NAFLD in type 1 DM: a report of 2 cases
P Kumar, A Ghatak, J C Blair, M Didi & P Paul
Introduction: Non-alcoholic steatohepatitis (NASH) is part of the spectrum of non-alcoholic fatty liver disease (NAFLD). NASH commonly occurs in patients with type 2 DM and is less recognised in type 1 DM. The natural history of NASH in adult patients suggests potential development of progressive fibrosis and cirrhosis. However, secondary glycogenosis, commonly occurs in type 1 DM, is reversible when good glycaemic control is achieved, but may be misidentified as NASH because of similar clinical features but are differentiated histologically.
Case 1: Fifteen-year-old girl with type 1 DM for 8 years. Her weight was 44 kg with BMI 20 kg m−2. She had numerous admissions with DKA. She presented with abdominal pain and distension. Her abdominal ultrasound showed diffuse hepatomegaly but was otherwise normal. Liver autoimmune and viral serology were unremarkable. Her HBA1C was 14%, ALT 579 IU/l (NR 140), AST 212 IU/l (NR 137), Alkaline Phosphatase (AlkP) 932 IU/l (NR 2031151). Her liver biopsy showed generalised moderate macrovesicular and microvesicular steatosis suggestive of Insulin induced steatosis. Four months later, her HBA1C was 13.4%, ALT 15 IU/l, AST 12 IU/l, AlkP 744 IU/l.
Case 2: Fifteen-year-old girl with type 1 DM for 4 years. Weight 54 kg, BMI 24 kg m−2. Frequent admissions with DKA. Presented with mild abdominal tenderness. Examination revealed 4 cm hepatomegaly. Results; Liver biopsy: microvacuolar steatosis, intracellular cholestasis, increased glycogen deposition and focal pericellular fibrosis. HbA1C 11.7%. ALT 132 IU/l, AST 204 IU/l, AlkP 458 IU/l. Six months later, ALT 17 IU/l, AST 25 IU/l, AlkP 254 IU/l.
Conclusion: We present 2 cases of NAFLD in adolescent girls with type 1 DM, both whose liver transaminases improved after intensified glycaemic control. Further studies are necessary to establish the prevalence of NAFLD in children with type 1 DM and to identify whether a period of intensification of insulin therapy is beneficial prior to invasive procedures.