Diabetes identified as risk factor for liver failure in a Chinese population

A study in Singapore has found an association between diabetes and risk of death from liver cirrhosis, especially from fatty liver disease. The paper, to be published in the February 2017 print issue of Liver International, adds to the evidence from other studies that have identified a link between diabetes and liver cirrhosis-related death. In addition, the study has found that patients with diabetes who are lean may have a higher risk for cirrhosis death from fatty liver disease compared to the heavier patients with diabetes.

In Asian populations, chronic infection with hepatitis B or C virus is the main risk factor for severe liver disease leading to death (cirrhosis death). However, with vaccination against hepatitis B infection and effective treatment for viral hepatitis B and C, cirrhosis death from viral causes is expected to decrease in Singapore and other Asian countries. On the other hand, fatty liver disease is increasing in both Western and Asian populations as an important cause of chronic liver disease and consequently cirrhosis death. Obesity and diabetes are known to be risk factors for fatty liver disease. As the prevalence of diabetes increases at an alarming rate in Singapore and other Asian countries, it is important to quantify the impact that diabetes has on the risk of cirrhosis mortality.

This research, led by Professor Koh Woon Puay of Duke-NUS Medical School and the Saw Swee Hock School of Public Health, National University of Singapore, and Dr George Goh, Consultant, Department of Gastroenterology and Hepatology, Singapore General Hospital, was conducted using data from the Singapore Chinese Health Study, a prospective study that recruited about 63,000 middle-aged and elderly Chinese living in Singapore between 1993 and 1998. Information on the participants’ diet, lifestyle and medical history was collected via in-person interviews at recruitment. Mortality cases from liver cirrhosis in the cohort were identified via linkage with the nationwide death registry. Up to the end of 2014, over an average 17 years of follow-up, there were 133 deaths from cirrhosis in this cohort.

After adjusting for other risk factors of cirrhosis, participants with a history of diabetes at recruitment had an approximately three-fold risk of cirrhosis death compared to those without diabetes. The relationship between diabetes and cirrhosis death was found to be present for both viral (mainly due to Hepatitis B) and non-viral related causes. Non-viral related causes were predominantly due to fatty liver disease.

Prof Koh and Dr Goh ‘s teams found that when using participants who were lean and had no diabetes as the reference group, the risk of death from fatty liver disease was 1.72 times higher among those who were overweight but had no diabetes. The risk increased three-fold for patients who were both diabetic and overweight. However, the risk was highest at 5.5 times among those who were diabetic but lean. Hence, the results showed that the impact of diabetes on the risk of death from fatty liver disease was actually higher among lean participants compared to overweight participants in the study’s population.

“We expect the increase in diabetes to become the most important factor in driving an increase in fatty liver disease among Singaporeans. Our finding of this mortality risk being higher in lean diabetic patients has important implications in Singapore and other Asian populations, where patients develop diabetes at lower BMI levels compared to Western populations,” said senior author, Prof Koh.

“The underlying reason for a higher risk of fatty liver disease related death among lean patients with diabetes has not been ascertained. Nonetheless, it is important that patients with diabetes be actively screened for liver disease, in addition to other known complications.  This may be even more so in lean diabetic patients as the risk is paradoxically highest in this group,” added Dr Goh.

The SCHS is funded by grants from the U.S. National Institutes of Health, and receives active collaboration and support from the Singapore Ministry of Health.