Cirrhosis

How accurate is glycated haemoglobin in patients with liver cirrhosis? A case series (2018)

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Type of publication:
Conference abstract

Author(s):
*Basavaraju N.; *Rangan S.; *Singh P.; *Moulik P

Citation:
Diabetic Medicine; Mar 2018; vol. 35 ; S1

Abstract:
Introduction: Glycated haemoglobin (HbA1c) is the gold standard for monitoring glycaemic control in patients with diabetes. We present three cases of chronic liver disease where HbA1c may be misleading. Case 1: A 71-year-old Caucasian woman with liver cirrhosis due to hepatitis C, Type 2 diabetes, previous bladder tuberculosis and chronic kidney disease stage 3 was evaluated in clinic. Her capillary glucose (CG) was 6 to 9 mmol/l, no hypoglycaemia. She was anaemic; HbA1c was low at 34mmol/mol. Fructosamine was elevated at 296umol/l (205 to 285). Case 2: A 38-year-old Caucasian man with alcoholic liver cirrhosis, portal hypertension, and Type 2 diabetes was admitted with haematemesis. His CG was 10 to 14 mmol/l and HbA1c 26mmol/mol. He had iron deficiency anaemia, deranged liver enzymes and renal function. Fructosamine was normal at 246umol/l. Case 3: A 65-year-old Caucasian woman with non-alcoholic steatohepatosis/cirrhosis, portal hypertension, Type 2 diabetes, iron deficiency anaemia was admitted with melena. Her CG was 12 to 14mmol/l and HbA1c 44mmol/mol. Results showed acute kidney injury, deranged liver enzymes, normal albumin but low haemoglobin. Fructosamine is awaited. All patients required insulin for management of their diabetes. Discussion: The degree of glycation (glucose binding to N-terminal valine of HbA) is dependent on glycation rate, glucose availability and lifespan of red blood cells. Reference range of HbA1c is based on normal lifespan of RBC. There are very limited studies in evaluating the accuracy of HbA1c in chronic liver disease (CLD). Multiple factors can shorten RBC survival in CLD, including anaemia, portal hypertension, hypersplenism, variceal bleeding, resulting in falsely low HbA1c. Fructosamine, glycated albumin can also be inaccurate. Capillary glucose monitoring should guide glycaemic management.

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Real world efficacy of 12 weeks sofosbuvir, daclastivir with ribavirin among cirrhotic pre and post-transplant genotype 3 (2017)

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Type of publication:
Conference abstract

Author(s):
Schmidt-Martin D.; Bufton S.; Haydon G.H.; Mutimer D.; Elsharkawy A.M.; Roberts M.; *Rye K.; Singhal S.; Eldred S.; Perry I.; Corbett C.; Unitt E.; Wood V.; Dillon H.

Citation:
Journal of Hepatology; 2017; vol. 66 (no. 1)

Abstract:
Background and Aims: Current EASL guidelines recommend combined Sofosbuvir and Daclatasvir with Ribavirin (SOF + DCV + RBV) for 24 weeks in compensated/decompensated cirrhosis for genotype 3 patients. We investigated response to 12weeks treatment in a large cohort of pre and post-transplant predominantly compensated cirrhotic genotype 3 patients. Methods: All patients who received a single dose and treated in 8 treatment centres within our hospital network included. SVR12 rates for all patients who started treatment are reported on an intention to treat (ITT) basis and we include a modified intention to treat (mITT) analysis excluding non virological failures. Results: 156 patients ((M:F) 109:47) mean age 51.5 were commenced on treatment. The overall SVR12 rate was 88.5% (138/156) (ITT) and 95.8% (138/144) (mITT). 2 patients stopped treatment without side effects. Five patients did not attend for confirmation of SVR12, three patients died on treatment (2 due to cardiac arrest, 1 due to sepsis) and a further patient died following completion of treatment prior to SVR12 (hepatocellular carcinoma). mITT SVR12 for patients with compensated and decompensated cirrhosis (Child Pugh B/C) were 96.7% (116/120) and 82% (23/28)respectively. 96.4% (80/83) of patients with previous exposure to interferon and ribavirin achieved SVR12. All patients with HIV co infection achieved SVR (n = 8). 89% of liver transplant patients achieved SVR. 18%(5/28) of the decompensated cohort (Child Pugh B/C) had died within 2 years of commencing treatment. Conclusions: SOF + DCV + RBV for 12 weeks achieved real world SVR12 rates comparable with 24 weeks treatment in cirrhotic genotype 3 patients or 12 weeks sofosbuvir/velpastasvir. This is the largest reported cohort of posttransplant genotype 3 patients with advanced fibrosis. Our data suggests 12 weeks treatment for all cirrhotic patients may be considered regardless of previous interferon and ribavirin exposure (Table presented).