Prevalence of Diabetes Mellitus in Hepatitis C Patients in Wazirabad Tehsil of Gujranwala District of Pakistan

Hepatitis, a condition of liver’s inflammation that can be self-limiting or, in certain chances, it may lead to liver cancer, fibrosis or cirrhosis. Hepatitis viruses mainly cause hepatitis in the world. People with hepatitis C have predominant chances to develop diabetes as HCV virus participates in causing type 2 diabetes. HCV virus causes pathogenesis in two ways: it either directly destroys the β cells of pancreas or contributes to the specific autoimmunity of β cells. The present cross sectional study was done in Wazirabad Tahsil of Gujranwala District to analyze the percentage of patients suffering from hepatitis C who had the risk of diabetes mellitus. For this research work, demographic information and data about any other medical history were collected by using a questionnaire. Blood samples were collected from hospital and real time PCR was performed to measure the viral load and blood sugar was measured by using glucometer. Data were then analyzed by using statistically designed software. A total of 29.33% patients, having hepatitis C, were found to be diabetic in Tehsil Wazirabad. 14.70% male and 38.59% female patients having hepatitis C were diabetic. From results shown that the patients of hepatitis C are at higher risk to develop diabetes, therefore; it is supposed that persons having hepatitis C should regularly visit doctors for routine check-up of diabetes and change their life style to reduce the risk of developing diabetes.

capacity in its cells but a severe injury leads to chronic diseases. Any severe damage to liver cells can cause hepatocellular carcinoma, hepatitis fibrosis and hepatitis (1).
Hepatitis is observed to be a major liver's inflammation. The situation could be self-limiting or it may lead to liver cirrhosis, fibrosis and cancer. The main cause of hepatitis is hepatitis viruses but some toxic substances that cause infections including certain drugs, alcohol and various autoimmune diseases. Hepatitis C infections has 15-40% chances to develop other chronic liver ailments such as liver cancer and cirrhosis. Currently, there is no effective vaccine available for hepatitis C therefore; there are many health hazards worldwide (2).
Hepatitis C virus effects about 150-170 million people in the whole world, that makes an estimate of 1.6 to 2.8% of the whole world population (3). Out of 170 million people that have hepatitis C infection, 40% people are from Asian countries (4,5). It has been estimated that 3-4 million people are infected with hepatitis C virus each year (6). Hepatitis C virus belongs to the family flaviviridae and genus Hepacivirus genus. It is a small virus which is enveloped and has 9.6 kb (1kb=10 3 base pairs) positive sense, single stranded RNA genome that shows both lymphotrophism and hepatotrophism (7).
On the other hand, diabetes mellitus is a noncommunicable and most prevalent disease. It has been estimated that it affects 347 million individuals worldwide. In 2015, a total of 415 million people were affected by diabetes (8). As well-known, all food is metabolized into glucose which is then used to generate energy. But in diabetes body is unable to produce energy from glucose.
Diabetes mostly develops when patient's body produces insufficient amount of insulin due to improper functioning of pancreas. Basically, diabetes mellitus is of two types, the first one is the Type I in which defective insulin is produced and is most common in children and young adults. Second is type 2 diabetes in which the insulin produced is either insufficient or defective and unable to move glucose into cells.
Although both types of diabetes are incurable but there are many medicines available which help to keep the blood glucose levels under control. Many studies showed that diabetic complications can be avoided by keeping blood glucose levels in normal range.
However, in case of type 2 diabetes choice of treatment depends upon blood glucose levels of the patient. Under this situation the patient is usually recommended to adopt healthy life style by adding exercise in daily life and eating healthy food (9).
It has been known that the hepatitis C patients have more chances to develop diabetes (10)."Hepatitis C virus causes diabetes type 2 by inducing insulin resistance (11). Hepatitis C virus impaired the insulin signaling pathway in the hepatocytes by many pathways that include stimulation of the tumor necrosis factor-α (TNF-α), serine phosphorylation of insulin receptors (IRSk) and over expression of suppressor of cytokines (SOC-3) and SOC-7 induction (12)." Although HCV affects liver but it also disrupts the whole body insulin sensitivity without inducing any type of the metabolic syndrome (13). Insulin resistance (IR) and diabetes can develop at any stage of HCV infection. Multiple mechanisms have been accounted for insulin resistance and development of diabetes in patients with chronic hepatitis C. It promotes IR mainly through interfering with insulin signaling pathway in hepatocytes, increasing inflammatory response with production of cytokines such as TNF alpha and IL-6, increasing oxidative stress and reduction in adiponectin levels which may result in liver steatosis (14)(15)(16).
Hepatitis C viral infection interferon alpha therapies also trigger the diabetes. It also results in autoimmune diseases due to immunomodulatory effects of IFN-α. Also, injection of IFNα to healthy persons impaired glucose tolerance and insulin sensitivity, stimulated counter regulatory hormone secretion (17).
However, data regarding trend of the prevalence of diabetes among hepatitis C patients in Pakistan is missing. There is no well-organized system available to regulate and monitor general trends in hepatitis C in Punjab province of Pakistan. Therefore, the present research work was done to find the link between HCV and diabetes. For this purpose, a cross sectional study was done in Wazirabad a Tahsil of Gujranwala district to analyze the percentage of patients suffering from hepatitis C having the risk of diabetes mellitus.

Materials and Methods:
This study was done to find the occurrence of diabetes mellitus in hepatitis C patients (both male and female) visiting civil hospital in Wazirabad Tehsil of District Gujranwala in Punjab province of Pakistan from January, 2018 to July, 2018.
A cross sectional study was performed that includes 1296 participants, out of which 273 were positive with HCV having age group from 25 to 60 years. Blood samples were collected from both male and female patients attending the hospital (Civil Hospital Wazirabad; DHQ) and labs (Chughtai lab Wazirabad; Hassan lab Wazirabad). To collect data from patients a consent form was developed to ensure that our study is totally voluntary based and we followed all the ethical rules. Socio demographic data of all patients were collected by filling questionnaire including age, gender, and history of exposure of associated factors, type of diabetes and treatments of any disease.
In this study, any patient having liver cancer or tumours in pancreas has been excluded. Blood samples were drawn with the help of Senior Health Supervisor. After collecting blood samples, they were centrifuged within one hour. After centrifugation, serum was collected in the vials and stored at -20 o C. Serum was then transported to Genomic Lab (Research and Diagnostic, Rawalpindi) for the analysis. Serum samples were run for RNA extraction, cDNA synthesis and real time PCR for the quantification of HCV viral load by using COBAS AmpliPrep/COBAS Taqman (CAP/CTM HCV Version 2, Roche Molecular System, Pleasanton, CA).
Oncall plus blood glucometer was used to measure blood glucose levels (ACON laboratories, San Diego, USA). Age, weight, height, body mass index, LFTs (serum bilirubin, alkaline phosphatase, AST, ALT) and CBCs (HB, TCL, lymphocytes, monocytes, eosinophil) of all patients have been measured.
Weight of all patients was calculated by using digital weighing machine while, waist size and height of all patients was measured by using inches tape, height measuring scale respectively. Body mass index (BMI) was measured by using height and weight of all patients.

Data Analysis:
The data were analysed by using Graphpad Prism 5 and Microsoft excel 2010. Chisquare test was applied to compare the two percentages to find the level of significance. Results were expressed as mean ± SD/ number and percent.

Results: Prevalence of diabetes in the studied population
The 1296 participants were included in the present study, out of which 246 (18.98%) were found to be diabetic as shown in Table 1. A total of female participants were 792, of whom 184 (23.23%) were diabetic. And total male participants were 504, of whom 62 (12.30%) were diabetic. Prevalence of diabetes among HCV positive patients 1296 participants were included in the present study, out of which 273 were suffering from Hepatitis C. 29.67% HCV patients were found to be diabetic as shown in Table 2. In our study total female participants were 171(62.64%) suffering from HCV, of whom 66 (38.59%) were diabetic. And total male HCV patients were 102 (37.36%), of whom 15 (14.70%) were diabetic. These results have shown that HCV was more prevalent in females than males.

Prevalence of diabetes among HCV negative patients
In the present study, 1023 participants were negative for HCV, out of which 165 (16.12%) were diabetic as shown in Table 3. Female participants negative for HCV were 118 (19%) diabetic. Male HCV negative were 47 (11.69%) diabetic. Chisquare analysis shows that HCV positive patients were more diabetic than that of HCV negative participants. The results of Chi-square analysis were found to be statistically significant as (p< 0.001) as shown in Fig 1. Figure 1. Comparison of the 2 percentages using Chisquare test to find the level of significance Mean viral load of male diabetic patients was 1063157.2±72661 IU/ml, of male non-diabetic was 912462.44±435781 IU/ml, of female diabetic was 1398253±47579 IU/ml and of female non-diabetic was 1266910.5±246145 IU/ml as shown in Fig. 2. Difference between mean viral load of diabetic and non-diabetic HCV positive patients was statistically non-significant. It has also been observed that hepatitis C disease was more prevalent during >30-40 age. Mean Viral loads of total patients were also more in female than in males. Alkaline phosphatases were elevated in both male and female patients of HCV. TCL was also elevated as shown in Table 4.

Discussion:
Hepatitis is basically an inflammation of liver and is increasing in Pakistan day by day. Our study found the diabetes prevalence in hepatitis C patients in Wazirabad area of Pakistan. Our study is in accordance with the previous studies which show strong connection between hepatitis C and diabetes (17). Many studies have reported patients undergone treatment with ribavirin and interferon increased chances of developing Type I diabetes in them (18).
However, the exact mechanism how these antiviral treatments ameliorate the insulin resistance is not fully understood. Nevertheless, it is clear from the previous studies that there is a link between diabetes and hepatitis C. However, the exact mechanism which links HCV and type 2 diabetes is still unclear. Hepatitis C virus may act on pancreas β cell which produce insulin.

Conclusions:
Based on the results it is concluded that persons having heptitis C have more chances to develop type II diabetes than that of normal healthy individuals. Therefore, we suggest that HCV must be treated timely to reduce the chance of developing other diseases likely type II diabetes. However, the exact mechanism which is involved in the association of these two diseases is still unclear. There may be the chance that hepatitis C virus may affect the liver and pancreas β cell which in turn affect the blood glucose levels. At the end, it can be summarized that Hepatitis C patients are more prone to develop type 2 diabetes therefore; they must be given attention in this regard.