Significance of Oral Glucose Tolerance Test for the Diagnosis of Diabetes Mellitus in Patients with Liver Cirrhosis

Abstract

criterion of fasting plasma glucose (FPG) for the diagnosis of diabetes mellitus in 1997 (1). The point was to diagnose diabetes with a reduced cut-off value of FPG (126 mg/dl) that corresponds to the 2-h plasma glucose (2-h PG) value of 200 mg/dl in the oral glucose tolerance test (OGTT). More recently, the Japan Diabetes Society published a report on the classification and diagnostic criteria of diabetes mellitus (2). Hyperglycemia due to liver cirrhosis (specific mechanismand diseases) was included in the classification and the same cutoff value of FPGwas adopted. However, here we report findings indicating that the FPGlevel is insufficient for the diagnosis of diabetes in patients with liver cirrhosis. FPG and 2-h PG during OGTTswere analyzed in 60 subjects with compensated liver cirrhosis by hepatitis C virus (HCV). Diagnosis of diabetes was done according to WHOcriteria (3) and HCV-positive cirrhosis was diagnosed by 1) the existence of HCVantibody, 2) liver deformity shown by an ultrasonography and/or a CT scan, 3) decreased synthetic liver function shown by serum albumin and prothrombin time, 4) absence of icterus, ascites or esophageal varices. The mean age was 67±8 years (mean±SD), and BMI, 22.5±3. 1 kg/m2. Scatterplots of FPGand 2-h PG and linear regression analysis showed that FPG of 107 mg/dl (95% CI: 71-143 mg/dl) was a corresponding value for 2-h PG of 200 mg/dl. The sensitivity and specificity to diagnose diabetes with FPGwere calculated. In addition, accuracy, defined as the sum of true-positive and true-negative subjects divided by the total number of the subjects, was determined. The sensitivity was 0.64 and 0.50, the specificity was 0.87 and 0.97, and the accuracy was 0.78 and 0.80, for the 107 and 126 mg/dl cutoff points, respectively. The 2 FPG cut-off points showed similar accuracy. In addition, 9 out of 42 patients whose FPGs were normal (<1 10 mg/dl) were classified as diabetic. Wetherefore assume that the FPGcriterion is not applicable for cirrhotic patients.Patients with cirrhosis have been shownto be insulin resistant both in muscle and liver tissues (4). This maycause a more marked elevation in 2-h PG levels. If cirrhotic patients are suspected to have postprandial hyperglycemia, an OGTTwould be recommended at lower FPG levels (<1 10 mg/dl). Another point we like to emphasize is that the patients with compensated liver cirrhosis are usually asymptomatic and without detailed blood test and special examinations, they would be regarded as normal individuals. It is highly recommendedthat subjects with occult liver disease undergo a screening for diabetes. Furthermore, since the recent development of the treatment has remarkably improved the prognosis of cirrhosis, diabetic vascular complications in cirrhosis with long-standing postprandial hyperglycemia cannot be overlooked.

Hepatogenous diabetes: Is it time to separate it from type 2 diabetes?

“…These findings indicate the need for performing an OGTT to diagnose DM in cirrhotic subjects presenting with normal FPG (and HbA 1c ) levels . Using this combined approach (Table ), the prevalence of abnormal glucose regulation (IFG, IGT or DM) and DM, respectively, were: 96.1% and 71.1% in this study by Holstein et al …”

Der hepatogene Diabetes – aktueller Stand der Diagnostik und Therapie

“…1). Daher sollte bei jedem Patienten mit Leberzirrhose und Nachweis einer Glukosurie, einer erhöhten "Gelegenheits-Plasmaglukose" (unabhängig von Tageszeit und Mahlzeiten) oder aber einer erhöhten Nüchternglukose ein oGTT angestrebt werden [24]. Falls eine orale Verabreichung von Glukose nicht möglich ist, kann alternativ ein intravenöser Glukosetoleranztest (ivGTT) durchgeführt werden.…”

“…Falls eine orale Verabreichung von Glukose nicht möglich ist, kann alternativ ein intravenöser Glukosetoleranztest (ivGTT) durchgeführt werden. Die Bestimmung der Nüchternglukose im venösen Blut zeigt beim hepatogenen Diabetes häufig keine signifikant erhöhten Werte an, sodass diese Messung sowohl als Screeninguntersuchung als auch zur Verlaufskontrolle nur eingeschränkt verwertbar ist [24]. Kapilläre Blutzuckermessungen (BZ) mithilfe von Teststreifen stellen keine qualitätskontrollierten Labormethoden dar und sind damit für die Diagnose einer diabetischen Stoffwechsellage oder einer Glukoseintoleranz nicht ausreichend.…”

Contribution of β-cell dysfunction and insulin resistance to cirrhosis-associated diabetes: Role of severity of liver disease

“…Therefore, an oral glucose tolerance test (OGTT) is often required for DM diagnosis in subjects with cirrhosis [6].…”