The relation between type-2 Diabetes and

Hepatitis C: a case-control study in a tertiary care

hospital in Pakistan.
Salman Bin Mahmood M10049

Introduction
Statement of the Problem
It has been estimated that about 3% of the worlds population is infected
with the Hepatitis C virus (HCV), 55-80% of which consists of individuals with
a chronic infection[1], and between 150 and 200 million people have been in
contact with the virus. HCV causes liver disease with a spectrum of severity,
being responsible for about 25% of both hepatocellular carcinoma (HCC) and
chronic liver disease (CLD) and is also a significant cause of global morbidity
and mortality[2], resulting in 366,000 deaths annually worldwide[3]. It has
already become the principal reason for liver transplantation in first world
countries and is accepted as one of the most common blood borne
pathogens causing chronic infection in the USA.
According to a Global Epidemiology study, Pakistans total population in the
year 2004 was approximately 159 million and HCV seroprevalence was
estimated to be 4%, whereas the range reported for the seroprevalence was
2.4-6.5%[4]. More than 10 million people in Pakistan are infected with HCV
and given the large population and high rates of infection reported in the
country, Pakistan is considered to be among the worst affected[5].
Furthermore, HCV has been repeatedly linked to several extra-hepatic
manifestations, porphyria cutanea tarda and glomerulonephritis being
among them[6-7]. Type-2 diabetes mellitus (DM) was first suggested to have
an association with HCV infection by Allison et al. (2004)[8] and since then it
has been studied multiple times as a potential extra-hepatic manifestation of
HCV infection.
DM is a chronic disease of metabolism and involves abnormal glucose
homeostasis[9]. More than 171 million people globally are affected by DM,
and this figure is expected to increase up to 366 million by 2030[10]. A
systematic review conducted by Jayawardena et al. (2012) from South Asia

showed the burden of diabetes to range from 3-7.2% in the general

population[11]. The prevalence of type-2 DM in the South Asian population is 4
to 6 fold, when compared with the European population[12].
Type-2 DM is a common complication of most liver diseases, independent of
the etiology, especially at stages of advanced disease[13]. However, clinical
and experimental data show a direct role of HCV in causing disturbances in
glucose metabolism. Many studies using a cross-sectional design and
comparing the prevalence of Type-2 DM in populations of chronic Hepatitis C
patients with those of comparator groups have supported these preliminary
observations with similar findings[14-17].
However, other studies found no evidence of excess risk[18-20] or excess risk
limited to specific populations[21-23]. Differences in sources of controls,
definitions of cases, sample size and target populations may provide an
explanation for such variability of results observed among these studies. For
example, a published systematic review examined the association between
HCV and type-2 DM in a highly limited sub-population of kidney transplant
recipients[24].
In a study conducted by Muhammad Sadik Memon et al. (2013) at Isra
University Hospital, Hyderabad, the prevalence of type-2 DM was found to be
31.5% in Hepatitis C seropositive patients and the prevalence was twice as
high as compared to the non-infected population. Also, patients infected with
HCV genotype 3 were significantly more likely to be diabetic. Thus, this study
showed a strong association between HCV and type-2 diabetes[25].
Hence, there is still a need to further confirm the association between HCV
and type-2 DM. Furthermore, only a few studies have been conducted in
Pakistan to evaluate this association. Our study would aim to confirm this
association and also provide positive or negative evidence regarding this
issue in our setting.

Theoretical Framework
After evidence for the link between type-2 diabetes and hepatitis C infection
was first described by Allison in 2004, many studies have been conducted to
confirm this association. Many have supported the association between the
two conditions, however, many have also found that there is no significant
excess risk of type-2 DM with HCV or that there is an increased risk but it is
limited to specific groups among the population.

Experimental data also suggests that HCV causes a direct interference in the
insulin signaling pathway. This was first observed when a study compared
liver specimens obtained from 42 HCV infected individuals with 10
specimens from non-HCV-infected individuals, matched for age and BMI, by
exposing them to insulin and testing the activation/phosphorylation of
certain molecules involved in the insulin signaling cascade. This study
concluded that HCV interacts directly with components of the insulin
signaling pathway and results in insulin resistance which may later progress
to type-2 diabetes[26].
Hence, increased risk of DM in HCV infected individuals may be of clinical
relevance, even when small, since the effectiveness of current
pharmacological treatments for HCV has been shown to be reduced in
patients with DM[27], and progression of the liver disease itself also becomes
worse[28].
As a result, screening and treatment for type-2 diabetes may be needed
earlier in HCV infected individuals and among diabetics, HCV would also
need to be ruled out.
We aim to conduct our study in light of the fact that enough information is
still not available to confirm the association between type-2 diabetes and
HCV infection, and that the clinical implications of this association are such
that the data currently available needs to be further verified in order to
strengthen our understanding and provide a better explanation.

Objective
To determine the association between hepatitis C infection and type-2
diabetes through a case-control study.

Specific Objectives
1. To determine and compare the prevalence of anti-HCV antibody among
type-2 diabetes patients visiting the Aga Khan University Hospital
versus non-diabetic controls.
2. To determine the odds of being infected with hepatitis C among
patients of type-2 diabetes patients.
3. To determine the contribution to the risk of development of diabetes of
other risk factors such as family history, increased blood pressures and
increased High Density Lipoprotein (HDL) levels and the effects they
have on the risk of development of diabetes among HCV patients.

Methodology
Study Setting
Our study will be based in the Aga Khan University Hospital, which is a
tertiary care hospital in Karachi, Pakistan.
The hospital, built on a 65-acre site, has a total of 599 beds and also
provides patient care to approximately 60,000 outpatients annually. The
hospital provides comprehensive secondary and tertiary care and is wellequipped to diagnose and treat both medical and surgical patients.
The Aga Khan University Hospital has a full-time Diabetes and Endocrinology
Clinic, which was launched in 2000.

Study Population
Patients diagnosed with type-2 diabetes, coming for follow-up at the
Diabetes and Endocrinology Clinic will be the cases. Patients newly
diagnosed during the study period and referred to the clinic will also be
included.
Controls will be patients attending any of the general medicine clinics other
than the Diabetes and Endocrinology Clinic, whose fasting blood sugar is
<100 md/dl or random blood sugar is <126 mg/dl, and who do not have any
overt liver disease.
Patients <18 years of age, pregnant women and acutely ill individuals will be
excluded.

Study Design

This study is an observational research and the study type is case-control.

Variables
1.
2.
3.
4.
5.
6.
7.
8.

Demographic variables: Age, sex, BMI.

Diagnosed diabetic or non-diabetic.
Family history.
Lifestyle: sedentary or non-sedentary, non-sedentary defined as
physical activity of at least 30 minutes, every day.
History of hypertension or cardiovascular disease.
Anti-HCV sero-positivity.
HDL levels.
Liver function tests (LFT): aspartate aminotransferase (AST) and
alanine aminotransferase levels (ALT).

Sampling Approach
The purpose of the study will be explained to the subjects and informed
consent will be obtained. A convenience sampling will be employed to select
the cases and the controls will be randomly selected, after assuming
diabetics to be a homogenous group.

Sample Size
As calculated by the free OpenEpi online software, the sample size needed
for our study is 1496, for a confidence interval of 95%, study power of 80%,
an equal ratio of cases to controls, and a minimum Odds Ratio to be detected
of 1.8.

Data Collection
The researcher will obtain the pertinent history from the study participants
regarding the risk factors of diabetes and also examine them for increased
blood pressures and overt liver disease. Legible participants will
subsequently be sent to the laboratory for investigations.
In the laboratory, senior laboratory personnel will draw 5 ml of participants
blood using sterile needle technique for anti-HCV, LFT and HDL testing.
The data collection tool will be a structured questionnaire filled in by the
researcher after obtaining the pertinent history from the patients and
reviewing the relevant patient records and lab reports.

Analysis Plan

Collected data will be entered in EpiData 3.1 software and then exported to
SPSS version 19 for analysis. Frequencies and means will be calculated for
various variables. Results will be presented in the form of tables and bar
charts for categorical data, and histograms for continuous data.
Demographic variables may be presented as follows:
Diabetes Status
Gender

Diabetic

Non-Diabetic

Male
Female

Comparisons will be done among the cases and controls by using the
students t-test for continuous variables and the chi2-squared test for
categorical variables. Continuous variables will be summarized as a mean
standard deviation and categorical variables as frequencies and percentages.
Univariate and multivariate logistic regression analysis will also be performed
and p-value and odds ratio will also be computed. A p-value of <0.05 will be
considered significant.
The Odds Ratio will be calculated by using a 2x2 table as follows:
Diabetic

Non-Diabetic

Anti-HCV +ve
Anti-HCV ve

Dummy Tables
Table 1 Proportions of sample characteristics and chi- 2 values for categorical
variables

Variable

Category

Gender

Male
Female
<25 kg/m2
25-30 kg/m2
>30 kg/m2
Positive
Negative
Positive
Negative

BMI
Anti-HCV
status
Family
history

Diabetic (%) Nondiabetic (%)

Chi-2
value

p-value

Lifestyle

History of
hypertensio
n or CVD

Sedentary
Nonsedentary
Positive
Negative

Table 2 Means and standard deviations of sample characteristics and t-test values
for continuous variables

Variable
Age
HDL
ALT
AST

Means SD

t-value

p-value

Ethical Considerations
This study involves a review of patient medical records. Ethical approval will
be sought from the Ethics Review Committee at Aga Khan University Hospital
and all information collected will be kept confidential, under lock and key,
and only the researchers will have access to the data.

References:
1. NIH Consensus Statement on Management of Hepatitis C: 2002. NIH Consens State
Sci Statements 2002;19: 146.
2. White DL, Ratziu V, El-Serag HB. Hepatitis C infection and risk of diabetes: a
systematic review and meta-analysis. J Hepatol 2008; 49: 831-844.
3. Perz JF, Armstrong GL, Farrington LA, Hutin YJ, Bell BP. The contributions of hepatitis B
virus and hepatitis C virus infections to cirrhosis and primary liver cancer worldwide. J
Hepatol 2006;45: 52938.
4. Shepard CW, Finelli L, Alter MJ. Global epidemiology of hepatitis C virus infection. The
Lancet Infectious Diseases 1 September 2005 (Volume 5 Issue 9 Pages 558-567 DOI:
10.1016/S1473-3099(05)70216-4)
5. World Health Organization fact sheets. Hepatitis C. Geneva: World Health
Organization; 2000.
6. Zignego AL, Ferri C, Pileri SA, Caini P, Bianchi FB. Extrahepatic manifestations of
Hepatitis C Virus infection: a general overview and guidelines for a clinical approach.
Dig Liver Dis 2007;39: 217.
7. Fabrizi F, Plaisier E, Saadoun D, Martin P, Messa P, Cacoub P. Hepatitis C virus
infection, mixed cryoglobulinemia, and kidney disease. American Journal of Kidney
Diseases 2013; 61(4):623637

8. Allison ME, Wreghitt T, Palmer CR, Alexander GJ. Evidence for a link between hepatitis
C virus infection and diabetes mellitus in a cirrhotic population. J Hepatol 1994; 21:
1135-1139
9. Imam K. Clinical features, diagnostic criteria and pathogenesis of diabetes mellitus.
Advances in Experimental Medicine and Biology 2012;771:340355
10. Gul N. Knowledge, attitudes and practices of type 2 diabetic patients. Journal of Ayub
Medical College, Abbottabad 2010; 22(3):128131
11. Jayawardena R, Ranasinghe P, Byrne NM, Soares MJ, Katulanda P, Hills AP. Prevalence
and trends of the diabetes epidemic in South Asia: a systematic review and metaanalysis. BMC Public Health 2012;12:380
12. Rees SD, Hydrie MZI, OHare JP et al. Effects of 16 genetic variants on fasting glucose
and type 2 diabetes in South Asians: ADCY5 andGLIS3 variants may predispose to
type 2 diabetes. PLoS ONE 2011;6(9):Article ID e24710
13. Negro F, Alaei M. Hepatitis C virus and type 2 diabetes. World Journal of
Gastroenterology, 15(13), 1537-1547.
14. Mason AL, Lau JY, Hoang N, Qian K, Alexander GJ, Xu L, et al. Association of diabetes
mellitus and chronic hepatitis C virus infection. Hepatology 1999; 29: 328-333
15. Zein NN, Abdulkarim AS, Wiesner RH, Egan KS, Persing DH. Prevalence of diabetes
mellitus in patients with end stage liver cirrhosis due to hepatitis C, alcohol, or
cholestatic disease. J Hepatol 2000; 32: 209-217
16. Howard AA, Klein RS, Schoenbaum EE. Association of hepatitis C infection and
antiretroviral use with diabetes mellitus in drug users. Clin Infect Dis 2003; 36: 13181323
17. Lecube A, Hernndez C, Genesc J, Esteban JI, Jard R, Sim R. High prevalence of
glucose abnormalities in patients with hepatitis C virus infection: a multivariate
analysis considering the liver injury. Diabetes Care 2004; 27: 1171-1175
18. Akbar DH, Siddique AM, Ahmed MM. Prevalence of Type-2 diabetes in patients with
hepatitis C and B virus infection in Jeddah, Saudi Arabia. Med Princ Pract 2002; 11:
8285.
19. Papatheodoridis GV, Chrysanthos N, Savvas S, Sevastianos V, Kafiri G, Petraki K, et al.
Diabetes mellitus in chronic hepatitis B and C: prevalence and potential association
with the extent of liver fibrosis. J Viral Hepat 2006; 13: 303310.
20. Costa LM, Mussi AD, Brianeze MR, Souto FJ. Hepatitis C as a risk factor for diabetes
type 2: lack of evidence in a hospital in central-west Brazil. Braz J Infect Dis 2008; 12:
2426.
21. Mehta SH, Brancati FL, Sulkowski MS, Strathdee SA, Szklo M, Thomas DL. Prevalence
of type 2 diabetes mellitus among persons with hepatitis C virus infection in the
United States. Hepatology 2001;33:1554.
22. Butt AA, Fultz SL, Kwoh CK, Kelley D, Skanderson M, Justice AC. Risk of diabetes in
HIV infected veterans pre- and post-HAART and the role of HCV coinfection.
Hepatology 2004;40:115119.
23. Jain MK, Aragaki C, Fischbach L, Gibson S, Arora R, May L, et al. Hepatitis C is
associated with type 2 diabetes mellitus in HIV-infected persons without traditional
risk factors. HIV Med 2007;8:491497.
24. Fabrizi F, Martin P, Dixit V, Bunnapradist S, Kanwal F, Dulai G. Post-transplant
diabetes mellitus and HCV seropositive status after renal transplantation: metaanalysis of clinical studies. Am J Transplant 2005;5:24332440.
25. Memon MS, Arain ZI, Naz F, Zaki M, Kumar S, Burney AA. Prevalence of type 2
diabetes mellitus in hepatitis C virus infected population: a southeast-asian study.
Journal of diabetes research, 2013: Article ID 539361

26. Gulcan A, Gulcan E, Toker A, Bulut I, Akcan Y. Evaluation of risk factors and
seroprevalence of hepatitis B and C in diabetic patients in Kutahya, Turkey. J Investig
Med 2008; 56: 858-863
27. Romero-Gomez M, Del Mar Viloria M, Andrade RJ, Salmeron J, Diago M, FernandezRodriguez CM, et al. Insulin resistance impairs sustained response rate to
peginterferon plus ribavirin in chronic hepatitis C patients. Gastroenterology
2005;128:636641.
28. Hui JM, Sud A, Farrell GC, Bandara P, Byth K, Kench JG, et al. Insulin resistance is
associated with chronic hepatitis C virus infection and fibrosis progression.
Gastroenterology 2003;125:16951704

Data Collection Form

Patient name:
Medical Record number:
Age:
Gender: M / F
Height:
Weight:
BMI:
Disease status: Diabetic / Non-diabetic
Family History:

Lifestyle: Sedentary / Non-sedentary

History of Hypertension or CVD:
Anti-HCV status: Positive / Negative
HDL levels:
ALT:
AST: