18100006002 THESIS

TITLE:

“LIVER FUNCTION TESTS IN TYPE II DIABETES MELLITUS IN RURAL TERITIARY CARE CENTRE”

INTRODUCTION: 

Diabetes mellitus is a complex metabolic condition defined by level of hyperglycemia giving rise to micro vascular and macro vascular complications 1 .

Current estimates suggests that there are 170 million people suffering from DM worldwide and this number is going up to 266 million by 20302.The prevalence of DM in India is around 31 million and this number will increase to 80 million by 20302. 

Indians develop diabetes at younger age, with lower degree of obesity and have increased risk of chronic diabetic complications. Hence DM is a major public concern in India. Various complications related to micro or macro vascular diseases like retinopathy, nephropathy, neuropathy, ischemic heart diseases and peripheral vascular disease have been reported. Liver diseases are often overlooked as a complication of DM. 

Infact VERONA-DIABETES POPULATION BASED STUDY has shown that among patients with DM standardised mortality rate from cirrhosis was higher than cardiovascular diseases 3 .Though association of diabetes with cirrhosis has been recognised for more than 100 years, liver diseases in diabetes remains under estimated 4 . 

Abnormal liver function test results are more common in diabetes mellitus than in the non-diabetic population as well as in patients with type 2 diabetes than in those with type 1 diabetes. Elevated activities of the two serum transaminases; alanine transaminase (ALT) and aspartate transaminase (AST) may be associated with liver disease. Elevation of these enzymes is strongly related to obesity, diabetes and dyslipidemia, and their measurement may act as a surrogate marker of NAFLD presence.

 This study was conducted to estimate the prevalence of elevated liver transaminase levels among patients with type 2 diabetes and to determine the associated risk factors. 

AIM:

To assess the pattern of liver function test in type 2 diabetes milletus. 

OBJECTIVES: 

To determine the liver function tests (serum bilirubin, AST, ALT, alkaline phosphatase) in patients with type II diabetes mellitus. 

To determine the associated risk factors for abnormal liver function tests in patients with type II diabetes mellitus.

PATIENTS AND METHODS: 

PLACE OF STUDY: Department of General medicine Kamineni Institute of Medical Sciences, Narketpally 

STUDY PERIOD: October 2018-September 2020 

STUDY DESIGN: Cross-sectional study 

SAMPLE SIZE: 80 

INCLUSION CRITERIA: 

• Presence of type 2 diabetes Mellitus in patients above the age of 40 years 

• Duration of type 2 diabetes Mellitus at least 1 year and above. 

EXCLUSION CRITERIA: 

1. Age less than 40 years.

 2. Duration less than one year. 

3. Consumption of alcohol. 

4. Seropositivity of HbsAg and antiHCV antibody. 

5. Seropositivity of HIV ELISA. 

6. Patient on drugs proven to cause steatohepatitis (steroids, amiodarone, oral contraceptive pills, and other estrogen containing preparations). 

7. Patients with renal failure and cardiac failure.

METHODOLOGY:

The study was approved by the ethics committee of Kamineni Institute of Medical Sciences, Narketpally. 

All patients satisfying the inclusion criteria are enrolled in the study. 

A written informed consent has been taken from the patients prior to the start of the study. 

Measurement of height, weight, waist circumference, hip circumference and calculation of BMI and waist to hip ratio. 

A total of 80 type 2 diabetic patients who met the inclusion criteria were studied during this period. Both inpatients and outpatients attending outpatient department were included in the study. 

Body weight was taken while the patients barefooted and in light clothing, using a weighing scale with accuracy of ±100 g. Standing height was measured without shoes to the nearest cm with the shoulders in a relaxed position and the arms hanging freely. Body mass index. (BMI) (kg/m 2) was calculated as the ratio of weight (kilograms) to the square of height (meters). Patients' BMI was classified according to WHO classification, as being normal (BMI; 18.5 to 24.9 kg/m 2), overweight (BMI; 25 to 29.9 kg/m 2) or obese (BMI>30 kg/m 2). 

Waist circumference and hip circumference was measured in a standing position using non stretchable tailor measuring tape to look for central obesity. Central obesity is defined in men by a waist-to-hip circumference ratio greater than 1.0 or a waist circumference greater than 40 inches (102 centimetres). In women, central obesity is defined by a waist-to-hip ratio greater than 0.8 or a waist circumference greater than 35 inches (88 centimetres). 

All the above patients were examined and screened for HbsAg, anti-HCV antibody, HIV ELISA and were found to be negative. Morning samples of venous blood were collected from patients after fasting for at least 14 hours and tested for glucose, urea, Creatinine (using semi auto analyser Merck 300), haemoglobin A1C 35 (HbA1C) [Using High Performance Liquid Chromatography method], for the liver enzymes; ALT and AST [Using semi auto analyser Merck 300], and for lipid profile including total cholesterol (TC), high density lipoprotein (HDL), triglycerides (TGL), and low density lipoprotein (LDL)[ Using semi auto analyser Merck 300] and serum protein, albumin, globulin(Using calorimetry photochem -5). Elevated ALT and AST levels were defined as enzyme activity >40 U/L respectively, according to the clinical assay adopted by the centre‘s laboratory. 

Ultrasound abdomen was done for all patients, to look for size of the liver, echogenicity of liver parenchyma, any evidence of chronic liver disease like coarse echo texture of liver, dilated portal vein and/or splenomegaly. The diagnosis of fatty liver was based on a diffuse hyperechoic echo texture (bright liver) and increased liver echo texture compared with the kidneys. 

INVESTIGATIONS: 

 Complete blood picture 

 Complete urine examination 

 HbsAg 

 AntiHCV antibody 

 HIV ELISA 

 Blood sugar: FBS,PLBS 

 HbA1C 

 Blood urea

 Serum Creatinine 

 Serum electrolytes 

 Liver function test

 Serum bilirubin 

 Direct bilirubin 

 Indirect bilirubin 

 Aspartate transaminase 

 Alanine transaminase 

 Alkaline phosphatase 

 Serum total proteins 

 Albumin 

 Fasting Lipid Profile 

 Total cholesterol 

 HDL 

 LDL 

 VLDL 

 Triglycerides 

 Ultrasound abdomen 

 ECG 

LINK TO COMPLETE THESIS WITH MASTER CHART

https://drive.google.com/file/d/15P7wrA8h3PYinbrBrxxxroJqoLGiZg-P/view?usp=sharing