Assessment of Vitamin D Levels in Patients of Chronic Liver Disease with Hepatic Encephalopathy

Abstract

Introduction: Patients with chronic liver disease (CLD) manifest various nutritional abnormalities associated with progression and severity of liver disease. Hepatic encephalopathy is a manifestation of disease progression with worsening liver function. The pathogenesis of hepatic encephalopathy is considered multi factorial and the exact mechanisms are yet to be deciphered.

25 hydroxyvitamin D (25 OHD) is a fat-soluble seco-steroid hormone associated with regulation of calcium, magnesium, and phosphate homeostasis. It is also associated with various other biological effects as an anti-inflammatory and immune-modulatory agent.

Levels of 25 OH vitamin D progressively declines with deteriorating liver function. Vitamin D deficiency is reported in patients with chronic liver disease and at least one- third of these have severe vitamin D deficiency. Vitamin D deficiency is also linked with severity of Child Pugh score in cirrhosis. Although uncertain is the role of vitamin D as a causative factor for hepatic encephalopathy, studies have demonstrated significant lower levels of vitamin D with worsening hepatic encephalopathy.

This study was therefore undertaken with the aim to access the vitamin D levels in patients of chronic liver disease and to draw its correlation with the degree of severity in hepatic encephalopathy.

Materials and Method:  This Hospital based observational study was done in the Department of Medicine, Assam Medical College and Hospital, Dibrugarh. One year (1st June 2020 to 31st May 2021).

Chronic liver disease with hepatic encephalopathy with patients >12 years of age included in the study.  Acute Hepatitis, Acute liver failure, Cardiac disease, Chronic kidney disease, Cerebrovascular accidents, Malignancy, Active tuberculosis, Steroids, bisphosphonates therapy, Vitamin D supplementation in past 3 months, Pregnancy and lactation, Malabsorption syndromes were excluded.

Results: Out of 88 patients, the majority of the subjects in the study group belonged to the age group of 51-60 years (51. 14%).The mean age was 54.44 ± 7.09 years.

Male were more common (71.5%, n=63) than female (28.4%, n=25). The sex ratio was 2.52:1.

The mean vitamin D levels in covert and overt subgroups were 24.11 ± 6.46 ng/ml and 11.72 ± 4.84 ng/ml respectively.

In the overt group, 47.92% (n=23) of subjects were having serum levels of vitamin D lower than 10ng/ml i.e. severe deficiency. The number of subjects in the deficiency level of vitamin D (10 - < 20 ng/ml) in the covert group were 30% (n=12) and in the overt group were 45.83% (n=22) respectively. 57.50% (n=23) in the covert group and 6.25% (n=3) in the overt group were having serum levels of vitamin D between 20-30 ng/ml. 12.5% (n=5) of the subjects in the covert group were having sufficient serum levels of vitamin D.

The mean serum vitamin D values in CTP Class A, B, C were 27.69 ± 6.66 ng/ml, 19.91 ± 3.76 ng/ml, 11.64 ± 5.06 ng/ml respectively. The results were statistically significant after One Way ANOVA analysis (p< 0.001).

The mean serum vitamin D level in patients with grade 1 Hepatic encephalopathy is 24.11 ± 6.46 ng/ml followed by grade 2 encephalopathy (13.61 ± 4.73 ng/ml), grade 3(8.41 ± 2.84 ng/ml) and grade 4 encephalopathy (8.00 ± 2.66 ng/ml). Statistical analysis with One Way ANOVA showed a significant p value (<0.001). There was a statistically significant negative correlation between serum vitamin D levels and hepatic encephalopathy (r = -0.731, p <0.001)

There was a statistically significant negative correlation between CTP score and serum vitamin D levels. (r = -0.767, p <0.001).

Conclusion: Our study showed that there was a significant negative correlation between serum levels of vitamin D and the grades of hepatic encephalopathy.