.31 For cases of chronic hepatitis C (CHC) infection, the incidence of insulin resistance was reported to be high (up to 80%).32 HCV infection with the G3 genotype is generally recognized as an independent risk factor for steatosis.33 The severity of hepatic steatosis correlates with the viral load, and the G3 genotype-associated steatosis is relieved after sustained virological response (SVR) with the antiviral treatment.33 HCV G3 genotype infection is associated with specific lipid accumulation. Hourioux et al. used an in vitro cell model to compare the lipid area of cell sections that produced the genotype G3 HCV core protein with the genotype 1a HCV core protein.34 It was found that the cumulative lipid droplet area was significantly greater in HCV G3 genotype cells, when compared to 1a genotype cells (p < 0.001).34 This may be attributed to the fact that phenylalanine residues have a higher affinity for lipids, when compared to tyrosine, and that these are specific to the G3 genotype.34 Furthermore, compared to the core protein of HCV-1b, the core protein of HCV-3a significantly upregulates fatty acid synthetase, which is an important enzyme for the synthesis of lipids.34 The HCV-1b core protein has previously been shown to inhibit both MTP and very low density lipoprotein (VLDL) secretion.35 This effect is more pronounced in the G3 genotype, and a recent study revealed that the MTP activity in the liver is significantly reduced in patients infected with the CHC G3 genotype, when compared to other genotypes (p = 0.004).36 CHC G3 genotype infection can reduce hepatic lipoprotein synthesis and release, and aggravate the degree of hepatic steatosis.37 In HCV cirrhosis patients, G3 genotype HCV has been independently associated with increased risk of HCC.37
Hepatocyte steatosis is the result of the combination of virus and host factors. The induction effects of different genotypes on steatosis are genotype specific, and the HCV genotype 3 virus has the strongest effect. Viral factors and HCV genotype 3 viral-induced steatosis are the most notable.38 For patients with non-genotype 3 HCV infections, NAFLD is mainly associated with host factors, such as BMI, obesity (especially visceral obesity),39 insulin resistance and type-II diabetes, which is known as, “metabolic steatosis”. For HCV-infected individuals, the prevalence and severity of fatty degeneration in patients with genotype 3 is much higher.40
HCV infection can affect liver steatosis through a variety of mechanisms (Fig. 1). Hemohemolytic oxygenase-1 (HO-1) is an important protective antioxidant defense enzyme. This is induced in some liver injury reactions, such as autoimmune hepatitis, CHB infection,41 and non-alcoholic steatohepatitis (NASH).42 It was reported that the HO-1 level decreases in the liver of HCV-infected subjects, and that this was considered to be part of the cause of HCV-induced liver damage.43 Furthermore, this may directly or indirectly interact with certain HCV proteins in the HO-1 induction pathway.44 Some studies have revealed that HCV core proteins promote lipid accumulation by activating sterol regulatory element binding protein-1 and -2,45 inhibiting the microsomal triglyceride transfer protein (MTP) activity35 and peroxisome proliferator-activated receptor (PPAR) expression, and promoting de novo lipid synthesis,46 depending on the specific genotype. Thus, the assembly, excretion and uptake of VLDL are impaired. The HCV core protein induces oxidative stress by upregulating SOCS-3, activating Kupffer cells, increasing proinflammatory cytokines (e.g., TNF-α), and increasing the reactive oxygen species, thereby promoting insulin resistance and liver fat degeneration, and further inhibiting the secretion of VLDL.47 Fat degeneration, which is common in CHC, plays an important role in the disease progression. Therefore, treating the liver fat degeneration is particularly important for HCV-infected patients with NAFLD. The presence of HCV infection and NAFLD can cause more severe interference with the steady state of essential minerals (zinc, selenium and copper) in the human body, thereby amplifying the oxidative stress and inflammation.48
There are various risk-related factors associated with HCV infection in NAFLD patients, such as leptin, adiponectin, HO-1, some serological indicators (alanine aminotransferase [ALT]/aspartate aminotransferase [AST] ratio, fasting glucose, and triglyceride), and trace minerals (zinc, selenium and copper). Leptin is a protein secreted by fat cells, and is associated with insulin resistance and fat degeneration by increasing proinflammatory cytokines.49 Elena reported that adiponectin levels were higher in CHC patients, when compared to non-chronic hepatitis C patients.50 However, these lipid levels declined in patients with obesity, diabetes, CHC and NASH.51 Furthermore, recent studies have confirmed the significant correlation between liver fat degeneration and insulin resistance, and the decrease in lipid levels.52 As previously mentioned, HO-1 is involved in the pathogenesis, and its serological level may indicate HCV infection. Lin conducted a study in Taiwan, and tested 1,354 CHC patients. The results revealed that participants with NAFLD had higher levels of fasting glucose, ALT/AST, blood pressure and triglyceride, when compared to non-NAFLD participants.53 This suggests that for CHC patients, the increase in the serological indicators above may be a sign of NAFLD.
Management
The gold standard to diagnose HCV infection is the HCV RNA test and HCV genotype test.54 In addition, the total HCV antibodies in serum or plasma can be detected to help diagnose the HCV infection.55
For patients with HCV infection, there are various novel treatment plans for certain patients to improve SVR. The data revealed that the combination of IFN-α and ribavirin treatment in CHC patients, especially for patients with fatty degeneration greater than 30%, decreased the SVR rate.56 Furthermore, some in vitro studies have revealed that the use of statins reduces HCV replication.57 A recent prospective study evaluated the use of rosuvastatin in a joint IFN-α and ribavirin treatment, and revealed that the use of these drugs is associated with improved SVR rates, and reduced fat degeneration and fibros.58 Therefore, statins, as an auxiliary treatment for patients with fat degeneration and CHC, may appear as a viable option. However, larger prospective and randomized studies are needed to evaluate the treatment responses. When patients received the combined treatment that included vitamin E and IFN-α, the viral load significantly decreased.59 The use of antioxidant d-α-tocopherol has been shown to reduce the rate of fibrosis progression via the inhibition of stellate cell activation, thereby limiting the stellate cell-induced fibrogenesis in CHC patients.60 Gyanranjan et al. reported that after the treatment of Direct-acting Antiviral Agents (DAAs), the liver stiffness measurement (LSM) values decreased, and the controlled attenuation parameter (CAP) values (suggestive of hepatic steatosis) increased in CHC patients.61 Although the HCV was cured after the treatment with DAAs, follow-ups for the liver disease are still required, because CHC patients have a high risk of NAFLD.62
In summary, HCV infection increases the risk of NAFLD. Based on the above studies, in addition to conventional antiviral therapy for NAFLD patients infected with HCV, there are various new therapeutic drugs related to HCV infection in patients with NAFLD, but the actual efficacy of these drugs remains to be further studied.