Executive Summary
Diabetes has many co–morbid conditions, such as cancer, heart disease, sleep apnea, kidney disease, obesity, and liver damage.
In diabetics, liver problem progresses from fatty liver to NASH, to liver fibrosis, to liver cirrhosis, to liver cancer. The last 2 stages are irreversible.
Liver function tests such as SGOT / SGPT and liver ultrasound cannot detect liver damage in the early stages. Liver Fibroscan is the only reliable test, besides a liver biopsy.
In a trial, 70% of the diabetics had fatty liver, and 20% of the diabetics had liver cirrhosis. This is too high a percentage to overlook.
The article also explains the science of liver damage and how to detect it.
Diabetes is linked to many medical conditions. Either diabetes causes them, or is associated with them.
Co–morbid conditions of diabetes
The medical conditions that are often seen along with a disease are called co–morbid conditions of that disease. For example, diabetic patients are often found to have high blood pressure, high cholesterol, kidney disease, liver disease, obstructive sleep apnea, and obesity. Thus, all these conditions are called co–morbidities of diabetes.
Note that each of these other conditions may exist in someone even without the presence of that diabetes. In that sense, they are separate diseases.
However, occasionally, both the conditions may have the same cause. For example, diabetes and obesity may be caused by the same condition — insulin resistance.
Some types of cancers share the same risk factors as diabetes. So, while we may not know if that cancer as well as diabetes have been caused by the same risk factor, that cancer and diabetes are co–morbidities.
On other occasions, some co–morbid conditions, such as kidney failure, may happen because of diabetes. In such a situation, diabetes is called the primary condition or Index condition.
In some situations, we may not be able to tell which condition caused which. For example, 75% of the diabetic patients also have high blood pressure.
Most of the adults have at least one co–morbid condition with diabetes. Up to 40% of diabetic patients, have at least 3 co–morbidities.
In other words, if you have diabetes, it is a good idea to keep a lookout for those conditions also. Better still, it will be good to regularly check for those conditions, if one has diabetes, as co–morbid conditions may develop as diabetes progresses.
Liver damage
Liver can get damaged by various conditions. If there is a sudden damage, such as due to a viral attack, the liver can repair itself, if the damage is in a limited area or extent.
Internally, liver has a grid made up of connective tissue, to which liver cells are attached. If some liver cells die, the grid still remains. The liver is capable of making new liver cells, which can attach to this grid. This can effectively repair the liver and almost a full recovery can happen.
Fatty liver, or NAFLD
If there is fat accumulation in the grid, the condition is called Fatty Liver, or NAFLD (Non-Alcoholic Fatty Liver Disease).
Fatty liver, if detected, can be reversed by losing some weight. Some studies have shown that if some patients lose 2 inches from their waist size, in three years, fatty liver can be reversed.
NASH
If the damage continues for a long period of time, or worsens, a lot of fat accumulates in the liver, and the condition is called NASH (Non-Alcoholic SteatoHepatitis).
Prolonged presence of NASH causes liver cell injury (Hepatocellular Ballooning) and inflammation.
If the body gets injury at any location, it develops scar tissue at that location. This is body’s way of strengthening that region. Scar tissue does not perform any of the original functions of the cells at that location but it does provide support.
Liver Fibrosis
At some point, the continuous repair of the damaged tissue in the liver causes scarring. This is called Liver Fibrosis. Fibrosis is reversible to some extent, if it is in the early stages.
Portal Hypertension
The scar tissue prevents easy flow of blood to the other liver cells. This can increase the blood pressure in the vein that carries blood from intestines to the liver. This vein is called Portal Vein and so, the condition is called Portal Hypertension.
Also, the scar tissue starts a vicious cycle. It blocks flow of blood to other, good liver cells, which may cause them to die. This creates more scar tissue, and so on.
Liver Cirrhosis
The scar tissue created in liver fibrosis cannot do any of the liver’s function. If this scar tissue gets spread all along the liver, the condition is called Liver Cirrhosis. This is an irreversible condition, often needing liver transplant as the only solution.
Of course, never say never. Some samaritans are trying to reverse even the cirrhosis. But, as of now, it is an irreversible condition. Don’t try your luck on science improving fast.
Liver Cancer
This cirrhotic liver can lead to liver cancer, another near–irreversible condition.
Testing for liver damage in diabetes
Fatty liver, liver fibrosis, and liver cirrhosis are known to be co–morbid conditions of diabetes. They can occur without any symptoms. However, there is a lot of medical controversy whether such diabetic patients should be checked for liver conditions.
The main problem is laboratory liver tests such as SPOT / SGPT do not tell with certainty, if there is an underlying liver disease.
Also, most patients undergo ultrasound to detect liver damage. But liver ultrasound cannot detect fatty liver, until nearly one-third of the liver is made up of fat. Early stage liver fibrosis also cannot be detected by the liver ultrasound test.
The benchmark test used earlier for testing liver cirrhosis was doing a liver biopsy. It was invasive, costly and complicated. However, now, a new, non-invasive test, called Liver Fibroscan, is used.
Liver Fibroscan
Liver Fibroscan measures liver stiffness, using a technique called transient elastography. It is simple, safe, and easy procedure. It can quantify the advanced liver fibrosis and liver cirrhosis. It can be considered the new Gold standard for liver damage testing.
New study
A new study tried to ascertain the level of liver problem in diabetic patients. If the problem was that common, it would be worth spending a lot of money in testing for liver damage. The study used liver Fibroscan to ascertain the liver damage in diabetics.
Study findings
In the study of diabetic patients in Hong Kong, which excluded those who were alcoholic or had hepatitis, 73% of patients had fatty liver and 18% had severe liver cirrhosis or liver fibrosis. Compared to normal people, the risk for the liver problems was 3.5 times for the diabetics. A big reason to get your diabetes in control.
If you add obesity to diabetes, that is, in patients with body mass index (BMI) ≥ 30, the problem was worse. 95% of them had fatty liver, and 35% had severe liver cirrhosis or fibrosis.
Tests for liver disease
Interestingly, half of these liver problem patients had normal SGOT / SGPT levels. So you cannot use the standard Liver Profile blood tests to check for fatty liver. Even liver ultrasound can not tell a fatty liver with certainty, as mentioned above.
To read in simple English: Fatty liver warning for diabetics.
In conclusion
In Hong Kong, 70% of the diabetics had fatty liver, and 20% of the diabetics had advanced liver fibrosis, or liver cirrhosis. This is too high a percentage to overlook, and not test regularly for.
If you are a diabetic, get rid of your obesity (reach BMI ≤ 25, at the very least) and get physically very active, before it gets too late.
Also, if you are diabetic, check for liver damage regularly. While expensive, liver Fibroscan is the only test that can tell with a good degree of confidence.
First published on: 8th August, 2016
Image credit: Analogicus from Pixabay