Abstract

Diabetes mellitus is being recognized as a serious global health problem and frequently associated with cirrhosis of liver. The cross-sectional comparative study was conducted among 83 diabetic cirrhotic patients admitted in Gastrointestinal Hepatobilliary and Pancreatic Disorders Department of Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic disorders and 83 non-diabetic cirrhotic patients admitted in Gastroenterology and Hepatology Department of Bangabandhu Sheikh Mujibar Medical University, Dhaka to assess the relationship between cirrhosis of liver and diabetes mellitus. The study was carried out during the period of January to June, 2010 and data were collected through face to face interview and reviewing medical documents by using a semi-structured questionnaire and checklist. Male, Muslims and illiterate were predominant in both diabetic and non-diabetic cirrhotic patients. It was found that non-viral cirrhosis was much higher in older age group (51-60years) than in younger age group (41-50years) in comparison to viral cirrhosis and this difference was found statistically significant [χ2(3)=20.97, p<0.001]. Association of non-viral cirrhosis was found with hyperglycemia [χ2(1)=15.65, p<0.001], poor glycaemic control [χ2(1)= 9.86, p<0.01] and longer duration of diabetes [χ2(2) =9.51, p<0.01]. Non-viral cirrhosis was significantly higher (28.3%) among the diabetic patients than the non-diabetic patients who suffered more (28.3%) from viral [χ2(1)=41.36, p<.001]. The study recommends for glycemic control by leading disciplined life and taking apposite therapy for prevention of non-viral cirrhosis among diabetic patients.

Ibrahim Med. Coll. J. 2012; 6(2): 59-63

Key Words: Cirrhosis, Diabetes mellitus

Address for Correspondence:Dr. Smita Debsarma, Lecturer, Department of Community Medicine, Ibrahim Medical College, 122 Kazi Nazrul Islam Avenue, Shahbagh, Dhaka 1000

Introduction

The increasing prevalence of non-communicable diseases is a serious challenge, where the success in extending life expectancy is translated into a real threat to global health.1 Non-communicable diseases are responsible for 60% of all deaths, 80% of these deaths are in low- and middle-income countries.2 In 2000, Bangladesh had 3.2 million people with diabetes and was listed at 10, which will occupy the 7th position with 11.1 million in 2030.3 The prevalence of type 2 diabetes observed in Bangladesh was 5.2 (rural 4.3%, urban 6.9%) at 1994-5 and 11.2% (urban) and 6.8% (rural) at 2003-4.4 Prevalence of diabetes is just double in urban areas due to unplanned urbanization and change in lifestyle.5

Cirrhosis is the twelfth leading cause of death by disease, accounting for 27,000 deaths each year.6 Exact prevalence of cirrhosis is unknown, but it has been estimated, through autopsies, to be between 5 and 10 percent. In countries with low alcohol consumption, hepatotropic viruses (hepatitis B and C) are the major contributors.7 Persons with diabetes mellitus (DM) are at an increased risk of developing a variety of liver diseases. The development of diabetes in patients with cirrhosis is well documented with overt diabetes present in up to 70% of cirrhotic subjects. However, evidence is emerging that the development of chronic liver disease and progression to cirrhosis may occur after the diagnosis of diabetes and that diabetes plays a role in the initiation and progression of liver injury.8 Non-alcoholic fatty liver disease (NAFLD), alcoholic cirrhosis, chronic hepatitis C (CHC) and haemochromatosis are more frequently associated with DM. DM increases the mortality of cirrhotic patients and has been associated with NAFLD, including its most severe form, nonalcoholic steatohepatitis (NASH).9

Nonalcoholic steatohepatitis (NASH) is an under-recognized cause of cryptogenic cirrhosis (CC) on the basis of higher prevalence of obesity and type II diabetes.10 NAFLD is observed principally in developed countries where sedentary lifestyle and high calorie, sugar, and fat diets lead to DM2 and obesity. Individuals with type-2 diabetes have a high (70.0%) prevalence of NAFLD, and seem to have an increased severity of disease. Prevalence of NAFLD is higher (20.0%) than that of NASH (3.0%) in developed countries and prevalence of each is presumably much higher among obese and diabetic persons because 55.0% of patients with NASH have DM2 and 95.0% are obese.11

The populations of Bangladesh are exposed to a number of unfavorable conditions like sedentary lifestyles, unhealthy living conditions and stress, which make them vulnerable for presence of higher proportion of diabetes mellitus.12 It is evident that both prevalence and incidence of diabetes mellitus is increasing in both urban and rural areas of Bangladesh but information related to cirrhosis of liver and diabetes mellitus in Bangladesh is scarce. As DM is often associated with cirrhosis of liver and its severity, it is pertinent to assess the association between cirrhosis of liver and DM in the context of Bangladesh. This study was designed to find out the proportion of viral and non-viral cirrhosis among diabetic and non-diabetic patients and accordingly to recommend suitable preventive measures to reduce the burden of diabetic cirrhosis patients.

Materials and Methods

The cross-sectional comparative study was conducted among 83 diabetic cirrhotic patients and 83 non-diabetic cirrhotic patients who were admitted in Bangladesh Institute of Research and Rehabilitation in Diabetes and Hepatology Department of Bangabandhu Sheikh Mujibar Medical University, Dhaka respectively. The study was carried out over the period of 6 months from January to June 2010. Both diabetic and non-diabetic cirrhotic patients were included conveniently irrespective of age and sex and obtaining informed written consent. Viral and non-viral cirrhotic patients were diagnosed by viral markers and USG of whole abdomen. HbA1C, fasting blood glucose and 2 hrs after breakfast were done to see glycemic control and blood glucose level of the diabetes patients.

Data were collected through face to face interview and reviewing medical documents by using pre-tested semi-structured questionnaire and checklist. Data were cleaned, edited, coded and analyzed by the SPSS software (17.0 version). Descriptive statistics included frequency, mean and standard deviation followed by Chi-square test was performed to find out the association between variables as required. p value 5% was considered significant at 95% CI and all the tests were two tailed.

Results

Mean age for diabetic patients was 56.93 (±11.68) years while mean age for the non-diabetic patients was 46.19 (±13.85) years. Among diabetic patients, majority were in the older age group (51-60 years) while majority of the non-diabetic patients were in the productive age group (<40years). Male, Muslim and married were predominant in both the groups. [Table-1]

Table-1: Socio-demographic variables between diabetic and non-diabetic patients

Of all (166) the cirrhotic patients, 111 had viral cirrhosis and 55 patients had non-viral cirrhosis. HBV infection was dominant in both diabetic (63.9%) and non-diabetic patients (82.7%) while majority (78.7%) of the diabetic patients suffered from non-alcoholic fatty liver disease. [Table-2]

Table-2: Distribution of patients by type of cirrhosis of liver

Mean age for developing viral cirrhosis was lower (48.75 ±13.01 years) than the mean age for developing non-viral cirrhosis (57.24±13.89 years). Majority (32.4%) of the cirrhotic patients of viral origin were in the age group of 41-50 years while majority (41.8%) of the cirrhotic patients of non-viral origin were in the age group of 51-60 years and this difference was found statistically significant [χ2(3)=20.97, p<.001]. Both viral and non-viral cirrhosis were significantly higher among married patients [χ2 (1) =7.133, p<.05]. Though both viral (66.7%) and non-viral (61.8%)cirrhosis were predominant among the males than their counterpart females but this sex differential was not statistically significant [χ2(1)=0.38, p=0.54]. Non-viral cirrhosis was significantly higher among the patients with hyperglycemia (76.6%) [χ2(1)=15.65, p<.001], poor glycaemic control (59.6%) [χ2(1)= 9.86, p<.01] and longer duration of diabetes (83.0%) [χ2(2)=9.51, p<.01]. [Table-4] Among the diabetics, majority (28.3%) patients had non-viral cirrhosis while 21.7% had viral cirrhosis while majority (45.2%) of the non-diabetes patients had viral cirrhosis and only 4.8% had non-viral cirrhosis and this difference was statistically significant [χ2(1)=41.36, p< .001].

Table-3: Distribution of socio-demographic variables by cirrhosis of liver

Table-4: Distribution of diabetic patients by diabetes characteristics

Table-5: Relationship between diabetes mellitus and cirrhosis of liver

Discussion

The cross sectional comparative study was aimed to assess the relationship between cirrhosis of liver and diabetes mellitus and to find out the underlying causes of cirrhosis of liver among 83 diabetes and 83 non-diabetes patients.

Mean age for diabetes patients and non-diabetes patients was 56.93(±11.68) and 46.19(±13.85) years respectively. Among diabetic patients, majority (34.9%) were in the age group of 51-60 years while majority (36.1%)of the non-diabetic patients were in the age group of <40 years. Similar finding was obtained in a study conducted by Hashem B, El-Serag, Thomas T and James E where patients with diabetes were older (62 Vs 54 years) than patients without diabetes.13 As per BBS (2008), most (90%)of the people of Bangladesh are Muslims14 and similar finding was revealed by the current study where Muslim constituted (92.77%).

The current study estimated 51.2% HBV and 15.7% HCV infections among diabetes patients. Previously reported by Pazhanivel M and Jayanthi V diverse findings where HBV infection was18.38% and HCV infection was 6.01% among DM patients.15 This variation may be due to unawareness and transfusion of unscreened blood and blood products in our country.

Among diabetic patients, majority (78.7%) had non-alcoholic fatty lever disease, 14.9% patients had non-alcoholic staetohepatitis, and each 2.1% patients had haemochromatosis, Wilson’s disease and cryptogenic cirrhosis. The study findings are different from the findings of the study conducted by Amarapurkar D which found 18.9% NASH, and 22.6% cryptogenic cirrhosis.16 No statistically significant sex difference of occurrence of cirrhosis of liver was found but statistically significant association was revealed between marital status and cirrhosis of liver because both viral and non-viral cirrhosis were higher in married patients [χ2 (1)=7.13, p<.01]

It was also found that majority (28.3%) diabetes patients had non-viral cirrhosis while majority (45.2%) of the non-diabetes patients had viral cirrhosis and this difference was found statistically significant [χ2(1)=41.36, p<.001]. But the study conducted by Amarapurkar D found majority of both diabetic (34.9%) and non-diabetic (28.2%) had non-viral cirrhosis.16

Conclusion

Older age group, males, Muslims, illiterates and married were predominant among the DM patients. Majority of the cirrhotic patients of viral origin were in the middle age group while majority of the cirrhotic patients of non-viral origin were in the older age group. Longer duration of DM, hyperglycaemic status and poor glycemic control were significantly associated with occurrence of liver cirrhosis. Non-viral cirrhosis of liver was more common among diabetics especially among the patients with sedentary lifestyle and HBV infection was predominant among the cirrhotic patients. The study recommends for specific measures like early detection and prompt treatment of DM, measures for enable the DM patients to lead disciplined life to maintain euglycemia and to raise their awareness regarding vaccination, lifestyle and safe blood transfusion.

References

1.   Quigley M. Commentary: Shifting burden of disease-epidemiological transition in India. Int J Epi 2006; 35: 1530–1531.

2.   Preventing chronic diseases; A vital Investment. WHO 2010. Available from: http://www.who.int/chp/chronic_disease_report/overview.

3.   Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes: Estimates for the year 2000 and projection for 2030. Diabetes Care 2004; 27:    1047–1053.

4.   Mahtab H, Latif ZA, Pathan F. Diabetes Mellitus- a handbook for professionals. Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) 2007; 4: 24-29.

5.   Ministry of Health and Family Welfare. Strategic Plan for Surveillance and Prevention of Non-communicable diseases in Bangladesh 2007-2010. NCD situation in Bangladesh. Dhaka: DGHS & MOH & FW; 2007; 4-5.

6.   Cirrhosis of Liver, 2010. Available from: http://www.digestive.niddk.nih.gov/ddiseases/pubs/cirrhosis.

7.   Cirrhosis, 2010. Available from: http://www.answers.com /topic/cirrhosis.

8.   Ingrid J. Hickman, Graeme A. Macdonald. Impact of Diabetes on the Severity of Liver Disease. The American Journal of Medicine 2007; 120: 829-834.

9.   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(3): 280-288.

10.Poonawala A, Nair SP, Thuluvath PJ. Prevalence of obesity and diabetes in patients with cryptogenic cirrhosis: A case control study. Hepatology 2000; 32(4): 689-692.

11.Nathalie C. Leite, Gil F. Salles, Antonio L. E. Araujo, Cristiane A. Villela-Nogueira and Claudia R. L. Cardoso. Liver International 2009; 113-119.

12.World Health Organization. Issues and challenges in the prevention and control of Non-communicable diseases in South East Asia Region. WHO regional office South East Asia, Delhi, India, 2009.

13.Hashem B El–Serag, Tran T, James E. Diabetes Increases the Risk of Chronic Liver Disease and Hepatocellular Carcinoma. Gastroenterology 2004; 126: 460–468.

14.Bangladesh Bureau of Statistics. Statistical Pocket book of Bangladesh 2008. Dhaka: Planning Division, Ministry of Planning, Government of the People’s Republic of Bangladesh 2009; 2, 6,10, 38.

15.Pazhanivel M, Jayanthi V. Diabetes mellitus and cirrhosis liver. Minerva Gastroenterol Dietol 2010; 56(1): 7-11.

16.Amarapurkar D, Das HS. Chronic liver disease in diabetes mellitus. Trop Gastroenterol 2002; 23(1): 3-5.

17.Mahtab H, Latif Z A, Pathan F. Diabetes Mellitus- A handbook for professionals. Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and metabolic Disorders (BIRDEM) 2004; 3: 123.

18.  Mahtab H, Latif Z A, Pathan F. Diabetes Mellitus- A handbook for professionals. Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and metabolic Disorders (BIRDEM) 2004; 3: 12-13.