Alterations in carbohydrate metabolism in cirrhotic patients before and after liver transplant

Hepatogenous Diabetes: A Primer

As liver is one of the primary organs involved in glucose homeostasis, it is not surprising that patients with liver dysfunction in chronic liver disease usually develop impaired glucose tolerance and subsequently overt diabetes later in their natural course. Diabetes that develops after the onset of cirrhosis of liver is usually referred to as hepatogenous diabetes (HD). It is an underrecognized and a hallmark endocrinological event in chronic liver disease. HD is associated with a higher risk of developing hepatic decompensations, such as ascites, variceal bleeding, hepatic encephalopathy, renal dysfunction, refractory ascites, and hepatocellular carcinoma along with reduced survival rates than normoglycemic patients with cirrhosis of liver. It is quite different from type 2 diabetes mellitus with the absence of classical risk factors, dissimilar laboratory profiles, and decreased incidence of microvascular complications. Furthermore, the management of patients with HD is challenging because of altered pharmacokinetics of most antidiabetic drugs and increased risk of hypoglycemia and other adverse effects. Hence, a clear understanding of the epidemiology, pathophysiology, clinical implications, laboratory diagnosis, and management of HD is essential for both hepatologists as well as endocrinologists, which is narrated briefly in this review.

Pretransplant diabetes mellitus predicts worse outcomes of liver transplantation: evidence from meta-analysis

BACKGROUND

It has been demonstrated that the prognosis of liver transplantation (LT) is significantly influenced by pretransplant factors, such as diabetes mellitus (DM). However, inconsistent observations are obtained.

METHODS

We comprehensively searched PubMed, Embase and Web of Science to identify eligible cohort studies to evaluate the impact of preexisting DM on LT prognosis. Overall mortality and graft loss, as the most frequently observed parameters, were used to evaluate the outcomes of LT. Hazard ratios (HRs) with their 95% confidence intervals (CIs) were pooled to assess the effect of DM.

RESULTS

15,768 diabetic LT recipients and 60,176 non-diabetic LT recipients from 13 populations were included in this meta-analysis. Preexisting DM increased the risk for overall death of LT by 40% (95% CI 1.22-1.61), compared with DM-free patients. In addition, the risk for graft loss was also elevated by pretransplant DM (HR 1.28, 95% CI 1.07-1.54). Both analyses showed high heterogeneities (I ² = 85.2 and 93.2%, respectively) and their sources were not identified by meta-regression analyses. In terms of the additive effect of hepatitis C virus (HCV) infection on poor outcomes of diabetic LT recipients, stratified meta-analyses were conducted. It was demonstrated that HCV infection increased the risk for mortality by 73% (95% CI 1.64-1.83), relatively higher than non-HCV recipients (HR 1.32, 95% CI 1.25-1.39) and general population (HR 1.40, 95% CI 1.22-1.61).

CONCLUSION

Preexisting DM predicts worse patient and graft survivals of LT. Concomitant HCV infection would further deteriorate this unfavorable impact. Given the high heterogeneities and the insufficient evidences, more studies are still warranted to support these observations.

Outcomes in patients with diabetes 10 years after liver transplantation

BACKGROUND

There are discrepancies between studies regarding the effect of diabetes mellitus on morbidity and mortality in patients undergoing liver transplantation. The aim of the present study was to compare mortality, risk of liver graft rejection, and cardiovascular events in patients with and without diabetes undergoing liver transplantation over a 10-year follow-up period.

METHODS

A retrospective study was performed on 183 patients who underwent liver transplantation in 2005 and 2006. Mortality and morbidity data were collected until 2016, including information on mortality and survival time, graft rejection and graft survival time, coronary heart disease, stroke, and peripheral arterial ischemia.

RESULTS

During the follow-up, 41.3% and 27.8% of patients in the groups with and without diabetes, respectively, died. A trend for lower survival time was observed in patients with diabetes, although this effect was not confirmed by the Cox regression model. There was an increased risk of graft rejection in the group with diabetes compared with the group without diabetes ( P  < 0.001). In the survival analysis, diabetes was associated with reduced graft survival time ( P  = 0.001). Cardiovascular events were also more likely in the group with diabetes ( P  = 0.005).

CONCLUSIONS

In the present study diabetes was associated with a higher risk of liver graft rejection and cardiovascular events. There was also a trend for higher mortality, although the effect was not statistically significant. These findings suggest that patients with diabetes require a more rigorous pretransplant evaluation and closer monitoring after transplantation in order to try to reduce associated complications.

Hepatogenous diabetes: Is it a neglected condition in chronic liver disease?

Diabetes mellitus (DM) that occurs because of chronic liver disease (CLD) is known as hepatogenous diabetes (HD). Although the association of diabetes and liver cirrhosis was described forty years ago, it was scarcely studied for long time. Patients suffering from this condition have low frequency of risk factors of type 2 DM. Its incidence is higher in CLD of viral, alcoholic and cryptogenic etiology. Its pathophysiology relates to liver damage, pancreatic dysfunction, interactions between hepatitis C virus (HCV) and glucose metabolism mechanisms and genetic susceptibility. It associates with increased rate of liver complications and hepatocellular carcinoma, and decreased 5-year survival rate. It reduces sustained virological response in HCV infected patients. In spite of these evidences, the American Diabetes Association does not recognize HD. In addition, the impact of glucose control on clinical outcomes of patients has not been evaluated. Treatment of diabetes may be difficult due to liver insufficiency and hepatotoxicity of antidiabetic drugs. Notwithstanding, no therapeutic guidelines have been implemented up to date. In this editorial, authors discuss the reasons why they think that HD may be a neglected pathological condition and call attention to the necessity for more clinical research on different fields of this disease.