مجلة جامعة الفاشر للعلوم التطبيقية - العدد الاول

1. Jfuas No.1 June 2013
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Assessment of Liver Function in Sudanese patients with
Long Standing Type2 Diabetes Mellitus
Mustafa Abdalla Yahya1
and Dr. Bader Eldein Hassan Elabid2
1- Faculty of Education, University of El Fashir . Email:
tawella69@gmail.com
2- Faculty of Medical Laboratory Sciences, University of Science
and Technology. Email: dr.alabid@gmail.com .
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2. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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Abstract:
Abnormal liver function tests are not uncommonly encountered
in diabetes mellitus. The aim of this study was to assess liver function
in Sudanese diabetic patients and to determine their correlation with
the duration of diabetes. A case-control study was conducted during
the period from January 2011 to December 2012, to compare the
plasma levels of alanine transaminase, aspartate transaminase, alkaline
phosphatase, bilirubin, total protein, albumin and HbA1c of 200
Sudanese patients with long standing Type2 diabetes mellitus (as a
test group) those of 100 apparently healthy volunteers (as a control
group).Participants in this study were from Jaber Abu Elez diabetic
center in Khartoum state, Sudan. Age and sex of the test group were
matched with the control group. The plasma levels of ALT,AST, ALP,

3. Jfuas No.1 June 2013
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bilirubin, total protein, albumin and HbA1c were measured using a
semi automated methods. The means of the plasma levels of ALT,
AST,ALP,bilirubin and HbA1c% of the diabetic group were
significantly raised compared to the control group. The means of the
plasma levels of total protein and albumin of the diabetic group were
significantly reduced when compared to the control group. In the
diabetic group the plasma levels of ALT, AST, ALP and bilirubin
showed positive correlations with the duration of diabetes, whereas
the plasma levels of total protein and albumin showed negative
correlation with the duration of diabetes. From the results of this
study, it is concluded that: in Sudanese patients, type2 diabetes
mellitus is associated with high plasma levels of ALT, AST, ALP and
bilirubin and low levels of total protein and albumin. In addition, there
is positive correlations between the plasma levels of ALT, AST, ALP
and bilirubin with the duration of diabetes, and negative correlation
between the plasma levels of total protein and albumin with the
duration of diabetes.
Keywords: Liver Function Tests, Glycosylated haemoglobin,
Nonalcoholic fatty liver disease.
Introduction:
Diabetes mellitus is a group of metabolic disorders with one
common manifestation, hyperglycemia, caused by famial disease or
acquired deficiency in production of insulin by the pancreas, or by the
ineffectiveness of the insulin produced (Jennifer, 1997).

4. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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In 2006 world health organization (WHO) reported, at least 171
million people worldwide were suffering from diabetes. Its incidence
is increasing rapidly, and it is estimated that by the year 2030, this
number will be doubled (Pefitti et al., 2007)
Diabetes mellitus is a disease with many complications that
represent the major cause of morbidity. Diabetes has two to four fold
greater risk of vascular disease occurrence as compared with non
diabetic diseases (Sone et al., 2002).
The liver plays a major role in regulation of carbohydrate
metabolism, as it uses glucose as a fuel, it has the capability to store
glucose as glycogen and also synthesize glucose from
noncarbohydrate sources. This key function of liver makes it
vulnerable to diseases in subjects with metabolic disorders,
particularly diabetes. In diabetes mellitus there is Increase activities of
liver enzymes, such as aspartate aminotransferase (AST), alkaline
aminotransferase (ALT) and γ- glutamyltranspeptidase (GGT) which
are indicators of hepatocellular injury (Levinthal et al., 1999 ).
Increased activity of these markers is associated with insulin
resistance, metabolic syndrome, and types 2 diabetes (Marchesini et al
2001 and Wannamethee et al., 2005). An association exists between
diabetes and liver injury. Liver pathology among diabetics is similar
to that of alcoholic liver disease, including fatty liver (steatosis),
steatohepatitis, fibrosis, and cirrhosis (Erbey et al., 2000). Elevated
serum activity of the two amino-transferases, aspartate
aminotransferase (AST) and alanine aminotransferase (ALT), is the

5. Jfuas No.1 June 2013
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most frequently measured indicator of liver disease and occurs in
diabetics more frequently than in the general population. The same
spectrum of liver injury and enzyme changes in diabetes has also been
described among overweight individuals without diabetes. Whether an
association of liver disease with diabetes is independent of
confounding factors, such as overweight and alcohol consumption is
unknown (7). Nearly 70 to 80% of the diabetic subjects have been
reported to have hepatic fat accumulation, referred to as nonalcoholic
fatty liver (NAFL). NAFL leads to nonalcoholic steatohepatitis
(NASH), a progressive fibrotic disease, which can result in cirrhosis
or liver related death (Wong et al., 2004).
Further proof of the association of liver disease with diabetes
comes from the insulin resistance atherosclerosis study (IRAS), which
showed that liver function markers like the aspartate aminotrans-
ferase (AST) and alanine aminotransferase (ALT) are predictors of
incident diabetes (Hanley et al., 2004 ). Sudan, and most of Africa, is
believed to have one of the highest mortality rates for non infectious
disease.
One study indicated that 10% of adult patient deaths in hospitals
were caused by diabetes. The current prevalence of diabetes in Sudan
is unknown although the very initial study estimated the prevalence by
3.4%, and with no doubt the risk of morbidity due to this disease is
increasing, especially in the urban areas (Ahmed et al., 2001).
Therefore, a comprehensive study of diabetes mellitus and its impact
needs to be undertaken. The present study was aimed to evaluate the

6. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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liver function in Sudanese patients with long standing type 2 diabetes
compared to non diabetic control group and to assess the impact of
diabetes on liver function in relation to duration of the disease.
MATERIALS AND METHODS
The current case-control study was conducted during the period
from January 2011 to November 2012 in Jaber Aboalez Diabetic
center in Khartoum to study the effect of long standing type 2 diabetes
mellitus on liver function test. A total of 200 sudanese patients
diagnosed as having type 2 diabetes mellitus for at least 10 years and
100 healthy individuals (control) were selected randomly to
participate in the study. The objective of the study were explained to
each individual under study after having his verbal consent to
participate in the study, data were collected by questionnaire then
clinical check was done by a medical practitioner to determine any
exclusion factor. Five ml of venous blood were then collected from
each participant under aseptic technique using disposable syringe. The
collected blood sample were divided into (3ml dispensed into heparin
container and the remaining 2ml into EDTA container). The blood
specimens were then centrifuged and the plasma separated into other
container and stored at -20°C in a deep freezer until tested. Plasma
were then tested for ALT, AST, ALP, Bilirubin, Total protein and
albumin using Roche diagnostic/Hitachi 902/Hitachi, Japan and using
the heparin specimen. While the EDTA blood was used to measure the
glaciated haemoglobin (HbA1c) using Nycard reader 11. Statistical
analsis of the results was done using SPSS. Data are presented as

7. Jfuas No.1 June 2013
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group (mean ± SD). T test was used for comparison of group and
linear regression and Pearson, correlation were used to assess
correlation between two variables. Statistical significance was set as
P 0.05. Permission to conduct the study was taken from the health
authorities in the study area.
RESULTS:
In the current study both the diabetic group and the control group
were matched for age and sex.Among the patients group 112 were
males representing 56% and 88 were females representing 44%, on
the other hand, 55% of the control group were males and 45% were
females .
Table(1) Demographic characteristic of the study and control group.
P.value
Control group
n=100
Test group
n=200
Variable
0.250
0.010
0.060
0.000
59.06±11.99
38-84)(
67.45±14.04
46-96)(
157.48±15.11
137-184)(
24.07±2.94
18.5-28.9)(
60.33±7.88
(39-84)
72.02±9.37
(50-103)
159.81±1.15
(139-193)
27.15±4.02
(19-40)
Age (years )
Weight(Kg)
Height(Cm)
BMI(Kg/m²)
Table (1) shows the mean± Standard deviation, range in brackets and
probability (P).

8. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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• t-test was used for comparison.
Table (2) Comparison between the plasma levels of ALT, AST, ALP and
bilirubin of the test group and the control group.
P.value
Control group
n=100
Test group
n=200
Variable
0.002
0.003
0.005
0.011
18.85±5.39
(10-29)
16.70±4.49
(9-27)
44.27±15.20
(40-77)
0.61±0.32
(0.220.86)
39.70±10.60
(17-66)
37.41±11.27
(15-79)
82.90±34.35
(30-180)
1.10±0.43
(0.332.10)
P.ALT(U/L)
P. AST(U/L)
P.ALP(U/L)
P.bilirubin(mg/dl)
The above table shows significant increase in the means of the
plasma levels of ALT, AST, ALP and bilirubin of the diabetic group
when compared to the control group.
Table (3) Comparison between the plasma levels of total protein ,albumin,
and HbA1c% of the test group and the control group.
P.value
Control group
n=100
Test group
n=200
Variable
0.006
0.004
0.003
8.36±2.21
(8-8.5)
4.49±0.14
(4-4.5)
5.33±0.36
(4-6.5)
7.45±0.02
(6.90-8)
3.46±0.01
(2.60-4)
8.28±0.16
(5-14)
P.total protein(g/dL)
P.albumin(g/dL)
HbA1c%
Table3 shows a significant difference between the means of the
plasma levels of total protein of the test group and the control group.
The mean of the test group is significantly reduced. The same table

9. Jfuas No.1 June 2013
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also shows a significant decrease of the mean of the plasma levels of
albumin of the test group when compared to the control group.
Table 3 also shows a significant difference between the means
of the blood levels of total HbA1c% of the test group and the control
group. The mean of the test group is significantly raised.
Figures 1,2,3 and 4 shows significant positive correlations
between the plasma levels of ALT, AST, ALP and bilirubin with
duration of diabetes, whereas there are significant negative
correlations between the plasma level of total protein and albumin
with duration of diabetes as shown in figures 5and 6 .
Fig(1) The relationship between the plasma levels of ALT and the duration
of diabetes.
(r = 0.217 , p = 0.002 )

10. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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Fig(2) The relationship between the plasma levels of AST
and the duration of diabetes.
(r = 0.367 , p = 0.000 )
Fig(3) The relationship between the plasma levels of ALP and the duration
of diabetes.
(r = 0.253 , p = 0.000 )

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Fig (4) The relationship between the plasma levels of bilirubin and the
duration of diabetes.
(r = 0.208, p = 0.003)
Fig(5) The relationship between the plasma levels of T.protein and the
duration of diabetes.
(r = 0.546, p = 0.000)

12. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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Fig (6) The relationship between the plasma levels of albumin and the
duration of diabetes.
(r = 0.239, p = 0.001)
Discussion:
Type2 diabetic patients have been reported to be associated with
higher incidence of abnormal liver function tests (LFTs) compared to
individuals without diabetes. Elevated ALT being the most common
abnormality (Harris, 2005). In our study the results showed a
significant difference between the mean of the plasma activity of ALT
and AST of the test group compared with that of the control group.
The means of the test group for both ALT and AST were both
significantly raised. These results agree with a study done by Mckenze
who found elevation in plasma ALT and AST activities in patients
with diabetes mellitus type2 (Mckenzie, 2006 ), as a result of
progressive liver cell damage as a consequence of long standing. Our
study also showed significant increase in the mean of the plasma
activity of ALP of the test group compared with the control group.
This may be due to the effect of long standing diabetes mellitus on

13. Jfuas No.1 June 2013
13
bone causing diabetic bone disease. This result agrees with a study
done by Maxwell et al who found that there was an elevation in
plasma ALP activity in patients with diabetes mellitus type 2
(Maxwell, 1986). The present result disagreed with a study done by
Tibi who reported that there was no significant difference between the
diabetic and the control group in the plasma levels of ALP (Tibi,
1988) .
The present study showed a significant difference between the
mean of plasma levels of bilirubin of the test group compared with
that of the control group. The mean of the test group is significantly
elevated as shown in table 2. This result is in agreement with a study
done by Han et al (15) who studied the liver function tests of 81
diabetic patients in whom 4.9% were found to have high bilirubin
(Han et al ., 2012 ).
Also the study showed a significant difference between the
means of the plasma level of total protein and albumin of the test
group when compared with that of the control group. These results in
agreement with a study done by Idris et al, who studied the liver
function of 50 sudanese diabetic patients and reported that plasma
total protein and albumin were significantly reduced among diabetic
sudanese compared to healthy controls. However the mean values
were within the reference range ( Idris et al ., 2011) . The current
study also showed positive correlations between glycemic control
(HbA1c%) and duration of diabetes with ALT and AST. These results
agree with Jayarama et al. Who reported positive correlations between

14. ‫اﻟﻔﺎﴍ‬ ‫ﺟﺎﻣﻌﺔ‬–‫ﻣﺠﻠﺔ‬‫اﻟﻌﻠﻮم‬‫اﻟﺘﻄﺒﻴﻘﻴﺔ‬-‫ﻳﻮﻧﻴﻮ‬ ‫اﻷول‬ ‫اﻟﻌﺪد‬2013‫م‬
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FBS,PPBS,the duration of type2 diabetes and ALT levels among the
cases (Jayarama et al., 2012).
Generally the liver enzymes in diabetic patients with type 2 are
due to physiological alternative pathway that leads diabetic patients to
consume fatty acids as energy instead of glucose, this leads to increase
activity of the liver enzymes (Harris, 2005).
In conclusion, values of liver function test for ALT, AST, ALP
and bilirubin in patients with type 2 diabetes mellitus are significantly
higher than that of healthy controls; moreover, diabetic patients have
lower concentration of plasma total protein and albumins in
comparison to healthy controls. In long standing diabetes there is a
possibility of underlying fatty liver, which might need further
evaluation and early intervention to prevent progression into cirrhosis
and chronic liver disease.
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