Management of Hepatogenous Diabetes in a Liver Transplant Patient Through Blood Sugar Regulation: A Case Report

Abstract

Background: Liver dysfunction causing hepatogenous diabetes (HD) is difficult to diagnose and research is limited. This case implemented a novel approach for managing hepatogenous diabetes with nutrition intervention. Case Description: The 55-year old malnourished male patient with a history of hepatitis C (HCV) and chronic liver disease (cirrhosis) underwent liver transplantation in 2016. He was also diagnosed with hemochromatosis, diabetes and a low serum magnesium prior to liver transplantation. He is married with children and without a history of alcohol, smoking, or drug use. There was no family history of diabetes or hemochromatosis. The patient was first diagnosed with HCV in 2006 and unsuccessfully treated with interferon (peg-IFN) plus ribavirin. He was placed on a liver transplant list in 2011. In the interim he was treated for: - Low hemoglobin which eventually led to hemochromatosis secondary to transfusions, - Chronic abdominal pain, ascites and anasarca requiring hospitalization - Malnourishment, nausea, jaundice, itchy skin, loss of appetite loss, - Diabetes (2015), with wide ranging fasting glucose from 46-325. - Hepatic encephalopathy prior to his liver transplant in January 2016. He was prescribed multiple medications for abdominal pain: morphine, hydromorphone, dilaudid, oxycontin, and tramadol. He was also prescribed rifaximin, lactulose, lasix and albumin; and insulin for his diabetes. During liver transplantation he suffered two cardiac arrests and ischemic brain injury, requiring five months of hospitalization. He was referred for a nutritional consultation for assistance with diabetes management, muscle atrophy, and chronic gastro-intestinal symptoms. Current medications include Cyclosporine and Mycophenolate (both calcineurin inhibitors) and prednisone. Other medications included metformin, onlgyza, and kombiglyze, and a sliding scale for insulin. Follow-up with the nutritionist continued for 4 years. involving monitoring every 8-16 weeks combined with motivational interviewing. Interventions were modified to honor the patient’s cultural and social needs, (e.g. fasting for the religious practice of Ramadan, prayer, religious rituals, weekly congregations, and art). A patient-centered process is likely to increase adherence. Although interventions were successful managing blood sugar, the patient occasionally experienced hypoglycemia with exercise. There were no other reported adverse outcomes, such as neuropathy or diabetic retinopathy. Conclusion: Liver dysfunction inducing hepatogenous diabetes should be considered when managing patients with liver disease. Medications may be used to reduce symptoms of hypoglycemia, and in severe cases, a liver transplant may be indicated. Dietary and lifestyle changes to manage glucose and insulin levels are a cost-effective approach to increase quality of life.