Diabetes Ups Risk of Hospitalization, Death From Liver Disease

Marlene Busko

April 25, 2016

In a cohort study of 40- to 89-year-old people who were followed for a decade, individuals with type 2 diabetes were more likely than nondiabetic individuals to be hospitalized for or die from chronic liver disease. These were defined as alcoholic liver disease, autoimmune liver disease, hemochromatosis, hepatocellular carcinoma, nonalcoholic fatty liver disease (NAFLD; including cirrhosis and hepatic fibrosis), and viral liver disease.

For example, diabetic men were three times more likely than other men their age to be hospitalized for or die from NAFLD — the most common type of liver disease in diabetic patients — whereas this was five times more likely to occur in diabetic versus nondiabetic women of the same age.

Thus, the increasing prevalence of type 2 diabetes is likely to result in an increasing burden of all chronic liver diseases, conclude Sarah H Wild, MB, BChir, PhD, University of Edinburgh, Scotland, and colleagues in their study, published online in the Journal of Hepatology.

The research, conducted in Scotland, should increase "awareness of clinicians of the higher risk of the full range of chronic liver diseases among people with diabetes," Dr Wild told Medscape Medical News in an email.

Doctors should therefore counsel patients with type 2 diabetes about the importance of managing their weight, drinking alcohol in moderation — or not at all — and being aware of other risk factors for hepatitis, she added.

Moreover, "effective treatment of liver disease is still being developed, so prevention is preferable, but there is some evidence to suggest that vitamin E and pioglitazone may be useful."

Up to Fivefold Risk of NAFLD, Other Liver Diseases in Diabetes

Type 2 diabetes is well-known to carry an increased risk of NAFLD, but its relationship with other chronic liver diseases is less clear, the researchers write.

They performed a retrospective national cohort study in Scotland to determine the number of adults with and without type 2 diabetes who were hospitalized for or died from chronic liver disease (defined as "an event") from 2004 to 2013. They then examined risks broken down by liver-disease type in men and women living in deprived or less deprived areas.

They identified 6667 events in diabetic adults during 1.8 million person-years of follow-up and 33,624 events in other adults during 24 million person-years of follow-up.

Men and women with type 2 diabetes had a 1.27-fold to 5.36-fold higher risk of the combined end point of being hospitalized for or dying from chronic liver disease, including cancer, compared with age- and sex-matched people without diabetes.

Compared with men with diabetes, women with diabetes had an especially heightened risk of being hospitalized for or dying from NAFLD. This was probably because women were more obese than men, Dr Wild suggested.

Risk of Being Hospitalized for or Dying From Liver Disease, Diabetic vs Nondiabetic Individualsa

Liver Disease Type Men, RR (95% CI)b Women, RR (95% CI)b
Alcoholic liver disease 1.51 (0.82–1.80) 1.77 (0.99–3.20)
Autoimmune liver disease 1.50 (1.12–2.01) 1.27 (1.04–1.55)
Hemochromatosis 1.70 (1.41–2.05) 1.67 (1.25–2.23)
Hepatocellular carcinoma 3.44 (2.85–4.17) 3.69 (2.99–4.56)
Nonalcoholic fatty liver disease 3.15 (2.50–3.97) 5.36 (4.41–6.51)
Viral liver disease 1.47 (0.54–3.98) 2.54 (1.18–5.47)
a. During a 10-year follow-up
b. Relative risk, adjusted for age

People with and without diabetes who lived in more deprived areas were more likely to be hospitalized for or die from alcoholic liver disease than people of the same age who lived in wealthier areas, likely due to greater obesity and greater cirrhosis among people living in poverty, the researchers suggest.

Screening, Diagnosing Liver Disease

Screening patients with type 2 diabetes for liver disease is controversial, but recent European guidelines for NAFLD (Diabetologia. 2016; published online April 7, 2016) and an accompanying commentary (Diabetologia. 2016; published online April 7, 2016) recommend screening every 2 to 3 years, Dr Wild said.

These recommendations were developed jointly by the European Association for the Study of the Liver, European Association for the Study of Diabetes, and European Association for the Study of Obesity.

To diagnose chronic liver disease, "clinical history, particularly relating to risk factors (including viral hepatitis, alcohol intake, obesity, and diabetes), is a key component," Dr Wild noted, and "abnormal liver enzymes are the key biochemical diagnostic tool."

Further information can be gained from ultrasound scans of the liver to show fat, transient elastography tests to detect fibrosis, and tests for autoantibodies, hepatitis markers, iron, and alpha fetoprotein for specific forms of chronic liver disease.

J Hepatol. 2016. Published online January 23, 2016. Abstract

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