Letter: metabolic dysfunction‐associated fatty liver disease increases risk of all‐cause mortality in patients with chronic hepatitis C

Editors, We read with great interest the study by Attia et al comparing the prevalence and characteristics of metabolic profiles among metabolicassociated fatty liver disease (MAFLD) patients with chronic hepatitis C virus (HCV) infection.1 They concluded that MAFLD was highly prevalent in patients with chronic HCV infection and has risen from the period 2007– 2013 to 2014– 2020 in Egypt. This study had a large sample size and validated the association between MAFLD and HCV.1 Patients with HCV infection and coexisting MAFLD had more severe hepatic fibrosis evaluated by Fibrosis4 (FIB4) score and nonalcoholic fatty liver disease (NAFLD) fibrosis score. However, the prognosis of those patients is still unclear. To analyse whether MAFLD contributes to the mortality associated with HCV infection, we recruited 348 patients with HCV infection from the third National Health and Nutrition Examination Surveys 1988– 1994 (NHANES III), and conducted a longitudinal study to examine the longterm mortality of participants with HCV infection and MAFLD. In the fully adjusted model, MAFLD was significantly and independently associated with higher risk for allcause mortality (adjust hazard ratio [aHR], 1.66; 95% CI, 1.13– 2.44; p < 0.01) in the overall population (Table 1). Moreover, participants with MAFLD had higher othercause(noncardiovascular disease [CVD], noncancer) related mortality rates (aHR, 2.23; 95% CI, 1.19– 4.17; p < 0.02). However, we found no significant difference in CVD and cancerrelated mortality between groups (Table 1). Chronic hepatitis B or hepatitis C infection could increase the risk of development of hepatic steatosis, cirrhosis and carcinogenesis.2– 4 Recently, van Kleef et al concluded that chronic hepatitis B could increase the risk of liverrelated clinical events and death in patients with MAFLD.5 Similarly, our study shows for the first time that MAFLD is associated with an increased risk of allcause mortality among patients with HCV infection. In conclusion, our results provide evidence for the clinical usefulness of the novel MAFLD criteria in HCV and emphasise the significance of metabolic health assessment in these participants. Further prospective studies are required to validate the impact of MAFLD on patients with HCV infection.