Direct-acting antiviral therapy reduces variceal rebleeding and improves liver function in hepatitis C virus-related cirrhosis: A multicenter retrospective cohort study

Table 1 Baseline characteristics of the studied groups

Variables	Group A (DAA-Treated)	Group B (Non-DAA-Treated)	P value
Demographics
Age (years)	48.7 ± 4.2	47.4 ± 4.6	0.137
BMI (kg/m2)	22.7 ± 1.6	23.2 ± 1.3	0.121
Comorbidities, n (%)
Hypertension	18 (31)	16 (27)	0.839
Dyslipidemia	11 (19)	15 (25)	0.506
Laboratory data
Hemoglobin (g/dL)	13.7 ± 1.5	14 ± 1.8	0.336
Platelets (10³/μL)	156.1 ± 39.6	166.4 ± 37.5	0.149
Creatinine (mg/dL)	0.9 ± 0.3	1 ± 0.3	0.095
Albumin (g/dL)	3.4 ± 0.4	3.6 ± 0.9	0.062
INR	1.5 ± 0.8	1.6 ± 0.9	0.671
ALT (U/L)	45 ± 15	50 ± 18	0.210
AST (U/L)	50 ± 20	55 ± 22	0.180
Bilirubin (mg/dL)	1.5 ± 0.8	1.6 ± 0.9	0.671
Alkaline phosphatase (U/L)	120 ± 30	130 ± 35	0.150
Liver Stiffness (FibroScan)
LSM (kPa)	15.2 ± 2.1	15.5 ± 2.3	0.450
Clinical features, n (%)
Ascites	4 (6.8)	16 (27.1)	0.006
MELD score	9 (8-10)	9 (7-10)	0.206
Child-Pugh Class, n (%)
Child-Pugh class A	56 (94.9)	38 (64.4)	< 0.001
Child-Pugh class B	3 (5.1)	21 (35.6)	< 0.001

Data presented as mean ± SD, median (Q1-Q3).

BMI: Body mass index; INR: International normalized ratio; LSM: Liver stiffness measures; MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.

Table 2 Cox proportional hazards regression analysis of direct-acting antiviral intake and its association with variceal bleeding

Variable	Mean survival (95%CI)	HR (95%CI)	P value
Group A	4.5 (4.2-4.7)	1 (Reference)	0.002a
Group B	3.2 (2.7-3.7)	2.57 (1.39-4.72)

^aP < 0.05.

Table 3 Kaplan-Meier estimated survival over 5 years

Group	1-year survival (%)	3-year survival (%)	5-year survival (%)	Median survival (95%CI)	Log-rank P value
Survival without Rebleeding
Group A (DAA-treated)	95	85	75	4.5 years (4.2-4.7)	< 0.001a
Group B (non-DAA-treated)	80	60	45	3.2 years (2.7-3.7)
Overall survival
Group A (DAA-treated)	98	92	88	Not reached	0.012a
Group B (non-DAA-treated)	90	75	65	4.8 years (4.2-5.4)

^aP < 0.05.

The log-rank test confirmed significant differences in survival without rebleeding and overall survival between groups. DAA: Direct-acting antiviral.

Table 4 Multivariable Cox regression and Time-dependent covariate analysis

Multivariable Cox regression analysis			Time-dependent covariate analysis
Variable	Adjusted HR (95%CI)	P value	Variable	HR (95%CI)	P value
DAA treatment (Group A)	0.42 (0.25-0.71)	0.001a	MELD score change	1.89 (1.23-2.91)	0.004a
MELD score (> 10)	1.89 (1.23-2.91)	0.004a	Child-Pugh change	1.56 (1.02-2.38)	0.039a
Child-Pugh class B	1.56 (1.02-2.38)	0.039a
Age (> 50 years)	1.45 (1.02-2.06)	0.038a
Platelets (< 150 × 10³/μL)	1.78 (1.15-2.76)	0.010a

^aP < 0.05.

MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 5 Time-dependent Cox regression for model for end-stage liver disease score progression

Variable	HR (95%CI)	P value
DAA treatment	0.42 (0.25-0.71)	0.001
MELD score (Time-dependent)	1.89 (1.23-2.91)	0.004
Child-Pugh Class B	1.56 (1.02-2.38)	0.039
Platelets < 150 × 10³/μL	1.78 (1.15-2.76)	0.010

Time-dependent Cox regression analysis was performed to account for changes in model for end-stage liver disease (MELD) score over time. MELD scores were updated at each follow-up visit. MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 6 Propensity score matching analysis

Variable	Before matching (Group A)	Before matching (Group B)	After matching (Group A)	After matching (Group B)	P value (after matching)
Age (years)	48.7 ± 4.2	47.4 ± 4.6	48.5 ± 4.1	47.6 ± 4.5	0.210
BMI (kg/m2)	22.7 ± 1.6	23.2 ± 1.3	22.8 ± 1.5	23.1 ± 1.4	0.312
MELD score	9 (8-10)	9 (7-10)	9 (8-10)	9 (7-10)	0.189
Platelets (10³/μL)	156.1 ± 39.6	166.4 ± 37.5	158.2 ± 38.4	165.3 ± 36.8	0.401
Ascites, n (%)	5 (8)	2 (3)	4 (8)	3 (6)	0.678
Child-Pugh class B, n (%)	6 (10)	11 (18)	5 (10)	8 (16)	0.319

Data presented as mean ± SD, median (Q1-Q3). Propensity score matching (PSM) was performed to balance baseline characteristics between Group A [Direct-acting antiviral (DAA)-treated] and Group B (non-DAA-treated). After matching, all standardized mean differences (SMD) were < 0.1, indicating good balance. PSM was conducted using nearest neighbor matching without replacement with a caliper width of 0.2 (on the logit scale) and a 1:1 matching ratio, resulting in 50 matched patients per group. Covariates included in the propensity score model were: Age, model for end-stage liver disease score, Child-Pugh class, platelet count, body mass index, serum bilirubin, serum albumin, INR, and presence of ascites. After matching, all SMD were < 0.1, indicating excellent covariate balance between the DAA-treated (Group A) and non-treated (Group B) groups. MELD: Model for end-stage liver disease; BMI: Body mass index.

Table 7 Competing risk analysis (Fine and Gray Model)

Variable	Sub-distribution HR (95%CI)	P value
DAA treatment	0.44 (0.26-0.74)	0.002a
MELD score (> 10)	1.89 (1.23-2.91)	0.004a
Child-Pugh B	1.56 (1.02-2.38)	0.039a
Age (> 50 years)	1.45 (1.02-2.06)	0.038a
Deceased during follow-up	2.10 (1.30-3.40)	0.003a

^aP < 0.05.

Subdistribution HR: Hazard ratio accounting for competing risks (e.g., death, liver transplantation). MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 8 Competing risk analysis for liver-related vs non-liver-related mortality

Variable	Subdistribution HR (95%CI)	P value
Liver-related mortality
DAA treatment	0.35 (0.20-0.61)	< 0.001
MELD score > 10	1.89 (1.23-2.91)	0.004
Child-Pugh Class B	1.56 (1.02-2.38)	0.039
Non-liver-related mortality
DAA treatment	1.10 (0.80-1.50)	0.560
Age > 50 years	1.45 (1.02-2.06)	0.038
Hypertension	1.20 (0.90-1.60)	0.210

A competing risk analysis was performed using the Fine and Gray subdistribution hazard model. Liver-related mortality included deaths due to hepatic failure, variceal bleeding, and other liver-related complications. Non-liver-related mortality included deaths due to cardiovascular events, infections, and other non-liver causes. MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 9 Competing risk analysis for hepatocellular carcinoma development

Variable	Subdistribution HR (95%CI)	P value
DAA treatment	0.50 (0.30-0.85)	0.010
MELD score > 10	1.80 (1.20-2.70)	0.005
Child-Pugh Class B	1.60 (1.10-2.30)	0.015
Platelets < 150 × 10³/μL	1.70 (1.15-2.50)	0.008

A competing risk analysis was performed using the Fine and Gray subdistribution hazard model, with hepatocellular carcinoma development as the primary event and mortality as a competing risk. MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 10 Subgroup analysis of variceal rebleeding risk

Subgroup	Adjusted HR (95%CI)	P value
MELD score > 10	0.38 (0.22-0.65)	0.001a
Child-Pugh class B	0.41 (0.24-0.70)	0.001a
Platelets < 150 × 10³/μL	0.35 (0.20-0.61)	< 0.001a

^aP < 0.05.

MELD: Model for end-stage liver disease.

Table 11 Sensitivity analysis

Analysis type	HR (95%CI)	P value
Excluding missing data	0.43 (0.26-0.72)	0.001a
Different LSM cutoff (≥ 10 kPa)	0.44 (0.27-0.73)	0.002a
Different LSM cutoff (≥ 12.5 kPa)	0.45 (0.28-0.74)	0.002a

^aP < 0.05.

LSM: Liver stiffness measurement.

Table 12 Machine learning predictors of variceal rebleeding

Variable	Importance Score	P value	AUC (95%CI)
DAA treatment	0.85	< 0.001a	0.82 (0.76-0.88)
MELD score	0.78	< 0.001a
Platelets (< 150 × 10³/μL)	0.72	< 0.001a
Child-Pugh class B	0.68	0.001a

^aP < 0.05.

Importance scores were derived from random forest and LASSO regression models. area under the curve for the final model: 0.82 (95%CI: 0.76-0.88). AUC: Area under the curve; MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 13 Validation of machine learning model

Validation method	AUC (95%CI)	Sensitivity	Specificity	Accuracy
Internal Cross-Validation	0.82 (0.76-0.88)	0.78	0.85	0.80
External Validation Cohort	0.80 (0.74-0.86)	0.75	0.82	0.78

The machine learning model was validated using 10-fold cross-validation. AUC: Area under the curve.

Table 14 Final outcomes of the studied groups, n (%)

Variables	Group A (n = 59)	Group B (n = 59)	P value
Variceal rebleeding	15 (25.4)	28 (47.5)	0.021a
Ascites	4 (6.8)	16 (27.1)	0.006a
MELD score	7 (7-8)	11 (9-12)	< 0.001a
Child-Pugh class A	56 (94.9)	38 (64.4)	< 0.001a
Child-Pugh class B	3 (5.1)	21 (35.6)

^aP < 0.05.

Data presented as median (Q1-Q3). MELD: Model for end-stage liver disease.

Table 15 Summary of clinical outcomes and longitudinal laboratory trends

Outcome/parameter	DAA-Treated (n = 118)	Non-DAA (n = 112)	P value
Variceal rebleeding, n (%)	12 (10.2)	31 (27.7)	0.001
Liver transplantation, n (%)	4 (3.4)	9 (8.0)	0.12
Liver-related mortality, n (%)	5 (4.2)	14 (12.5)	0.032
MELD score (baseline)	9 (8-10)	9 (7-10)	0.50
MELD score (36 months)	8 (7-10)	10 (9-12)	0.002
Platelets (baseline, × 10³/μL)	156 ± 40	166 ± 38	0.11
Platelets (36 months)	165 ± 42	148 ± 36	0.015

MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral.

Table 16 Laboratory results at 5-year follow-up

Parameter	Group A (DAA-Treated)	Group B (Non-DAA-Treated)	P value
Hemoglobin (g/dL)	14.2 ± 1.3	12.5 ± 1.8	< 0.001
Platelet count (10³/μL)	180.5 ± 40.2	130.4 ± 35.6	< 0.001
Serum creatinine (mg/dL)	0.8 ± 0.2	1.2 ± 0.3	< 0.001
Albumin (g/dL)	4.0 ± 0.5	3.2 ± 0.6	< 0.001
INR	1.2 ± 0.3	1.6 ± 0.4	< 0.001
ALT (U/L)	25 ± 10	45 ± 15	< 0.001
AST (U/L)	30 ± 12	50 ± 18	< 0.001
Bilirubin (mg/dL)	1.0 ± 0.5	2.5 ± 1.0	< 0.001
Alkaline phosphatase (U/L)	90 ± 20	130 ± 30	< 0.001
Liver Stiffness (FibroScan) LSM (kPa)	10.5 ± 1.8	16.0 ± 2.5	< 0.001
MELD score	7 ± 2	12 ± 3	< 0.001
Child-Pugh class A (%)	95	60	< 0.001
Child-Pugh class B (%)	5	40	< 0.001

INR: International normalized ratio; LSM: Liver stiffness measures; MELD: Model for end-stage liver disease; DAA: Direct-acting antiviral; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase.

Table 17 Multivariate regression analyses adjusted for study center as a covariate (sensitivity analysis)

Outcome	Variable	Adjusted HR/OR (95%CI)	P value
Variceal Rebleeding (Cox)	SVR achieved	0.52 (0.34-0.81)	0.004
	MELD score ≥ 15	1.78 (1.12-2.84)	0.015
	History of EVL	0.67 (0.45-1.00)	0.049
	Study center (ref = C1)	HR range: 0.91-1.16	> 0.1
Hepatic Decompensation (Logistic)	SVR achieved	0.47 (0.25-0.90)	0.022
	Platelet count < 100 × 109/L	2.14 (1.10-4.17)	0.026
	Study Center (ref = C1)	OR range: 0.95-1.21	> 0.1
Mortality (Cox)	SVR achieved	0.58 (0.36-0.94)	0.028
	Child-Pugh C	2.30 (1.41-3.75)	0.001
	Study Center (ref = C1)	HR range: 0.88-1.19	> 0.1

C1-C5 refer to the five participating centers. No statistically significant differences were observed across centers in any model. MELD: Model for end-stage liver disease; SVR: Sustained virologic response; EVL: Endoscopic variceal ligation.