Discussion:
Within 1959 patients, this study illuminates the effect of cofounding factors such as HTN, DM, BMI, age and gender in patients having HCV virus infection. Illustrating each of these points depends on a multivariate analysis for diverse parameters and patients risk factors in positive HCV patients. After analyzing the results of the study, infected female patients were found to be more with (1156) patients with 59 %, and male patients where 803 patients with 41 %. Infected patients aged ≥ 40 year old were 85.6 % , Obese patients with BMI ≥ 30 ( Kg/ m2) were 45.4 % and patients with uncontrolled blood pressure with systolic blood pressure ≥ 130 mm.Hg were (43.7 %) and diastolic blood pressure ≥ 80 mm.Hg were 72.1%.
In this study we found that in all patients with chronic HCV that the age ≥ 40 , BMI ≥ 30 (Kg/ m2) and high systolic blood pressure with esteem of ≥ 130 mm.Hg , are all independent factors for DM2. These findings suggest that ageing , being corpulent and having a high uncontrolled blood pressure all together with positive HCV infection increases the rates of glucose abnormalities including anomalies in carbohydrate metabolism, insulin resistance, metabolic clutters which may progress into DM2 [14] .
Several studies had mentioned some explanations for this hypothesis which is increasing risk of getting DM in HCV infected patients . In an important study by Abdelaziz, S.B., et al, suggesting that diabetic patients might get infected due to contaminated injections or nosocomial transmission, but this hypothesis was reduced due to the widespread use of universal precautions in hospitals. Other possible mechanisms include that the progressive increase of liver fibrosis and cirrhosis as common complications of being HCV positive patient [14] are inducing glucose metabolism impairment or reduction in glucose uptake by the cells [1] . Cirrhosis itself is considered diabetogenic . On the other hand, diabetes can worsen hepatitis C outcomes, including increasing the risk for cirrhosis and hepatocellular carcinoma (HCC) [16] [17] . .
Also, another study has suggested that eradication of HCV patients with direct-acting antiviral (DAA) therapy leads to improved glycemic control in patients with T2DM , decrease level of HbA1c and decrease the proportion of patients taking insulin [18] .
For other factors linking being diabetic and HCV positive patient, as mentioned before females have higher rate than men in the current study and another study [1] . Unlike other studies which found that Hepatitis C is more common among men than women , and male gender is also associated with more hepatitis C disease progression to fibrosis and cirrhosis [16] .
Occurrence and recurrence of HCC are high among patients with chronic HCV infection, obesity, and heavy alcohol intake. Also, nonalcoholic fatty liver disease (NAFLD) due to obesity by itself can increase the inflammation of liver or cause other obesity-related diseases [19]. [20]. Also in this current study , one of the interesting finding was the impact of BMI , as the multivariate analysis in the study revealed that having BMI ≥ 30 (Kg /m2) affects different parameters in HCV positive patients. The study noticed that the incidence of getting HCV infection is highly increased in those obese, aged ≥ 40 years, diabetic ≥ 200 mg/dL and with uncontrolled blood pressure ( diastolic blood pressure ≥ 80 mm.Hg) .
In Ali-Eldin, Z.A., et al, study showed that free fatty acid and cytokine secretion induced by adipose tissue dysfunction may contribute in both liver steatosis and induction of inflammation and as a result fibrosis level and the degree of hepatic affection in chronic HCV patients. Furthermore, changes in glucose metabolism which results into insulin resistance as mentioned before , all are associated with more liver disease , so changes in the hosts lipid metabolism due to chronic HCV increase viral replication, which can lead to steatosis and may affect the efficacy of interferon-based therapy. This represents a novel target for therapeutic intervention in HCV eradication [21] .
Another vital factor in the multivariate analysis is that cardiovascular diseases appear to be increased with higher rate of morbidity and mortality especially hypertensive patients with blood pressure ≥ 130 mm.Hg ( with systolic blood pressure ≥ 130 mm.Hg and diastolic blood pressure ≥ 80 mm.Hg) , and also BMI ≥ 30 ( kg/m2) [22] . Unlike other studies which depends only on hypertension and diabetes and showed two-fold higher risk of subclinical carotid plaques among HCV-infected individuals compared to uninfected controls and increase in the rate of peripheral arterial diseases as well. This maybe due to the severity of the liver damage or even due to direct viral activity [23] .
In recent study untreated HCV infected persons have twice risk of CVD (Cardiovascular diseases) as: (coronary artery disease events, acute myocardial infarction, congestive heart failure, unstable angina, and revascularization procedures, stroke and peripheral vascular disease) than those who initiated treatment [24]. As a result, significant benefit of HCV treatment on the incidence and risk of possible CVD events in the future [24]. Other studies have mentioned that co-infection with both HCV/HIV viruses are associated with more risk to CVD [25] [26], so reduction in survival is obvious in HIV/HCV- coinfected patients than HIV-monoinfected patients and HIV-coinfected patients without cirrhosis [27] . Concerning another study, persistent HCV replication leads to a state of systemic inflammation and immune activation that leads to endothelial dysfunction, atherosclerosis and increased CVD risk [15] .