Diabetes and Liver – All You Need to Know

By Dr. Sanjiv Saigal in Liver Transplant and Biliary Sciences

Oct 28 , 2022 | 3 min read


Liver involvement in patients with diabetes is a common presentation. The spectrum of liver involvement varies from abnormal liver enzymes to chronic liver disease and even liver failure. A healthy liver helps keep blood glucose within the normal range. Additionally, it protects against excessive fluctuations, as both hyperglycaemia (high blood sugar) and hypoglycaemia (low blood sugar) can be detrimental to our health.

Patients with diabetes have a prevalence of liver disease, and patients with liver disease have a prevalence of diabetes. Altered metabolism, drug interactions, and liver toxicity can complicate diabetes management in those with diabetes-induced liver disease.

The spectrum of liver disease in diabetes

An abnormal elevation of liver enzymes, especially ALT, is common among people with diabetes, the most common cause of which is Non-Alcoholic Fatty Liver Disease (NAFLD). NAFLD is associated with metabolic and cardiovascular disorders, such as obesity, insulin resistance (IR), hypertension, altered lipid profile [elevated triglycerides, decreased HDL (good) cholesterol, and predominance of small LDL (bad) cholesterol] and Type 2 diabetes. It is the liver manifestation of metabolic syndrome and the most common liver disease seen in those with no other causes to account for their altered liver functions.

NAFLD starts as fatty deposition in the liver, leading to inflammation, fibrosis, cirrhosis and even liver cancer if left untreated. Insulin resistance is the primary culprit for the above process.

Severe fibrosis is seen in diabetics with liver involvement, leading to cirrhosis. Liver cirrhosis (CLD) and diabetes form a vicious cycle, as cirrhosis itself is a cause of insulin resistance, which can have implications for managing diabetes in cirrhosis. The incidence of liver failure also increases in diabetics. However, whether diabetes, its medications, or other factors are involved remains unclear.

Liver cancer has increased in patients with diabetes and vice versa. Like in all cases, insulin resistance forms the basis, and subsequent pathologic changes result in the development of cancer. In fact, NAFLD-related end-stage cirrhosis seen in diabetics is among the leading causes of liver transplantation.

Management of liver disease in diabetes

All people with diabetes should have a liver function test (LFT) done as a part of their initial workup. NAFLD/NASH should be suspected in obese diabetics with elevated enzymes. If enzyme elevations are seen, we should rule out other causes, including viral, metabolic syndrome and alcohol aetiology. Ultrasound abdomen is essential to screen for fatty liver. Some patients may need further assessment, including liver MRI to quantify liver fat. Select patients may need a liver biopsy to further evaluate NAFLD/NASH.

Frequently Asked Questions

1. I am a diabetic - What are my chances of having fatty liver?

About 50% of diabetics have fatty liver. It is even more if there is associated obesity and genetic predisposition.

2. How do I know if I have fatty liver if I also have diabetes?

To diagnose fatty liver, you will be advised to undergo a liver function test (LFT) and a USG abdomen. In some situations, you may be advised to undergo a Fibroscan for further assessment of fatty liver.

3. What kind of lifestyle changes should I make if I have been detected with fatty liver disease?

Keep track of your sugar levels and control them as per the advice of your physician. Maintain average weight and BMI. Avoid unhealthy foods like high fat-low fibre foods and alcohol.

4. What are the chances that I may develop liver cirrhosis or cancer from fatty liver disease?;

Some patients proceed to the complications mentioned above of fatty liver. Regular follow-up and imaging tests can detect complications early, and necessary measures can be taken. Please be up-to-date with vaccinations.

5. How much should I exercise?

Moderate-intensity exercise like jogging or brisk walking for 30-40 minutes for 5 days a week would be sufficient. Do note that some exercise is better than no exercise.

6. Can I undergo surgery or tooth extractions if I have liver disease?

You can undergo surgery without concerns if LFTs are near normal or with minimal enzyme elevations. However, if it’s progressed to fibrosis/cirrhosis, the risk of surgery will have to be graded according to the stage of liver disease.

7. Should I be concerned about my other organ systems if I have diabetes and fatty liver?

Diabetics have risks of other organ involvement like cardiac, renal and nervous involvement. Please note that your chances of other organ dysfunction increase if you have liver disease along with diabetes. You could also get ulcer on feet which is not cure or heal easily also you may have to get ulcer treatment for feet that is known as diabetic foot ulcer treatment in medical terms.

8. I have poorly controlled diabetes and liver cirrhosis. What is the best way to control my blood sugar?

In those with diabetes & liver cirrhosis, the patient is advised to take insulin for better blood sugar control.

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