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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 16  |  Issue : 2  |  Page : 197-204

Retrospective study of hepatitis c virus relapse after treatment with sofosbuvir and daclatasvir with or without ribavirin


1 Department of Tropical Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
2 Qina Fever Hospital, Ministry of Health, Qina City, Egypt

Date of Submission10-Apr-2018
Date of Acceptance15-Aug-2018
Date of Web Publication27-Feb-2019

Correspondence Address:
Mohamed DA Abd Alla
Gouhar Al-Kaed Street, El-Hussein University Hospital, Al Azhar University, Al-Darasah, Cairo, 11675
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AZMJ.AZMJ_22_18

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  Abstract 

Background and aims The highest prevalence of chronic hepatitis C virus (HCV) genotype 4 infection is reported in Egypt. Fortunately, the oral anti-HCV therapy (OAT) has been available with more than 95% reported 12-week sustained virologic response (SVR) after treatment for 84 days. The current study goals included evaluation of 12-week SVR after treatment with sofosbuvir (SOF) plus daclatasvir (DCV) with or without ribavirin for 12 weeks. An additional goal was to study the correlation between post-OAT HCV serologic relapse and diabetes mellitus, liver fibrosis, and pretreatment viral loads.
Patients and methods Patients with chronic HCV infection (n=590) were retrospectively enrolled in the current study. They were subjected to OAT for 12 weeks. Single daily dose of SOF (400 mg) plus DCV (60 mg) constituted the baseline therapy in all study cases, and ribavirin (RBV) was coadministered in 262 patients. Responses to OAT were assessed 12 weeks after end of treatment by single-step reverse transcription polymerase chain reaction (SRT-PCR).
Results We found that overall 12-week SVR was 98% (579/590), which showed insignificant advantages on adding ribavirin (99%) compared with solitary directly acting antivirals regimen (97%) (P>0.05). The SVR in normoglycemic and/or none or early hepatic fibrosis (F0–F2) (>99.0%) was significantly higher compared with diabetic and/or late fibrotic (F3–F4) (94%) patients (P<0.05). Pretreatment detection of HCV loads by SRT-PCR was significantly lower in F0 compared with F4 hepatic fibrosis (P<0.001), with insignificant changes when compared with F1–F3 (P>0.05).
Conclusion SOF plus DCV with or without ribavirin regimens achieved 12-week SVR in 98% of the patients with chronic HCV infection. Hepatic fibrosis and diabetes mellitus have negative effects on 12-week SVR. Despite F4 hepatic fibrosis being associated with the highest pre-treatment HCV-SRT-PCR values, baseline viral loads do not affect anti-HCV oral therapy outcomes.


How to cite this article:
Abd Alla MD, Gomaa AA, Farrag GA, Shikhroho MG, Mousa WM, Mahmoud OA. Retrospective study of hepatitis c virus relapse after treatment with sofosbuvir and daclatasvir with or without ribavirin. Al-Azhar Assiut Med J 2018;16:197-204

How to cite this URL:
Abd Alla MD, Gomaa AA, Farrag GA, Shikhroho MG, Mousa WM, Mahmoud OA. Retrospective study of hepatitis c virus relapse after treatment with sofosbuvir and daclatasvir with or without ribavirin. Al-Azhar Assiut Med J [serial online] 2018 [cited 2020 Jul 6];16:197-204. Available from: http://www.azmj.eg.net/text.asp?2018/16/2/197/253083


  Introduction Top


Chronic hepatitis C virus (HCV) infection is a major cause of chronic liver disease, cirrhosis, and liver cancer as well as an important indication for liver transplantation [1]. Egypt has the highest prevalence of HCV infection in the world. The prevalence of HCV viremia was estimated to be 7.3% for the year 2013 based on data from the 2008 Egypt Demographic and Health Survey [2].

Up to 2011, a combination of weekly peginterferon-α and daily doses of RBV in a 24-week or 48-week course was the standard treatment for chronic HCV infection [3]. The introduction of directly acting antivirals (DAAs) in the treatment of chronic HCV infections has revolutionized the field. The pan-genotypic combination of daclatasvir (DCV) and sofosbuvir (SOF), with or without ribavirin, has achieved high sustained virologic response (SVR) rates in phase 2 and phase 3 studies. DCV is an inhibitor of the HCV NS5A replication complex; SOF is a nucleotide inhibitor of the HCV NS5B polymerase. Both have favorable safety profiles and are dosed once daily, with few clinically significant drug-drug interaction [4]. DAA therapy has successfully treated most chronic HCV infection in a brief time by using well-tolerated therapeutic regimens [5]. Although ribavirin’s mechanism(s) of action remain elusive, it has proven harder to replace than expected, and for the time being continues to play a useful role in HCV therapy [6]. Merat et al. [7] reported high 12-week SVR (98%) upon using SOF plus DCV with ribavirin.

Liver fibrosis grades influence the response of anti-HCV medications, as advanced fibrosis or cirrhosis shows a decreased both serum [8] and cellular HCV particle elimination rates [9]. Evaluation of DAA therapy outcomes by using both plasma and intraperipheral blood mononuclear cells (intra-PBMCs) PCR has been valid and in use by some ID clinics in Egypt [9]. Combined post-DAA therapy testing with both plasma and cellular PCR can predict probabilities of early post-treatment HCV-RNA seroconversion and can recommend the need to continue oral antiviral therapy (OAT) beyond the scheduled therapeutic duration by application of HCV therapy follow-up fractionation (CTF2) protocol application [10],[11]. The pretreatment risk factors that might affect the SVR were evaluated by Nelson et al. [12], in ALLY-3 phase III study in 2015 where they analyzed the 12-week SVR in patient subgroups based on baseline characteristics and showed no notable differences by sex, age, and HCV-RNA levels.

The published meta-analysis data in 7 March 2017 by World J Gastroenterol [13] indicate that HCV infection is associated with increased rates of glucose abnormalities, including diabetes mellitus and insulin resistance. The same study reported that presence of glucose abnormalities in HCV-infected patients, including diabetes mellitus and insulin resistance, is associated with negative liver-related outcomes [i.e. severe liver fibrosis, decreased response to antivirals, and increased occurrence of hepatocellular carcinoma (HCC)]. During clinical practice, we found that successful elimination of HCV viremia has been associated with dose reduction of both oral-hypoglycemics and insulin, which is associated with improved manifestations of both peripheral nerve affection and diabetic retinal disturbance (unpublished data). However, a recent preliminary report suggests that metabolic factors such as diabetes and hyperlipidemia still compromise the effect of DAA treatment. Further studies are needed to evaluate the effect of diabetes on the response to DAA treatment [14].


  Aims Top


Goals of the current study included the following:
  1. Evaluation of 12-week SVR after treatment with SOF plus DCV with or without ribavirin (RBV) for twelve weeks.
  2. Studying the relationship between relapse of HCV infection after OAT and risk factors like diabetes mellitus, liver fibrosis, and pretreatment serum viral loads.



  Patients and methods Top


Study patients

A total of 590 Egyptian patients presented with chronic HCV infection were enrolled in the current study. The study was approved by Al Azhar University ethical committee and all patients signed informed consents. The studied cases were recruited from the outpatient clinics between January 2016 and June 2016. Their ages ranged between 18 and 70 years, and they were either naïve or experienced (previously treated with interferon plus ribavirin at least one year ago). All patients tested positive for serum HCV RNA genomic materials by single-step reverse transcription −PCR. The exclusion criteria included decompensated cirrhosis (Child grades B and C), ascites, hepatic encephalopathy, pregnant women, HCC, and HBV or HIV coinfection. Patients with renal impairment (glomerular filtration rate <30 ml/min), those with international normalized ratio (INR) greater than 1.7, serum albumin less than 2.8 g/dl, total bilirubin greater than 3 mg/dl, or platelet count less than 50 000/mm3 were excluded. All patients were subjected to clinical examination and laboratory testing for liver functions, kidney functions, and fasting blood sugar. Pregnancy test was done for women in childbearing period. Abdominal ultrasonography was performed to assess hepatic echo pattern of the liver, patency of portal vein, presence of splenomegaly, and to exclude HCC. Fibroscan was used to determine the degree of fibrosis and was performed within 6 months before treatment induction. According to fibrosis stage, patients were classified as non-cirrhotic patients having F0–F2 fibrosis and scored less than 9.5 kPa and cirrhotic patients who had F3–F4 fibrosis and scored greater than 9.5 kPa.

Medicine administration

The anti-HCV drugs were administered according to guidelines regarding doses, routes of administration, and duration of therapy. The antiviral therapeutic regimens included SOF at 400 mg plus DCV at 60 mg plus ribavirin dosage was initiated at 600 mg per day and gradually titrated upward after the exclusion of its significant adverse effects to reach 1000 mg per day.

Real-time PCR for quantification of HCV-RNA [9]

Collection and transport of specimens

Standard specimen collection tubes [artus HCV RG RT-PCR Kit tubes (red cap)] were used to withdraw blood samples (5–10 ml). Plasma and cellular components were separated from the whole blood by centrifugation for 20 min at 800–1600 g within 6 h. Whole blood cells (200 μl) were transferred to a sterile polypropylene tube for PBMCs studies. Plasma were also transferred into sterile polypropylene tube. The blood samples were shipped at 2–8°C, and the separated plasma was transported to be frozen at −15 to −30°C.

Isolation of RNA and procedure of single-step reverse transcription-PCR

Viral RNA purification from human plasma was performed using QIAamp DSP Virus Kit (catalog no. 60704; QIAGEN, 19300 Germantown Road Germantown, Maryland 20874, USA). RNA was extracted from 200 μl of plasma, and the purified RNA was eluted in 60 μl DEPC water and stored at −80°C. Artus HCV RG RT-PCR Kit was used for quantification of HCV-RNA. In summary, 4 μl of RNA was incubated with 1 pmol of a HCV 5NC primer RC21 for 8 min at 70°C and 5 min at 4°C. RNA template was reverse transcribed at 60°C for 1 h with 7.5 U of Thermoscript Reverse Transcriptase, 20 U of RnaseOut, 1 mmol/l deoxyribonucleotide, 10 mmol/l DTT, and cDNA buffer [50 mmol/l Tris acetate (pH8.4), 75 mmol/l potassium acetate, and 8 mmol/l magnesium acetate] (GibcoBRL Life Technologies, 8717 Grovemont Circle Gaithersburg, Maryland 20877, USA) in an end volume of 10 µl. At 95°C for 5 min, a denaturation step was performed and was followed by a RnaseH treatment with 1 U of E. coli RnaseH (GibcoBRL Life Technologies) at 37°C for 20 min. cDNA was stored at −20°C. Amplification of a 220-bp fragment within the five noncoding region of the HCV genome was designed using the following primers RC1 ‘‘5-GTCTAGCCATGGCGTTAGTA-3" and RC "5-CTCCCGGGGCACTCGCAAGC-3".

Internal control of the isolated RNA and/or contamination

We used an internal control (HCV RG IC) for both to control the RNA isolation procedure and to check for possible PCR inhibition. For such application, adding the internal control to the isolation mixture at a ratio of 0.1 µl per 1 µl elution volume was used. For example, 6 µl of the internal control should be added initially upon using the QIAamp DSP Virus Kit, as the RNA was eluted in 60 µl of elution buffer (AVE).

Quantification of HCV-RNA

The later mentioned quantification standard (HCV RG QS1–4) was treated as previously purified samples, and the same volume is used (20 µl). All four quantitation standards were used to generate a standard curve on Rotor-Gene Q Instruments. The quantitation standards are reported in IU/µl. The values determined using the standard curve into IU/ml of sample material was converted by application of the following equation:

Result (IU/ml)=result (IU/µl)×elution volume (µl)/sample volume (ml).

Considering changes in sample volume, the initial sample volume was entered in the equation above.

Statistical analysis

All tests performed were two sided, and statistical significance was considered at a P value of 0.05. SSPS version 9.0 for windows (SPSS Inc., Chicago, Illinois, USA) was used for statistical analysis. The Komolgorov–Smirnov and Levene’s tests were employed to test the normality and homogeneity, respectively, of continuous variables. We compared means with the Student’s t-test (variables with normal distribution) or with the Mann–Whitney U-test (variables with non-normal distribution). Categorical variables were compared using the χ2 or Fisher’s exact tests. To study the existence of correlation between the variables, Pearson’s (variables with Gaussian distribution) or Spearman (non-normally distributed variables) correlation coefficients were determined. To study the existence of correlation between the variables, Pearson’s (variables with Gaussian distribution) or Spearman’s (non-normally distributed variables) correlation coefficients were determined.


  Results Top


HCV-RNA seroconversion (virologic relapse) in various grades of postviral hepatic fibrosis

The relationship between hepatic fibrosis and SVR is illustrated by [Figure 1] in all study populations. Most of the studied patients (n=440) had F0–F2 compared with F3–F4 (n=150) grades of hepatic fibrosis. HCV serologic relapse was significantly lower in patients presented with F0–F2 (two (0.5%) of 440) compared with those who presented with F3–F4 (nine (6%) of 150) grades of hepatic fibrosis (P<0.001).
Figure 1 Relationship between sustained virologic response (SVR) and grades of hepatic fibrosis in study populations. SVR is significantly higher in F0 - F2 compared to F3 - F4 hepatic fibrosis (P<0.001).

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On the contrary, relapse frequencies in relation to the used therapeutic regimens are demonstrated in [Table 1]. It shows that patients who presented with F0–F2 hepatic fibrosis (n=440) were treated with SD (n=328) and SDR (n=112). In hepatic fibrosis grade F0–F2, two patients who showed HCV-RNA seroconversion (serologic relapse) [two (0.61%) of 328] were treated with SD compared with none (0 out of 112) of those who were treated with SDR (P=0.555).
Table 1 Comparison of SD with SDR treatment outcomes in hepatic fibrosis grade ranges from F0 to F2

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The role of hepatic fibrosis grades in developing HCV serologic relapse in solitary SDR regimen is described in in [Table 2]. HCV-RNA serologic relapse was significantly higher in F3 (two out of 36 = 5.56%) and F4 (seven out of 114 = 6.14%) hepatic fibrosis compared to F0 as well as earlier stages (F1–F2) of liver tissue changes (zero out of 114) (P<0.05). On the contrary, the above mentioned virologic serum relapse showed insignificant differences on comparing hepatic fibrosis grades F3 with F4 (P=0.8975).
Table 2 Correlation of hepatitis C virus serologic relapse to grades of hepatic fibrosis in SDR therapeutic regimen

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In addition, routine laboratory assessment in hepatic fibrosis was compared with those of fibrosis free liver, as shown in [Table 3]. The mean±standard deviation of liver function tests [serum albumin, serum bilirubin, INR, and alanine transaminase (ALT)], serum creatinine, platelet count, Hb%, and total white blood cells (WBCs) count in all the study patients is described. Patient who presented with hepatic fibrosis showed significant decrease in levels of serum albumin, Hb, PLTs, and WBCs counts, with significant increase in the levels of serum bilirubin and INR ratio, compared with fibrosis-free patient (P<0.05). However, the ALT and serum creatinine were equally recognized in those who presented with hepatic fibrosis compared with fibrosis-free patients (P>0.05).
Table 3 Relationships of changes in hepatic fibrosis with biochemical tests, hemoglobin %, and blood cell count in all studied patients

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Evaluation of sustained virologic response in diabetic patients after oral antiviral therapy

As illustrated in [Figure 2], diabetic patients (n=82) represented 13.9% of the total study populations (n=590). The same figure shows the relationship between diabetes mellitus and HCV-RNA seroconversion (serologic relapse) in the studied patients. Diabetes mellitus had a significant positive effect on HCV serologic relapse [five (6%) of 82] compared with HCV seroconversion in nondiabetic patients (six out of 508=1%) (P<0.001).
Figure 2 Association of Diabetes Mellitus with sustained virologic response (SVR) in study populations. SVR is significantly higher in non-diabetic compared to diabetic patients (P<0.001).

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Diabetes mellitus had minimal effects on routine laboratory data in the current study as shown in [Table 4]. The mean and standard deviation of liver function tests (serum albumin, serum bilirubin, and ALT), serum creatinine, platelet and WBCs counts, and Hb%, showed insignificant variations upon comparing diabetic with nondiabetic patients (P>0.05). Patient who presented with diabetes mellitus showed significant increase in INR ratio compared with nondiabetic patients (P<0.05).
Table 4 Association of diabetes mellitus with changes in biochemical tests, hemoglobin %, and blood cell count in diabetic compared with nondiabetic patients

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Correlation of baseline serum hepatitis C virus loads by single-step reverse transcription PCR with viral relapse, hepatic fibrosis and diabetes mellitus

The relationship between HCV load at baseline and viral serologic relapse is reported in [Table 5]. The mean and standard deviation of HCV load in relapsers (1181.0±1000.5) did not show any significant change when compared with viral load in nonrelapsers (1133.7±2773.1) (P=0.643).
Table 5 Relationship between baseline serum hepatitis C virus loads by single-step reverse transcription PCR and viral relapse

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The correlation of HCV load at baseline with grades of hepatic fibrosis is described in [Table 6]. The sum of means in all hepatic fibrotic grades (F1–F4) as well as the initial stages of hepatic fibrosis (F1–F3) did not have significant changes in HCV loads when compared with baseline viral loads (P>0.05). The HCV load of solitary F4 hepatic fibrosis was significantly higher compared with viral load in hepatic fibrosis-free patients (P<0.001).
Table 6 Correlation of baseline serum hepatitis C virus loads by single-step reverse transcription-PCR with grades of hepatic fibrosis

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The effect of diabetes mellitus on HCV loads at study entry was demonstrated in [Table 7] in diabetic (n=82) and nondiabetic (n=508) patients. The mean±standard deviation of HCV viral load at baseline in diabetic patients (1038.3±1702.4) did not have significant difference when compared with the mean±SD (1150.0±2884.2) of nondiabetic patients (P=0.461).
Table 7 Relationship between baseline serum hepatitis C virus loads by single-step reverse transcription-PCR and diabetes mellitus

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  Discussion Top


Our study compared two regimens of OAT in treatment of chronic HCV infection according to the current guideline. The analyzed data set that belongs to the aforementioned results described OAT outcomes on using combination therapy of SOF plus DCV with or without ribavirin. Both regimens proved very effective, because the 12-week SVR rate was 98% in overall treated patients. The current data agreed with the reported results by Merat et al. [7] who showed the same overall 12-week SVR rate by using SOF plus DCV with ribavirin regimen.

Role of genetic background in liver cirrhosis can be evaluated by studying the seven genes signature as calculated by cirrhosis risk score [15]. Until now, the relationship between HCV relapse and cirrhosis risk score has not been established yet. However, a positive correlation between post-treatment persistent solitary PBMCs HCV infection and hepatic cirrhosis in non-viremic cases was proved [15]. On the contrary, serologic HCV relapse was reported in patients with F4 hepatic fibrosis who presented with post-OAT failure, which was diagnosed by positive PBMCs-PCR in non-viremic patients, because of persistent intracellular HCV-RNA strands [10]. The same group of scientists strongly recommended using the nonresponders term instead of relapsers, as they have a convincing argument that persistence of intra-PBMC HCV-RNA at 12-week SVR after treatment with OAT for 24 weeks should be the source of later viremia. They added that it is a matter of time for intracellular infection to convert into full-blown HCV-RNA seroconversion. For this reason, they reported lower 12-week SVR rate (90%) than the reported ones in other studies, including our current data set. The same group of scientists offered a clinically applied solution for false recognition of HCV 12-week SVR. They considered HCV-RNA serologic relapse at 12 weeks after DAA therapy as none response, as almost all of relapsed patients failed to clear HCV RNA genomic materials from their PBMC during treatment. They proposed application of HCV therapy follow-up fractionation (CTF2) protocol. The core idea of the CTF2 is to check on the intra-PBMC HCV-RNA infection status during anti-viral administration to address the appropriate therapy termination point [11].

High SVR rates used to be observed in none to low grades of post-HCV hepatic fibrosis compared with cirrhotics, as viral relapse has been more commonly reported in cirrhotic liver [10]. At the same time, the current data set correlated HCV-RNA seroconversion to the increasing grades of post-HCV fibrosis. Late grades of post-HCV liver fibrosis (F3–F4) have higher HCV-RNA seroconversion compared with low grades or fibrosis free (F0–F2). This finding was supported by other reports from different countries [12],[16]. The interpretation of decreased SVR rates during late post-HCV hepatic fibrotic stages has not been clear yet. However, the circulation of HCV-RNA genomic materials for long time (years), enough to reach late hepatic fibrosis grades, would cause chronic infection of extrahepatic virotropic cells in different tissues like bone marrow with subsequent infection of mononuclear cells before releasing to patient circulation. This is supported by the unpublished data from our research group that indicates intracellular HCV infection of bone marrow nuclear cells in 15% of cirrhotic patients who reached 12-week SVR. Adding to the previous speculation, the resistance-associated variants have been concomitantly seen during our practice with late HCV cirrhotics who received anti-NS5A antivirals, which might add a joint connection between developing HCV-RNA genomic nucleotide replacement and duration of viremia that causes hepatic cirrhosis (unpublished data).

The current data reported a novel finding regarding association of diabetes mellitus with occurrence of HCV-RNA seroconversion after 12 weeks of end of treatment. The increasing HCV-RNA seroconversion in diabetic patients compared with non-diabetic cases could be attributed to (a) unusual host cell-mediated and humoralimmune responses because of the impaired glucose tolerance functions, (b) the increased frequencies of resistance-associated variants merging among diabetics, and (c) higher rates of occurrence of extra-hepatic cellular HCV-RNA strand infections. The previously mentioned interpretations are supported by the published meta-analysis data in 7 March 2017 by World J Gastroenterol [13], indicating the following: (a) HCV infection is associated with increased rates of glucose abnormalities, including diabetes mellitus and insulin resistance and (b) the presence of glucose abnormalities in HCV-infected patients, including diabetes mellitus and insulin resistance, is associated with negative liver-related outcomes (i.e. severe liver fibrosis, decreased response to antivirals, and increased occurrence of HCC). There is a full agreement between these findings and what have been happening during clinical practice. We found that successful elimination of HCV viremia has been associated with dose reduction of both oral-hypoglycemics and insulin with improved manifestations of both peripheral nerve affection and diabetic retinal disturbance (unpublished data).

The relationship between grades of liver fibrosis and baseline serum HCV particle loads was tested and analyzed in the current data. It was obvious that absence and early grades of liver fibrosis (F0–F3) had almost the same pretreatment HCV viral loads. On the contrary, more advanced hepatic fibrosis (F4) showed higher baseline blood viral loads without any changes in HCV relapses and subsequently the 12-week SVR rates. The same findings were reported by Nelson et al. in ALLY-3 phase III study in 2015 [12]. However, the analysis of 12-week SVR in patient subgroups based on baseline characteristics showed no notable differences by sex, age, and HCV-RNA levels.

Our study concluded the following: (a) DCV plus SOF with or without ribavirin anti-HCV therapeutic regimens achieved SVR after 12 weeks of end of treatment in 98% of chronic hepatitis C viral infection cases, (b) post-HCV liver fibrosis and diabetes mellitus are associated with increased frequencies of HCV-RNA seroconversion and relapses at 12-week SVR, and (c) advanced hepatic fibrosis (F4) is associated with the highest pre-treatment HCV serum viral loads, which do not affect the anti-HCV oral therapy outcomes.

Acknowledgements

The corresponding author took care of study design, data analysis, and writing the manuscript; the other co-authors helped in recruiting patients, patient management, revising and formatting the manuscript, and in executing the virological investigation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
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Nelson DR, Cooper JN, Lalezari JP, Lawitz E, Pockros PJ, Gitlin N et al. All-oral 12 week treatment with daclatasvir plus sofosbuvir in patients with hepatitis C virus genotype 3 infection: ALLY-3 phase III study. Hepatology 2015; 61:1127–1135.  Back to cited text no. 12
    
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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