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World J Gastroenterol. Jan 28, 2009; 15(4): 462-466
Published online Jan 28, 2009. doi: 10.3748/wjg.15.462
Clinical expression of insulin resistance in hepatitis C and B virus-related chronic hepatitis: Differences and similarities
Marcello Persico, Mario Masarone, Vincenzo La Mura, Eliana Persico, Francesco Moschella, Monica Svelto, Savino Bruno, Roberto Torella
Marcello Persico, Mario Masarone, Vincenzo La Mura, Eliana Persico, Francesco Moschella, Monica Svelto, Roberto Torella, Internal Medicine and Hepatology Unit, Second University of Naples, Naples 80122, Italy
Savino Bruno, Internal Medicine and Hepatology Unit, Fatebe-nefratelli Hospital, Milan 20121, Italy
Author contributions: Persico M and Masarone M analyzed data and wrote the paper; Persico M, Masarone M, La Mura V, Bruno S and Torella R designed research; Persico E and Moschella F performed research.
Correspondence to: Marcello Persico, MD, Internal Medicine and Hepatology Unit, Second University of Naples, Via F. Petrarca, 101/b, Naples 80122, Italy.
Telephone: +39-81-5666838
Fax: +39-81-5666838
Received: January 30, 2008
Revised: October 31, 2008
Published online: January 28, 2009


AIM: To investigate the prevalence of the clinical parameters of insulin resistance and diabetes in patients affected by chronic hepatitis C (CHC) or chronic hepatitis B (CHB).

METHODS: We retrospectively evaluated 852 consecutive patients (726 CHC and 126 CHB) who had undergone liver biopsy. We recorded age, sex, ALT, type 2 diabetes and/or metabolic syndrome (MS), body mass index (BMI), and apparent disease duration (ADD).

RESULTS: Age, ADD, BMI, prevalence of MS and diabetes in patients with mild/moderate liver fibrosis were significantly higher in CHC. However, the degree of steatosis and liver fibrosis evaluated in liver biopsies did not differ between CHC and CHB patients. At multivariate analysis, age, sex, BMI, ALT and diabetes were independent risk factors for liver fibrosis in CHC, whereas only age was related to liver fibrosis in CHB. We also evaluated the association between significant steatosis (> 30%) and age, sex, BMI, diabetes, MS and liver fibrosis. Diabetes, BMI and liver fibrosis were associated with steatosis > 30% in CHC, whereas only age and BMI were related to steatosis in CHB.

CONCLUSION: These data may indicate that hepatitis C virus infection is a risk factor for insulin resistance.

Key Words: Insulin resistance, Diabetes, Metabolic syndrome, Hepatitis C virus, Hepatitis B virus

Citation: Persico M, Masarone M, Mura VL, Persico E, Moschella F, Svelto M, Bruno S, Torella R. Clinical expression of insulin resistance in hepatitis C and B virus-related chronic hepatitis: Differences and similarities. World J Gastroenterol 2009; 15(4): 462-466

Recent years have seen numerous studies devoted to the relationship of such clinical variables as age, gender and body mass index (BMI) with metabolic alterations involving the liver in patients affected by hepatitis C virus (HCV)-related chronic hepatitis. Attention has focused on the metabolic syndrome (MS), diabetes[12345], steatosis/steatohepatitis[678910] and associations between these conditions[1112131415]. It remains to be established whether the relationship between HCV and deranged cellular metabolic pathways is casual or whether it results from a direct effect exerted by HCV.

In an attempt to shed light on this issue, we examined the prevalence of these phenomena in chronic hepatitis C (CHC) and in chronic hepatitis B (CHB) in order to distinguish between alterations due to presence of an advanced liver disease and those due to HCV[161718].

We have investigated the prevalence of MS and/or diabetes and their effect on liver fibrosis and/or steatosis/steatohepatitis in a large cohort of patients affected by HCV- or hepatitis B virus (HBV)-related chronic hepatitis. Our aim was to look for differences and similarities between the two types of viral hepatitis and to confirm or refute the hypothesis of metabolic cofactors in HCV-related liver disease(s).


We retrospectively evaluated 852 consecutive patients (726 CHC and 126 CHB) who underwent clinical evaluation and liver biopsy for HBV- or HCV-related hypertransaminasemia in the Internal Medicine and Hepatology Unit at the Second University of Naples from April 1999 to November 2005. The inclusion criterion was HBsAg-positive or HCV-Ab-positive chronic hepatitis. The exclusion criteria were: patients with a recent (< 6 mo) history of high alcohol consumption (> 30 g/d in females, > 40 g/d in males ) or a history of intravenous drug abuse, clinical and/or ultrasound evidence of cirrhosis, an human immunodeficiency virus (HIV)-positive test and HBV/HCV co-infection. In addition to a complete blood count, each patient underwent tests for: serum markers for hepatitis B infection determined by radioimmunoassay (Abbott Laboratories, North Chicago, IL, USA), antibodies to HCV assayed by a second-generation enzyme-linked immunoassay (ELISA; Ortho Diagnostic Systems, Raritan, NJ, USA), the presence of type 2 diabetes according to American Diabetes Association criteria[19] by assessing fasting serum glucose and/or the oral glucose tolerance test (OGTT) on two different occasions, and for the presence of MS based on NCEP-ATP III criteria[20]. BMI (kg/m2) was recorded and the apparent disease duration [(ADD) in years] was determined by considering the exposure to major risk factors as the start of infection. Each patient underwent an echo-assisted liver biopsy performed with a 17G Menghini modified needle (Surecut, TSK Laboratory, Japan) through an intercostal entry. The liver specimens were formalin-fixed, embedded in paraffin and evaluated with the Ishak scoring system for viral liver disease[21] by skilled liver pathologists, who also evaluated the presence of liver steatosis and steato-hepatitis according to Brunt et al[22].

Statistical analysis of data was performed using the SPSS® 13.0 software for Windows®. Non-parametric tests (χ2 or Fisher’s exact), Spearman’s rho test, ANOVA, linear and logistic regression tests were performed where appropriate.


As shown in Table 1, HCV-positive patients had a significantly longer ADD (P < 0.005), a significantly older age (P < 0.0001) and a significantly higher BMI (P < 0.005) vs HBV-positive subjects. The MS was present in 76 out of 726 HCV patients (10.46%) and in only 2 of the 126 HBV subjects (P < 0.005). The prevalence of diabetes did not differ significantly between the two groups, but it was significantly higher in HCV subjects when comparing only patients with mild fibrosis (Ishak S0-S3) at liver biopsy (P < 0.005) (Figure 1). The prevalence of diabetes in mild fibrosis patients did not differ between the two groups when patients were stratified by age. No differences were found at liver biopsy as regards grading and staging, neither was there a difference in the prevalence of patients with higher degrees of steatosis.

Table 1 Epidemiological and histological data of the two groups studied.
Epidemiological data
Number of patients (M/F)726 (426/300)126 (83/43)NS
DD (yr)25.78 ± 14.2221.4 ± 11.91< 0.005
Age (yr)53.88 ± 13.2045.68 ± 14.40< 0.0001
BMI (kg/m2)26.74 ± 4.2525.43 ± 3.43< 0.005
Metabolic syndrome76 pt (10.46%)2 pt (1.72%)< 0.005
Liver Biopsy (Ishak Score)
Grading11.25 ± 3.506.61 ± 3.36NS
Staging2.66 ± 1.992.44 ± 1.57NS
Steatosis > 30%98 pt (13.49%)14 pt (12.06%)NS
Figure 1
Figure 1 Diabetes prevalence divided by fibrosis score (Ishak).

To evaluate whether age, sex, BMI, ALT, diabetes, MS and steatosis were independent risk factors for liver fibrosis we carried out a univariate and a multivariate analysis in the two groups of patients. At univariate analysis, all the variables tested were significantly related to higher degrees of fibrosis in HCV patients, whereas only age was correlated to liver fibrosis in HBV patients (Table 2). The results of the multivariate analysis confirmed these findings, namely age, sex, BMI, ALT and diabetes were independent risk factors for fibrosis in HCV subjects, whereas only age was related to fibrosis in HBV patients (Table 3).

Table 2 Univariate analysis (Spearman test) between liver fibrosis (Ishak staging on liver biopsy) and anthropometric, clinical and metabolic characteristics in the two groups of patients.
Linearity coefficientStandard errorPtLinearity coefficientStandard errorPt
Age (yr)0.3320.046< 0.00017.3770.5320.071< 0.00015.689
Sex0.2840.046< 0.053.7640.1320.108NS1.209
BMI0.2430.050< 0.00014.6330.1420.113NS1.162
ALT0.2270.045< 0.00014.8330.1570.082NS1.435
Diabetes0.2110.050< 0.00014.5320.0140.123NS0.103
Metabolic syndrome0.1080.039< 0.052.2780.0150.011NS0.112
Steatosis0.0950.045< 0.052.0060.0680.187NS0.283
Table 3 Multivariate analysis (multiple regression) of the correlation between liver fibrosis (Ishak staging on liver biopsy) and anthropometric, clinical and metabolic characteristics in the two groups of patients.
Linearity coefficientStandard errorPLinearity coefficientStandard errorP
Age (yr)0.04690.0068< 0.00010.05616.01420.0001
Sex0.03620.1794< 0.05---
BMI0.04170.0208< 0.05---
ALT0.00380.0010< 0.0001---
Diabetes0.47420.2172< 0.05---
Metabolic syndrome0.28300.2846NS---

We next carried out statistical analyses to evaluate whether age, sex, BMI, ALT or diabetes were related to steatosis, which is a well known negative predictor of both disease outcome and response to therapy in HCV patients[23242526]. None of these parameters were significantly associated with degree of steatosis. However, when we did the same analysis considering only patients with steatosis > 30%, a higher BMI, diabetes and fibrosis were correlated with severe steatosis in CHC patients (Tables 4 and 5).

Table 4 Univariate analysis of the correlation between the presence of higher degrees of steatosis (> 30%) assessed on liver biopsy and anthropometric, clinical and metabolic characteristics in the two groups of patients.
Age (yr)1.7470.888-3.430NS4.4321.056-18.310< 0.05
BMI (> 30)2.5101.593-3.954< 0.00110.4352.166-38.338< 0.005
Diabetes1.8941.193-3.007< 0.050.9130.213-4.017NS
Metabolic syndrome0.9680.486-1.931NS4.1800.531-3.367NS
Fibrosis (staging)4.7002.750-8.034< 0.0010.4590.073-2.981NS
Table 5 Multivariate analysis (logistic regression) of the correlation between the presence of significant steatosis (> 30%) assessed on liver biopsy and anthropometric, clinical and metabolic characteristics in the two groups of patients.
Age (yr)---1.2141.085-1.359< 0.001
BMI (> 30)2.2161.186-4.143< 0.051.0491.007-1.094< 0.05
Diabetes2.6841.444-4.987< 0.005---
Fibrsis (Staging)4.7002.750-8.034< 0.001---

In our cohort study, the prevalence of MS and diabetes was significantly higher in patients with HCV-related chronic hepatitis than in patients with HBV-related chronic liver disease. This suggests that insulin resistance, which is the mechanism underlying MS, might at least in part be related to HCV infection. Insulin resistance is identified with the euglycemic clamp technique[27] or with the homeostasis model assessment insulin resistance (HOMA-IR) test[28]. Neither euglycemic clamp nor the HOMA-IR test was performed in our patients. However, we used the most practical worldwide accepted definition of MS according to the ATP-III NCEP clinical criteria[20]. Moreover, unlike other authors[1629303132], we were able to measure, using these criteria, central obesity which is considered the fundamental condition for a clinical diagnosis of MS[33]. The association of diabetes and severe chronic liver disease is widely recognized[4163234], therefore the effect of severe liver disease on diabetes onset should be considered when comparing groups of patients affected by chronic liver disease. In our study, we were able to rule out that diabetes was related to the altered hepatic glycaemic homeostasis due to severe liver disease (i.e. cirrhosis). In fact, whereas the total prevalence of diabetes did not differ between HCV and HBV patients, the prevalence of diabetes among patients with mild chronic hepatitis was significantly higher in HCV subjects.

This finding confirms reports of a higher prevalence of diabetes in HCV patients[142934], and, vice versa, a report of a higher prevalence of HCV in diabetic patients[30]. Moreover, our data are in line with recent reports of a higher prevalence of diabetes in HCV patients compared with other liver diseases (e.g. HBV infection)[1]. In particular, Jan et al[17] reported a significantly higher prevalence of MS in HCV patients vs HBV patients, and an inverse ratio between HBV infection and clinical expression of MS in a population-based study carried out in Taiwan.

The association between diabetes and HCV-related chronic hepatitis was reported to influence the clinical outcome of liver disease[353637]. Moreover, diabetes and/or obesity were found to be cofactors of liver disease in that they affect liver fibrosis progress and response to antiviral therapy[2324373839]. Here we report that, besides ALT, sex and age, also diabetes and BMI were independent risk factors for more severe liver fibrosis in HCV-positive patients, whereas they were not associated with the severity of liver fibrosis in HBV subjects. This finding supports the idea that obesity and diabetes might represent clinical epiphenomena of the pathogenesis of HCV infection. In line with this hypothesis, using an animal model, Shintani et al[40] found that HCV directly affects serum glycaemic and insulinaemic levels, probably by acting via TNF-α. Similarly, Kawaguchi et al[41] reported that HCV directly affects intracellular insulin metabolic pathways via genetic up-regulation. However, we cannot exclude the possibility that synergism between the two diseases (diabetes/non-alcoholic steatohepatitis and virus-related chronic hepatitis) affects the outcome of liver fibrosis[711].

Steatosis has been associated with more severe liver fibrosis[23242526] as well as with a worse response to antiviral therapy. Moreover, steatosis is defined “metabolic steatosis” in non-3-genotype-infected patients as opposed to the viral steatosis typical of genotype 3 patients[11]. In our cohort of HCV patients, steatosis did not appear to be an independent risk factor for fibrosis stage. The discrepancy between our results and previous findings is apparent. Indeed, univariate and multivariate analyses vs fibrosis showed that steatosis was associated with the severity of liver fibrosis in our HCV patients if they were also affected by diabetes and/or obesity. Moreover, at multivariate analysis vs steatosis, BMI, diabetes and fibrosis were independent risk factors only for steatosis > 30%. This suggests that histological features of fibrosis, whether related to non-alcoholic steatohepatitis or to virus-associated steatohepatitis, will be found only in cases in which steatosis is > 30%.

This study provides clinical evidence that HCV directly affects insulin resistance in a large Italian retrospective, single-centre, consecutive population of HCV- and HBV-infected subjects. Biological, molecular and genetic studies are required to test this hypothesis.


Glucose metabolism derangements are common in hepatitis C virus (HCV) patients but there is still a lot of deliberation as to whether the relationship between HCV and deranged cellular metabolic pathways is casual or whether it results from a direct effect exerted by HCV.

Research frontiers

To investigate the prevalence of the clinical parameters of insulin resistance and diabetes in patients affected by chronic hepatitis C (CHC) or chronic hepatitis B (CHB).

Innovations and breakthroughs

A direct comparison of the prevalence of clinical features of insulin resistance in HCV and HBV infection in a large cohort of Italian patients.


To shed light on the association between insulin resistance and HCV infection and recommend further biological, molecular and genetic studies, and finally to suggest a careful assessment of insulin resistance status in HCV clinical care.

Peer review

The authors retrospectively analyzed a large cohort of consecutively-enrolled HCV (726) and HBV (126) patients undergoing liver biopsy in order to find a correlation between clinical expressions of insulin resistance (diabetes and metabolic syndrome) and HCV liver disease in comparison with HBV-related chronic hepatitis. This is an interesting paper and is of importance.

1.  Mason AL, Lau JY, Hoang N, Qian K, Alexander GJ, Xu L, Guo L, Jacob S, Regenstein FG, Zimmerman R. Association of diabetes mellitus and chronic hepatitis C virus infection. Hepatology. 1999;29:328-333.  [PubMed]  [DOI]
2.  Mehta SH, Brancati FL, Sulkowski MS, Strathdee SA, Szklo M, Thomas DL. Prevalence of type 2 diabetes mellitus among persons with hepatitis C virus infection in the United States. Ann Intern Med. 2000;133:592-599.  [PubMed]  [DOI]
3.  Knobler H, Schihmanter R, Zifroni A, Fenakel G, Schattner A. Increased risk of type 2 diabetes in noncirrhotic patients with chronic hepatitis C virus infection. Mayo Clin Proc. 2000;75:355-359.  [PubMed]  [DOI]
4.  Zein NN, Abdulkarim AS, Wiesner RH, Egan KS, Persing DH. Prevalence of diabetes mellitus in patients with end-stage liver cirrhosis due to hepatitis C, alcohol, or cholestatic disease. J Hepatol. 2000;32:209-217.  [PubMed]  [DOI]
5.  Hui JM, Sud A, Farrell GC, Bandara P, Byth K, Kench JG, McCaughan GW, George J. Insulin resistance is associated with chronic hepatitis C virus infection and fibrosis progression [corrected]. Gastroenterology. 2003;125:1695-1704.  [PubMed]  [DOI]
6.  Monto A, Alonzo J, Watson JJ, Grunfeld C, Wright TL. Steatosis in chronic hepatitis C: relative contributions of obesity, diabetes mellitus, and alcohol. Hepatology. 2002;36:729-736.  [PubMed]  [DOI]
7.  Ramesh S, Sanyal AJ. Hepatitis C and nonalcoholic fatty liver disease. Semin Liver Dis. 2004;24:399-413.  [PubMed]  [DOI]
8.  Lonardo A, Adinolfi LE, Loria P, Carulli N, Ruggiero G, Day CP. Steatosis and hepatitis C virus: mechanisms and significance for hepatic and extrahepatic disease. Gastroenterology. 2004;126:586-597.  [PubMed]  [DOI]
9.  Koike K, Moriya K. Metabolic aspects of hepatitis C viral infection: steatohepatitis resembling but distinct from NASH. J Gastroenterol. 2005;40:329-336.  [PubMed]  [DOI]
10.  Adinolfi LE, Gambardella M, Andreana A, Tripodi MF, Utili R, Ruggiero G. Steatosis accelerates the progression of liver damage of chronic hepatitis C patients and correlates with specific HCV genotype and visceral obesity. Hepatology. 2001;33:1358-1364.  [PubMed]  [DOI]
11.  Ong JP, Younossi ZM, Speer C, Olano A, Gramlich T, Boparai N. Chronic hepatitis C and superimposed nonalcoholic fatty liver disease. Liver. 2001;21:266-271.  [PubMed]  [DOI]
12.  Younossi ZM, McCullough AJ, Ong JP, Barnes DS, Post A, Tavill A, Bringman D, Martin LM, Assmann J, Gramlich T. Obesity and non-alcoholic fatty liver disease in chronic hepatitis C. J Clin Gastroenterol. 2004;38:705-709.  [PubMed]  [DOI]
13.  Sanyal AJ, Contos MJ, Sterling RK, Luketic VA, Shiffman ML, Stravitz RT, Mills AS. Nonalcoholic fatty liver disease in patients with hepatitis C is associated with features of the metabolic syndrome. Am J Gastroenterol. 2003;98:2064-2071.  [PubMed]  [DOI]
14.  Chitturi S, George J. Interaction of iron, insulin resistance, and nonalcoholic steatohepatitis. Curr Gastroenterol Rep. 2003;5:18-25.  [PubMed]  [DOI]
15.  Clouston AD, Powell EE. Interaction of non-alcoholic fatty liver disease with other liver diseases. Best Pract Res Clin Gastroenterol. 2002;16:767-781.  [PubMed]  [DOI]
16.  Papatheodoridis GV, Chrysanthos N, Savvas S, Sevastianos V, Kafiri G, Petraki K, Manesis EK. Diabetes mellitus in chronic hepatitis B and C: prevalence and potential association with the extent of liver fibrosis. J Viral Hepat. 2006;13:303-310.  [PubMed]  [DOI]
17.  Jan CF, Chen CJ, Chiu YH, Chen LS, Wu HM, Huang CC, Yen MF, Chen TH. A population-based study investigating the association between metabolic syndrome and hepatitis B/C infection (Keelung Community-based Integrated Screening study No. 10). Int J Obes (Lond). 2006;30:794-799.  [PubMed]  [DOI]
18.  Sangiorgio L, Attardo T, Gangemi R, Rubino C, Barone M, Lunetta M. Increased frequency of HCV and HBV infection in type 2 diabetic patients. Diabetes Res Clin Pract. 2000;48:147-151.  [PubMed]  [DOI]
19.  Diagnosis and classification of diabetes mellitus. Diabetes Care. 2006;29 Suppl 1:S43-S48.  [PubMed]  [DOI]
20.  Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.  [PubMed]  [DOI]
21.  Ishak K, Baptista A, Bianchi L, Callea F, De Groote J, Gudat F, Denk H, Desmet V, Korb G, MacSween RN. Histological grading and staging of chronic hepatitis. J Hepatol. 1995;22:696-699.  [PubMed]  [DOI]
22.  Brunt EM. Nonalcoholic steatohepatitis. Semin Liver Dis. 2004;24:3-20.  [PubMed]  [DOI]
23.  Hourigan LF, Macdonald GA, Purdie D, Whitehall VH, Shorthouse C, Clouston A, Powell EE. Fibrosis in chronic hepatitis C correlates significantly with body mass index and steatosis. Hepatology. 1999;29:1215-1219.  [PubMed]  [DOI]
24.  Castera L, Hezode C, Roudot-Thoraval F, Bastie A, Zafrani ES, Pawlotsky JM, Dhumeaux D. Worsening of steatosis is an independent factor of fibrosis progression in untreated patients with chronic hepatitis C and paired liver biopsies. Gut. 2003;52:288-292.  [PubMed]  [DOI]
25.  Leandro G, Mangia A, Hui J, Fabris P, Rubbia-Brandt L, Colloredo G, Adinolfi LE, Asselah T, Jonsson JR, Smedile A. Relationship between steatosis, inflammation, and fibrosis in chronic hepatitis C: a meta-analysis of individual patient data. Gastroenterology. 2006;130:1636-1642.  [PubMed]  [DOI]
26.  Ratziu V, Trabut JB, Poynard T. Fat, diabetes, and liver injury in chronic hepatitis C. Curr Gastroenterol Rep. 2004;6:22-29.  [PubMed]  [DOI]
27.  DeFronzo RA, Tobin JD, Andres R. Glucose clamp technique: a method for quantifying insulin secretion and resistance. Am J Physiol. 1979;237:E214-E223.  [PubMed]  [DOI]
28.  Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC. Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia. 1985;28:412-419.  [PubMed]  [DOI]
29.  Lecube A, Hernandez C, Genesca J, Esteban JI, Jardi R, Simo R. High prevalence of glucose abnormalities in patients with hepatitis C virus infection: a multivariate analysis considering the liver injury. Diabetes Care. 2004;27:1171-1175.  [PubMed]  [DOI]
30.  Chen HF, Li CY, Chen P, See TT, Lee HY. Seroprevalence of hepatitis B and C in type 2 diabetic patients. J Chin Med Assoc. 2006;69:146-152.  [PubMed]  [DOI]
31.  Mangia A, Schiavone G, Lezzi G, Marmo R, Bruno F, Villani MR, Cascavilla I, Fantasia L, Andriulli A. HCV and diabetes mellitus: evidence for a negative association. Am J Gastroenterol. 1998;93:2363-2367.  [PubMed]  [DOI]
32.  Allison ME, Wreghitt T, Palmer CR, Alexander GJ. Evidence for a link between hepatitis C virus infection and diabetes mellitus in a cirrhotic population. J Hepatol. 1994;21:1135-1139.  [PubMed]  [DOI]
33.  Alberti KG, Zimmet P, Shaw J. The metabolic syndrome--a new worldwide definition. Lancet. 2005;366:1059-1062.  [PubMed]  [DOI]
34.  Zein CO, Levy C, Basu A, Zein NN. Chronic hepatitis C and type II diabetes mellitus: a prospective cross-sectional study. Am J Gastroenterol. 2005;100:48-55.  [PubMed]  [DOI]
35.  Prati D, Shiffman ML, Diago M, Gane E, Rajender Reddy K, Pockros P, Farci P, O’Brien CB, Lardelli P, Blotner S. Viral and metabolic factors influencing alanine aminotransferase activity in patients with chronic hepatitis C. J Hepatol. 2006;44:679-685.  [PubMed]  [DOI]
36.  Davila JA, Morgan RO, Shaib Y, McGlynn KA, El-Serag HB. Diabetes increases the risk of hepatocellular carcinoma in the United States: a population based case control study. Gut. 2005;54:533-539.  [PubMed]  [DOI]
37.  Tarantino G, Conca P, Sorrentino P, Ariello M. Metabolic factors involved in the therapeutic response of patients with hepatitis C virus-related chronic hepatitis. J Gastroenterol Hepatol. 2006;21:1266-1268.  [PubMed]  [DOI]
38.  D'Souza R, Sabin CA, Foster GR. Insulin resistance plays a significant role in liver fibrosis in chronic hepatitis C and in the response to antiviral therapy. Am J Gastroenterol. 2005;100:1509-1515.  [PubMed]  [DOI]
39.  Sanyal AJ, Chand N, Comar K, Mirshahi F. Hyperinsulinemia blocks the inhibition of hepatitis C virus (HCV) replication by interferon: a potential mechanism for failure of interferon therapy in subjects with HCV and nonalcoholic liver disease. Hepatology. 2004;40:A179.  [PubMed]  [DOI]
40.  Shintani Y, Fujie H, Miyoshi H, Tsutsumi T, Tsukamoto K, Kimura S, Moriya K, Koike K. Hepatitis C virus infection and diabetes: direct involvement of the virus in the development of insulin resistance. Gastroenterology. 2004;126:840-848.  [PubMed]  [DOI]
41.  Kawaguchi T, Yoshida T, Harada M, Hisamoto T, Nagao Y, Ide T, Taniguchi E, Kumemura H, Hanada S, Maeyama M. Hepatitis C virus down-regulates insulin receptor substrates 1 and 2 through up-regulation of suppressor of cytokine signaling 3. Am J Pathol. 2004;165:1499-1508.  [PubMed]  [DOI]