Z Gastroenterol 2010; 48 - K33
DOI: 10.1055/s-0030-1267683

Hepatogenous diabetes in liver cirrhosis: a survey of awareness in an expert collective and a study of medical treatment, frequency of cirrhosis-related and diabetes-induced sequelae, compared with a large population of non-diabetic cirrhotic patients

F Gundling 1, H Seidel 1, I Strassen 1, N Löffler 1, C Pehl 2, T Schmidt 1, B Haller 3, PM Schumm-Draeger 4, W Schepp 1
  • 1Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany
  • 2Department of Medicine, Vilsbiburg Hospital, Vilsbiburg, Germany
  • 3Institut für medizinische Statistik und Epidemiologie, Technical University of Munich, University of Munich, Munich, Germany
  • 4Department of Endocrinology and Angiology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany

Aims: Hepatogenous diabetes (HD) is frequently prevalent in liver cirrhosis (LC) and represents an important prognostic risk factor for decreased long-term survival and an increased rate of several complications. Thus, compared with other complications of LC it is often overlooked in everyday practice. Furthermore, HD represents a different therapeutical entity than type 2 diabetes due to the large spectrum of contraindications for several anti-diabetic drugs in the presence of cirrhosis. However, investigations of current practice concerning treatment are extremely sparse.

Aims and Methods: (I) To evaluate the awareness of this problem anonymous questionnaires were sent to 576 members of the Bavarian Society of Gastroenterology representing a highly specialised sample in digestive and hepatological diseases. (II) A retrospective study of a large series of patients with LC and HD [n=87 (73.6% men, 26.4% women)] was performed analysing several features of interest including anti-diabetic treatment, prognostic impact of a sufficient glycemic control and frequency of cirrhosis-related and diabetes-induced sequelae which were compared with a large population of non-diabetic cirrhotics [n=198 (58.1% men, 41.9% women)].

Results: (I) Only 23 (9.1%) and 145 (57.3%), respectively, of the respondents could name the correct prevalence of impaired glucose tolerance and diabetes in advanced cirrhotic patients while 60 (23.7%) underestimated and 39 (15.4%) overestimated this problem. (II) The vast majority of diabetic subjects (DS) in our cirrhotic population showed no sufficient glycemic control (71.3%). 53.4% received insulin therapy alone and in 7.3% in combination with oral hypoglycemic agents. Remarkably, 32.7% received anti-diabetic therapy which should be avoided in HD due to contraindications while 28.7% reported about chronic alcohol abuse and 37.9% were described as noncompliant. Compared to non-diabetic subjects (NDS), the frequency of some typical complications associated with LC {hepatocellular carcinoma (HCC): 14.1% (NDS) vs. 18.4% (DS), hepatic encephalopathy (HE): 20.7% (NDS) vs. 36.6% (DS), p=0.001; ORadj=3.21 (KI=[1.63;6.28])} and diabetes-induced sequelae including cardiovascular diseases {coronary heart disease/stroke: 10.6% (NDS) vs. 35.6% (DS), p=0.0001; ORadj=3.40 (KI=[1.71;6.74])} was higher in patients with LC and HD. Furthermore, diabetic patients had a higher rate of arterial hypertension {48.3% (DS) vs. 26.8% (NDS), p=0.078, ORadj=1.68 (KI=[0.944;2.978])} and hypercholesteremia {17.2% (DS) vs. 8.6% (NDS), p=0.120, ORadj=1.93 (KI=[0.842;4.410])} than non-diabetics in our cirrhotic population. Diabetic cirrhotics with an insufficient glycemic control compared with subjects demonstrating a sufficient glycemic control showed an even higher rate of HE (40.3% vs. 28.0%), HCC (16.0% vs. 19.4%) arterial hypertension (32.0% vs. 54.8%) and hypercholesteremia (4.0% vs. 22.6%). In contrast to previously published data the frequency of ascites and portal hypertension (PH) was lower in the diabetic subgroup of cirrhotic patients {[ascites: 48.3% ((DS) vs. 61.6% (NDS)], [PH: 59.8% (DS) vs. 65.2% (NDS); OR=0.939]}.

Conclusion: Even in an expert collective, HD represents an underestimated complication of LC. However, as it is shown in our study, the anti-diabetic treatment is often inappropriate in daily routine. Regarding typical complications of LC, diabetic cirrhotics have a higher frequency of HE (especially in subjects with an insufficient glycemic control) and HCC than nondiabetic cirrhotics while the prevalence rate of ascites and PH was lower in the diabetic subgroup. Regarding the limited variety of anti-diabetic medication in LC, further studies analysing patient-oriented end-points and guidelines or guideline-like recommendations for an adequate treatment of HD are necessary.