https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/46 Tue, 02 Aug 2016 10:27:27 +0000 The occurrence of liver disease and raised liver enzymes is common in diabetic patients and the increasing level of enzymes indicates the severity of hepatic injury. Very few studies have addressed this issue in Bangladesh though Bangladeshi population is very much susceptible to diabetes. The biochemical markers (ALT, AST, ALP, bilirubin) did not differ significantly between non-diabetic male and female subjects. Neither the differences were significant between diabetic males and females though the diabetic patients had higher level of markers. In contrast, when compared between diabetic and non-diabetic subjects there were striking differences in either sex. Compared with the non-diabetic the diabetic subjects had significantly higher level of ALT (48.3 vs. 277.0), AST (42.0 vs. 213.0) and ALP (148 vs. 302) in males (p<0.005 for all). Similarly, these values were found significantly higher in diabetic females than their non-diabetic counterparts (p<0.01). For bilirubin, it was also found significant in males (p<0.001). Ibrahim Med. Coll. J. 2011; 5(2): 46-50 Key words: Liver function tests (LFTs), bilirubin, ALT, AST, ALP, hepatitis. Table-1: Proportion of Diabetic and non-diabetic subjects referred to BIRDEM with the clinical diagnosis of chronic hepatitis     These biochemical markers when tested only for the abnormally elevated groups with the exclusion of normal values, as shown in table 2, the mean (±se) values were found markedly elevated in diabetic than their non diabetic counterparts in either sex. For example, male and female of non-diabetic groups showed mean (U/L) of ALT (48.3 vs. 51.9), AST (42.0 vs. 41.7) and ALP (148 vs. 154) almost within similar range. Similar range, though at much higher level, were also observed between male and female in diabetic groups. In contrast, when compared between diabetic and non-diabetic referred subjects there were striking differences. The mean values showed markedly elevated in diabetic than non-diabetic groups. Thus, these observations were for ALT (48.3 vs. 277.0), AST (42.0 vs. 213.0) and ALP (148 vs. 302) in males. Likewise, in females these were ALT (51.9 vs. 228.0), AST (41.7 vs. 205.0) and ALP (154 vs. 238). In either sex, the differences of ALT, AST and ALP between diabetic and non-diabetic subjects were found significant (p<0.005).  For bilirubin, it was also found significant in male (p<0.001); whereas, in females, comparison could not be made due to lack of non-diabetic patients (table 2).   Table-3: Pearson’s correlations ( r ) between biochemical markers for hepatitis in non-diabetic (n=100) and diabetic (802) subjects.     Discussion This study compared the biochemical markers, commonly used for liver function tests (LFT), between diabetic and non-diabetic subjects. The study is unique in the sense that there has been no such comparative study conducted on Bangladeshi population. But, the study has some limitations. Socio-demographic and clinical variables have not been taken properly and could not be analyzed. The study could have taken the final or confirmed diagnosis of the patients. Age, nutritional status, fasting blood glucose and lipids could have been the important biophysical variables for determination of association between liver enzymes. The study findings are consistent with other studies. Elevated activities of serum aminotransferases are a common sign of liver disease and are observed more frequently among diabetics than in the general population.12 In a previous study by Erbey et al, type-2 diabetes has been reported to be associated with mild (asymptomatic) elevations in the serum levels of certain enzymes including serum ALT.13 Elevated ALT levels have been reported as more frequently observed for diabetics than for the general population studies by Everhart JE.14  We found that the prevalence of elevated ALT and AST was higher in diabetic patients (1400 patients, male 808, female 592) than in non diabetic patients. The prevalence of elevated ALT and AST in type 2 diabetic patients was higher than general population,15 but lower than studies done in diabetic patients.16  M. A. Meybodi et al, of 348 patients that entered the study, mean age was 58.8±11.5. Elevated ALT and AST were found in 10.4 and 3.3% of type 2 diabetic patients, respectively. The prevalence of elevated ALT increased with increasing age. Overall, the prevalence of elevated alanine transaminase (ALT) was 10.4% (n=105) with the gender-wise prevalence of 12.8% (n=71) in men, and 7.4% (n=34) in women. The prevalence of elevated AST was 5.4% (n=56) with the gender-wise prevalence of 5.6 %( n=31) in men and 5.4 % (n=25) in women. Only 4.5% (n=44) showed elevated levels of both ALT and AST. Of patients with high ALT levels, 88 patients (83.8%) had mild, 13 (12.4%) had moderate, and only four patients (3.8%) had marked elevation of the enzyme activity. Male gender and high waist circumference were associated with an increased risk of elevated ALT levels. Younger patients had a higher tendency to have elevated ALT compared to those over 65 years. As age and nutritional variables were not included in the study these could not be compared.   Conclusion It may be concluded that the liver enzymes were found elevated in both diabetic and non-diabetic subjects who were referred with a clinical diagnosis of hepatitis. Very markedly elevated enzymes were found among the diabetic than non diabetic patients indicating hepatic injury was more likely among the diabetic patients. Further study may confirm these findings. It is suggested that other socio-demographic and biophysical risk factors are important to be investigated in order to prevent hepatic damage among the diabetic subjects.   References 1.   Bradley RF, Sagild V. and Schertenleib FE. Diabetes mellitus and liver function. New England Journal of Medicine1955; 253: 454-458. 2.   Guyton C. Text Book of Medical Physiology. 8th ed. W.B. Saunders Company, Harcourt brace Jovanovich Inc, Philadelphia, PA. 1991; 772-800. 3.   Consoli A, Nurjhan N, Capani F and Gerich J. Predominant role of gluconeogenesis in increased hepatic glucose production in NIDDM. Diabetes 1989; 38(5): 550-557. 4.   Chatila R and West AB. Hepatomegaly and abnormal liver tests due to glycogenesis in adults with diabetes. Med Balt 1996; 75: 327-333. 6.   Bowers GN Jr, and McComb RB. A continuous spectrophotometric method for measuring the activity of serum alkaline phosphatase. Clin. Chem 1966; 12(2): 70-89. 8.   Bessay OA, Lowry OH and Brock M. The determination of alkaline phosphatase activity from blood serum. J. Biol.chem 1964; 164: 321-329. 10.Bergmeyer HU, Herder M and Rej R. Approved recommendation 1985 on IFCC methods for the measurement of catalytic concentration of enzymes Part 3. (IFCC Method for Alanine aminotransferase. J Clin Chem Clin Biochem 1998; 24(15): 481-489. 12.Fagiuoli SR and Van Thiel DH. The liver in endocrine disorders. In: Rustgi VK, Van Thiel DH, editors. The liver in systemic disease. New York: Raven Press 1993; 285-301. 14.Everhart JE. Digestive diseases and diabetes. In: Diabetes in America. 2nd ed. National Institute of Health. National Institute of Diabetes and Digestive and Kidney Diseases. Washington, DC: GPO: 1995; 457-483. 16.West J, Brousil J, Gazis A, Jackson L, Mansell P, Bennett A and Aithal GP. Elevated serum alanine transaminase in patients with type 1 or type 2 diabetes mellitus. Q. J. Med 2006; 99: 871-876. 2026 Ibrahim Medical College. All rights reserved.