Clinicopathological profile of hepatic involvement in type-2 diabetes mellitus and its significance.

AIMS AND OBJECTIVES: Involvement of liver as an organ complication in Type 2 Diabetes Mellitus (T2DM) is known. Studies are few about their baseline parameters from our country. Study the disease burden and clinicopathological profile of hepatic involvement in T2DM, find the associations with known risk factors and thus try to identify simple markers of advanced disease. MATERIAL AND METHODS: A screened group of randomly selected 47 patients of T2DM without other liver diseases (viral, alcoholic, drug, autoimmune, etc.) was selected. Their clinical (age, sex, body mass index, family history, blood pressure), biochemical (transaminases, lipid profile), and hepatic ultrasonographic (USG) and histopathological (HPE) profiles were studied. Segregation was done according to the histological severity and duration of diabetes (< 5 yrs, 5-10 yrs, > 10 yrs). RESULTS: On histology, normalcy was maintained in 17%, only fatty change was present in 43%, nonalcoholic steatohepatitis (NASH) could be identified in 40% with more advanced disease in 23%. Prevalence of cirrhosis was low. Positive family history, hypertension, longer duration, female sex and increased body mass index were significantly associated with NASH; more advanced disease was associated with male sex only. Incident lipid profile and transaminases levels were non-contributory. In the early stage, USG detected abnormality correlated poorly with HPE. CONCLUSION: The burden of hepatopathy in T2DM is high; with improving cardiovascular mortality, a higher burden awaits us in the next decade or so. Naturally, it becomes imperative to the treating clinician for targeting this aspect of diabetic complication from the very beginning of therapy.

Role of GFR estimation in assessment of the status of nephropathy in type 2 diabetes mellitus.

OBJECTIVES: Study the status of glomerular filtration rate (GFR) estimation vis-a-vis other noninvasive modes of assessment of renal involvement in Type2 Diabetes Mellitus (T2DM) and assess the temporal profile of the prevalence of nephropathy with a cross sectional cohort. METHODS: A total of 100 patients of T2DM were selected after screening and segregated into 3 groups according to duration of T2DM. Duration of < 5 years constituted group A and had 31 patients, group B duration was between 5-15 years and had 40 patients, rest belonged to group C with duration > 15 years. The parameters studied and compared were (1) various grades of albuminuria--normal, micro and macro by 24 hrs. urinary albumin excretion rates (UAER- gm/24 hr), (2) sonologically detected renal size(normal, small, large) and morphology (loss or presence of corticomedullary differentiation, (3) serum creatinine level (</> 1.4 mg/dl) and (4) different levels (high, normal, low, very low) of GFR (ml/min) by DTPA renal scan. RESULT ANALYSIS: There was high prevalence of nephropathy in all durations. Microalbuminuria had a high prevalence in patients of shorter duration (group A-74.2%). Albuminuria increased with duration but plateued off with longer duration (> 15 yrs) (UAER - 0.0842 +/- 0.083 vs. 0.906 +/- 0.84 vs. 1.346 +/- 1.28). Sonographic loss of corticomedullary differentiation and azotemia were late feature only and none had a contracted kidney. Only the parameter of GFR showed a graded and rather linear decrement with duration (132.57 +/- 19.3 vs. 76.33 +/- 20.8 vs. 40.08 +/- 17.1). Hyperfiltration had a high prevalence in patients of early detection (61.3%) and was the earliest change noted before change in any other parameter. GFR shows wide variation in various grades of albuminuria, especially microalbuminuria, and azotemia. A value in the normal range was uncommon (8%). CONCLUSION: GFR estimation is probably the most rational noninvasive mode of assessing the renal status in patients of T2DM, irrespective of the status of the other noninvasive methods as they express significant variation in inception and progression.

Effect of tight glycaemic control on fetal complications in diabetic pregnancies.

AIMS: To find the incidence of fetal complications in Indian diabetic mothers with tight glycaemic control (TC), its comparison with other levels of glycaemic control, i.e., acceptable control (AC), uncontrolled (UC), and relevant international data. METHODS: A total of 240 mothers with diabetes mellitus (DM) and pregnancy were risk-matched and selected from the Antenatal Clinic of NRS Medical College, 176 of whom had gestational diabetes mellitus (GDM) and 64 had pregestational diabetes mellitus (PGDM), and were put on exercise, diet and or insulin therapy. Glycaemic parameters monitored include fasting plasma glucose (FPG), 2 hr. postprandial plasma glucose (PPPG) and HbA1C. TC had - FPG < 70 mg/dl, PPPG < 100 mg/dl, HBA1C < 6.5%; AC with FPG 70-95 mg/dl, 2 hr. PPPG 100-120, HBA1C 6.5-7.5% and UC had FPG > 95 mg/ dl, 2 hr. PPPG > 120 mg/dl and HBA1C > 7.5%. Fetal parameters monitored included large-for-date babies (LGA), small-for-date babies (SFD), birth asphyxia, perinatal death, neonatal hypoglycemia, neonatal hypocalcaemia and congenital anomalies. RESULTS: (i) LGA-AC had the best results (0% vs. 12.5 and 22.29%); (ii) SFD-TC and AC had worst results (16.7% and 18.18% vs. 0%); (iii) Birth asphyxia-AC fared worse 18.18% vs. 4.16% and 0%; (iv) perinatal death and congenital anomalies showed significant reduction with tight control (4.16% and 0% respectively); (v) Neonatal hypoglycemia is lowered in TC compared with UC while neonatal hypocalcaemia does not show any alteration. For PGDM patients there is little intra-group variability of the parameters. The UC subgroups of GDM fared better than PGDM as far as all complications and congenital anomalies were concerned. Compared with international data, there is a dichotomy of the results of GDM and PGDM. CONCLUSION: For GDM patients all parameters may not be uniformly affected by the same degree of glycaemic control. A tight control may not be theonly factor to decide on the outcomes for PGDM patients.