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ORIGINAL ARTICLE
Year : 2016  |  Volume : 30  |  Issue : 2  |  Page : 84-88

Prevalence of diabetes in chronic liver disease patient admitted in medicine ward in RIMS Hospital, Imphal


Department of Medicine, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Web Publication24-May-2016

Correspondence Address:
Obang Perme
Department of Medicine, RIMS, Imphal, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.182906

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  Abstract 

Context: First study on prevalence of diabetic among chronic liver disease (CLD) patient in Manipur and North-East India as a whole. Aims: To determine the prevalence of diabetes in CLD patient and to correlate the presence of diabetes with clinical features and complications of CLD. Settings and Design: A prospective study was carried out in the Department of Medicine, RIMS, Imphal, from September 2011 to August 2013. Subjects and Methods: Total of 155 cases of CLD who qualify the inclusion criteria was included in analysis. CLD was diagnosed based on history, liver function test, ultrasonography abdomen, and upper gastrointestinal endoscopy. Diabetes diagnosed based on history and who criteria. Statistical Analysis Used: Data obtained from study were analyzed by SPSS Version 16. Results: The prevalence of diabetes was 12.9%. Most common age group was 31-40 years. However, percentage wise diabetes tends to be higher among younger age group 18-30 years groups (27.3%) compared to other age groups. The common clinical findings were ascites (95.5%), pallor (83.8%), and icterus (74.8%). Most common finding among diabetic patient was ascites (95%). Anemia, upper gastrointestinal bleeding, and hepatic encephalopathy (HE) were slightly higher in diabetic group. Conclusions: In this study, prevalence of diabetes was 12.9% among CLD. Complication of CLD was slightly higher among diabetic patient. Presence of diabetes mellitus in patients of CLD post a difficulty in diagnosis as well as management of complications, especially HE.

Keywords: Chronic liver disease, complications, diabetes, prevalence


How to cite this article:
Perme O, Singh YI, Singh KR, Devi BS, Rao A, Singh SK. Prevalence of diabetes in chronic liver disease patient admitted in medicine ward in RIMS Hospital, Imphal. J Med Soc 2016;30:84-8

How to cite this URL:
Perme O, Singh YI, Singh KR, Devi BS, Rao A, Singh SK. Prevalence of diabetes in chronic liver disease patient admitted in medicine ward in RIMS Hospital, Imphal. J Med Soc [serial online] 2016 [cited 2021 Apr 12];30:84-8. Available from: https://www.jmedsoc.org/text.asp?2016/30/2/84/182906


  Introduction Top


The prevalence of diabetes is increasing worldwide, and it is expected to affect around 300 million adult all over the world and around 57 million in India by the year 2025. Chronic liver diseases (CLDs) are arising in a diabetic patient as a cause or effect of diabetes. [1] Association between diabetes mellitus (DM) and liver cirrhosis was first described by Bohan, [2] and named as hepatogenous diabetes by Megyesi et al. [3] in which 57% of cirrhotic patients showed increased insulin resistance. Up to 80% of patients with cirrhosis may be glucose intolerant and between 10% and 20% may be clinically diabetic. [1]

The liver is a central regulator of glucose homeostasis and store or release of glucose according to metabolic demands. In diabetes or insulin resistance states, the dysregulation of hepatic glucose release contributes significantly to the pathophysiology of those conditions. DM is identified risk factor for hepatocellular carcinoma (HCC) and increase the risk of HCC by 2-4 fold even after adjusting for other predisposing factors. [4] Acute or CLD can aggravates insulin resistance and pathophysiological effects of insulin on hepatocyte are disturbed. [5] In presence of hepatic disease, the metabolic homeostasis of glucose is impaired as a result of disorder such as insulin resistance, glucose intolerance, and diabetes. Insulin resistance develops not only in muscle but also in adipose tissue which combined with hyperinsulinemia may seem as important pathophysiologic base of diabetes in liver disease. [6]

Glucose absorbed from the intestinal tract is transported via portal vein to liver where most of the glucose is retained by the liver, so that most of the raise in peripheral glucose concentration is a reflection of only a minor component of postprandial absorbed glucose. Therefore, it is possible that liver may play a more significant role than peripheral tissue in maintaining systemic blood glucose level following a meal. [1] DM in cirrhotic patients may be subclinical. Hepatogenous diabetes is clinically different from type 2 DM, since it is less frequently associated with microangiopathy and patients more frequently suffer complications of cirrhosis and increases the mortality of cirrhotic patients. [6]

There are various studies conducted regarding diabetes in CLD in different parts of the world and also in India but has never been done in Manipur earlier. This is the first study on the prevalence and association of diabetes with CLD in the Manipur and North East region as a whole.


  Subjects and methods Top


This prospective study was carried out in the Department of Medicine in collaboration with the Department of Radiology, Biochemistry, and Pathology, Regional Institute of Medical Sciences, Imphal, Manipur, from September 2011 to August 2013. A total of 155 cases of CLD patients was included in this study. Ethical approval was taken from the Institute of Ethical Committee, RIMS, Imphal, Manipur, before the start of study. Diabetes status of patient was established by history and blood sugar levels as per the World Health Organization Criteria. The CLD was diagnosed based on history, clinical examination, liver function test abnormalities, ultrasonographic findings of changes in liver echotexture, ascites, dilatation of portal vein and splenomegaly, and upper gastrointestinal tract endoscopic finding of portal gastropathy or esophageal varices.

Inclusion criteria

The inclusion criteria were as follows:

  • Any case of CLD patient admitted in medicine ward that is willing to participate in the study
  • Age more than 18 years.


Exclusion criteria

The exclusion criteria were as follows:

  • Patients with pituitary, adrenal, thyroid diseases, and other endocrine disorders
  • Patients on immunosuppressive drug or drug likely to affect glucose metabolism
  • Congestive cardiac failure
  • HIV infected patients
  • Collagen vascular disorders
  • Malignancy and those patients who are not willing to participate in this study were excluded from this study.


Statistical analysis

Data obtained from study were analyzed by SPSS Version 16 (Statistical Package for Social Sciences (SPSS) Version 16 for Windows). Data were described using percentages, mean with standard deviation, and median with range. Analysis was done by Chi-square test or Fisher exact test for qualitative data and for quantitative data analysis was done by t-test or Mann-Whitney U-test.


  Results Top


The study included 155 cases of CLD admitted in the Department of Medicine, RIMS Hospital from October 2011 to September 2013. Among these 155 cases, diabetes was present in 20 cases giving a prevalence rate of 12.9%. Most of the diabetes were in age groups of 31-40 years 7 (19%) cases and 41-50 years 6 (12%) cases but percentage of diabetes was higher in younger age group <30 years groups (27.3%) compared to other age groups [Table 1]. Diabetes was present in 20 (13.7%) cases of males and none of female participants was diabetic; however, P = 0.10 was not significant [Table 2]. Diabetes was present in 16 (13.0%) cases of Hindu and 4 (17.4%) cases of Christian respondents among CLD cases [Table 3]. Diabetes was present in 6 (27.3%) and 14 (10.9%) of employed and unemployed, respectively [Table 4]. Most of the cases were alcoholic liver disease 110 (70.9%) followed by chronic hepatitis C in 38 (24.5%) cases and chronic hepatitis B in 7 (4.5%) cases. There was no statistically significant relationship between diabetes and hepatitis C infection in CLD [Table 5]. The most common complication was anemia in 130 (83.9%) followed by upper gastrointestinal bleeding in 76 (49%) and hepatic encephalopathy (HE) in 57 (36.8%). Among diabetic cases, the most common one were upper gastrointestinal bleeding in 11 (55%), HE in 7 (35%), and hepatorenal syndrome in 3 (15%). Pleural effusion was found in 8 (5.2%) cases out of which only one was diabetic as shown in [Table 6]. It is evident from [Table 7] that most of the patients were discharged, i.e., 133 (85.8%) cases, and 20 (12.9%) cases were expired. More death occurs among diabetic cases than nondiabetic cases (20% vs. 11.9%) but this finding is statistically insignificant (P = 0.29). The comparison of Child Pugh score and the Model for end stage liver disease (MELD) score between CLD with diabetes and non-diabetic CLD is shown in [Table 8], and the findings are comparable.
Table 1: Distribution of base on age

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Table 2: Distribution of respondents based on sex

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Table 3: Distribution of respondents by religion

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Table 4: Distribution base on occupation

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Table 5: Hepatitis B and C related chronic liver disease

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Table 6: Comparison of complications between chronic liver disease diabetes and nondiabetes

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Table 7: Distribution of respondents by outcome

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Table 8: Comparison between chronic liver disease diabetes and nondiabetes various scoring

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  Discussion Top


Increased risk of cirrhosis of liver has been found among the diabetic population. [7] The higher glucose levels seen in cirrhotics after oral glucose has been attributed to an increase in the amount of ingested glucose appearing in the systemic circulation and subsequently to an impairment in glucose uptake by peripheral tissues due to insulin resistance. [8] In the present study, 155 cases of cirrhosis of liver have been evaluated for the prevalence of diabetes and an attempt has been made to correlate the presence of diabetes with clinical feature and complications of CLD. Most of the cases were alcoholic liver disease, i.e., 110 (70.9%) cases followed by chronic hepatitis C in 38 (24.5%) cases, hepatitis B related 7 (4.5%) cases, and one hepatitis B and C coinfection. In the study, 20 cases were having diabetes giving a prevalence rate of 12.9%. Pazhanivel and Jayanthi found the prevalence of diabetes to be 17.69% among the cirrhotic population. [9] On the other hand, Singal and Ayoola found a prevalence rate of 19.2% [10] while Kobashi Margαin et al. [11] found a higher prevalence of 23.2%, and our finding agrees with these workers.

In the present study, majority of the patients, i.e., 86 (55.5%) cases were between the age of 31 and 50 years but the highest number of diabetes was found in age group 31-40 years (7 cases) contributing 19.4% of diabetic population in study. In age group of 18-30 years, out of 11 participants, 3 cases were diabetic which account for 27.3% of diabetic. The reason for higher prevalence among younger age group was poorly understood may be related to higher amount of alcohol intake. Mehta et al. found that persons of age 40 years or older with hepatitis C infections were more likely to have diabetes. [8]

Most of the study population were males (94.2%) and 13.7% of them had diabetes. None of the females had diabetes. It is difficult to draw any conclusions as the number of females was small (5.8%). Child Pugh score of diabetics and nondiabetics (median 10.5 vs. 11, P = 0.668). Model for End Stage Liver Disease (MELD) Score of diabetic and nondiabetic (median 18 vs. 19, P = 0.854) but Alavian et al. found higher Child Pugh score to be associated with higher prevalence of diabetics in cirrhotics. [12] The inconsistency between their study and the present study might be due to variation in the study populations. The most common complication among the study population was anemia 130 (83.9%) followed by upper gastrointestinal bleeding 76 (49%) and HE 57 (36.8%). Complications were compared between diabetic and nondiabetic: Upper gastrointestinal bleeding (11 [55%] vs. 65 [48.1%], P = 0.636), HE (7 [35%] vs. 50 {37.0}, P = 0.860), hepatorenal syndrome (3 [15%] vs. 16 [10.3%], P = 0.437), and anemia (17 [85%] vs. 130 [83.7%], P = 1.00). Complication such as hepatorenal syndrome, upper gastrointestinal bleeding was slightly higher among diabetic CLD and but difference was not statistically significant, which may be due to small sample size of the study. Quintana et al. found significantly higher frequency of anemia in cirrhotics with diabetes. [13] This finding partially agrees with our finding. In the study, hepatitis C and B was not associated with increased chance of developing diabetes. However, Pazhanivel and Jayanthi, Kim and Choi found increased prevalence of diabetics among hepatitis C infected cirrhotics. [9],[14] The discrepancy between their findings and our study may be explained by the small number of hepatitis B and hepatitis C infected related CLD in the present study. Out of 20 cases of diabetes CLD, 4 (20%) cases expired compared to 16 (11.9%) cases of nondiabetes CLD. Thus, mortality was slightly higher among cirrhotics patients with diabetes though the finding was statistically insignificant (P = 0.29). These findings agree with those of Trombetta et al., Kwon, et al., and Nishida et al. [7],[15],[16]


  Conclusion Top


The most common cause of cirrhosis of liver was alcoholic liver disease followed by hepatitis C and hepatitis B. The prevalence of diabetes was 12.9% among the cases. The most of the patients belong to the age group of 41-50 years, and most diabetics were from the age group of 31 to 40 years. The common complications among the study population were anemia, upper gastrointestinal bleeding, HE, spontaneous bacterial peritonitis, and hepatorenal syndrome. Child-Pugh score and MELD score were comparable between diabetics and nondiabetics. Mortality was higher among cirrhotics patients with diabetes compared to the nondiabetics.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mukhopadhyay J. Use of insulin in chronic liver disorders. In: Gupta SB, editor. Medicine Updates. Mumbai: Physicians Association of India; 2005. p. 203-5.   Back to cited text no. 1
    
2.
Bohan EM. Diabetes mellitus and cirrhosis of the liver; a case report. Del Med J 1947;19:212-15.  Back to cited text no. 2
    
3.
Megyesi C, Samols E, Marks V. Glucose tolerance and diabetes in chronic liver disease. Lancet 1967;2:1051-56.  Back to cited text no. 3
    
4.
Amarapurkar D. Diabetes and liver disease. Med Update 2010;20:466-9.   Back to cited text no. 4
    
5.
Schattenberg JM, Schuchmann M. Diabetes and apoptosis: Liver. Apoptosis 2009;14:1459-71.   Back to cited text no. 5
    
6.
Garcia Compean D, Jaquez Quintana JO, Gonzalez Gonzalez JA, Maldonado Garza H. Liver cirrhosis and diabetes: Risk factors, pathophysiology, clinical implications and management. World J Gastroenterol 2009;15:280-8.   Back to cited text no. 6
    
7.
Trombetta M, Spiazzi G, Zoppini G, Muggeo M. Review article: Type 2 diabetes and chronic liver disease in the Verona diabetes study. Aliment Pharmacol Ther 2005;22 Suppl 2:24-7.   Back to cited text no. 7
    
8.
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;133:592-9.   Back to cited text no. 8
    
9.
Pazhanivel M, Jayanthi V. Diabetes mellitus and cirrhosis liver. Minerva Gastroenterol Dietol 2010;56:7-11.   Back to cited text no. 9
    
10.
Singal AK, Ayoola AE. Prevalence and factors affecting occurrence of type 2 diabetes mellitus in Saudi patients with chronic liver disease. Saudi J Gastroenterol 2008;14:118-21.   Back to cited text no. 10
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11.
Kobashi Margáin RA, Gutiérrez Grobe Y, Ponciano Rodríguez G, Uribe M, Méndez Sánchez N. Prevalence of type 2 diabetes mellitus and chronic liver disease: A retrospective study of the association of two increasingly common diseases in Mexico. Ann Hepatol 2010;9:282-8.   Back to cited text no. 11
    
12.
Alavian SM, Hajarizadeh B, Nematizadeh F, Larijani B. Prevalence and determinants of diabetes mellitus among Iranian patients with chronic liver disease. BMC Endocr Disord 2004;4:4.  Back to cited text no. 12
    
13.
Quintana JO, García Compean D, González JA, Pérez JZ, González FJ, Espinosa LE, et al. The impact of diabetes mellitus in mortality of patients with compensated liver cirrhosis A prospective study. Ann Hepatol 2011;10:56-62.   Back to cited text no. 13
    
14.
Kim MG, Choi WC. Differential diagnosis of diabetes mellitus caused by liver cirrhosis and other type 2 diabetes mellitus. Korean J Hepatol 2006;12:524-9.   Back to cited text no. 14
    
15.
Kwon SY. Prevalence and clinical significance of diabetes mellitus in patients with liver cirrhosis. Taehan Kan Hakhoe Chi 2003;9:205-11.   Back to cited text no. 15
    
16.
Nishida T, Tsuji S, Tsujii M, Arimitsu S, Haruna Y, Imano E, et al. Oral glucose tolerance test predicts prognosis of patients with liver cirrhosis. Am J Gastroenterol 2006;101:70-5.  Back to cited text no. 16
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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