2288 Diabetic Hepatosclerosis Presenting as Severe Pruritis

Abstract

INTRODUCTION: Diabetic hepatosclerosis (DH) is an uncommon type of hepatic injury associated with poorly controlled diabetes mellitus (DM). Unlike steatohepatitis or glycogenic hepatopathy, DH is a form of end-organ damage due to microvascular injury. This case illustrates a patient with advanced DM who presented with cholestatic liver injury and histologic findings of DH. CASE DESCRIPTION/METHODS: A 34 yo woman with poorly controlled type 1 DM (HgA1C 17%) complicated by diabetic nephropathy presented with one month of generalized pruritis. Symptoms were most severe after hot showers and at night. She denied rash, fevers, unusual exposures, ingestions, or new medications. On exam, she appeared well, had no visible skin lesions, no scleral icterus, and a soft abdomen without organomegaly. Labs were notable for ALP 612 U/L, ALT 205 IU/L, AST 109 IU/L, TB 0.9 mg/dL, WBC 8.3 K/uL, PLT 306 K/uL. Abdominal ultrasound revealed a normal appearing liver and biliary ducts. Ultrasound-guided liver biopsy showed perivenular and perisinusoidal fibrosis without inflammation, steatosis, or bile duct injury. These findings were consistent with DH. After one year of aggressive glycemic control, her pruritus resolved. Her HgA1C was 7.6%, ALP 313 IU/L, ALT 32 IU/L, AST 29 IU/L. DISCUSSION: While non-alcoholic fatty liver disease (NAFLD) and glycogenic hepatopathy are more commonly seen in patients with advanced DM, DH is a distinct form of microangiopathic liver injury characterized by dense perisinusoidal fibrosis (Figure 1), lack of steatosis (Figure 2), and basement membrane deposition of laminin and type IV collagen1,2. DH can be seen in both type 1 and type 2 DM, and rarely occurs in the absence of other microvascular complications. DH is characterized by a predominantly elevated ALP, suggesting a primary bile duct or canalicular injury. Diabetics with hypertension seem to be at increased risk for DH3. The long term consequences of DH remain unclear. In our patient, a decrease in HgA1c level resulted in normalization of AST and ALT levels, a marked reduction in ALP, and resolution of pruritus.