“ASSOCIATION OF SERUM URIC ACID LEVEL WITH

SEVERITY OF CHRONIC LIVER DISEASE - A CROSS

SECTIONAL STUDY”

A Dissertation Submitted to
THE TAMILNADU DR. M.G.R MEDICAL UNIVERSITY
CHENNAI

In Partial Fulfillment of the Regulations

For the Award of the Degree of

M.D. (GENERAL MEDICINE) - BRANCH – I

Reg. No .:

GOVERNMENT KILPAUK MEDICAL COLLEGE

CHENNAI

MAY - 2021
 BONAFIDE CERTIFICATE

This is to certify that “ASSOCIATION OF SERUM URIC ACID

LEVEL WITH SEVERITY OF CHRONIC LIVER DISEASE - A

CROSS SECTIONAL STUDY” is a bonafide work done by Dr.

PRASANNA R, Post graduate student, Department of General Medicine,

Kilpauk Medical College, Chennai-10, under my guidance and supervision

in partial fulfillment of rules and regulations of the TamilNadu Dr. M.G.R

Medical University, for the award of M.D. Degree Branch I (General

Medicine) during the academic period from MAY 2019 To MAY 2022.

PROF. Dr. P . PARANTHAMAN M.D. Prof. Dr. K.E.GOVINDARAJALU

Professor and Head of the Department, Guide of the Study,
Department of Medicine, Govt.Kilpauk Professor and Chief of the unit,
Medical College , Chennai – 10. Govt.Kilpauk Medical College,
Chennai -10.

The DEAN
Govt. Kilpauk Medical College
Chennai - 600 010
 DECLARATION

I solemnly declare that this dissertation “ASSOCIATION OF

SERUM URIC ACID LEVEL WITH SEVERITY OF CHRONIC

LIVER DISEASE - A CROSS SECTIONAL STUDY” was prepared by

me at Government Kilpauk Medical College and Hospital, Chennai, under

the guidance and supervision of Professor.K.E.GOVINDARAJALU M.D

Professor of General Medicine, Department of Internal Medicine,

Government Kilpauk Medical College and Hospital, Chennai. This

dissertation is submitted to The Tamil Nadu Dr. M.G.R.Medical

University, Chennai in partial fulfillment of the Universityregulations for

the award of the degree of M.D. Branch I (General Medicine).

Place: Chennai-10 Dr. PRASANNA.R

Date :
 CERTIFICATE BY THE GUIDE:

This is to certify that the dissertation titled “ASSOCIATION OF SERUM

URIC ACID LEVEL WITH SEVERITY OF CHRONIC LIVER

DISEASE - A CROSS SECTIONAL STUDY” in the General Medicine

department, at Govt Kilpauk Medical College and Hospital is a bonafide

research work done by Dr. PRASANNA .R, Post Graduate in MD General

Medicine, Govt Kilpauk Medical College and Hospital, Chennai 10 under

my direct guidance and supervision in my satisfaction and in partial

fulfillment of the requirements for the degree of MD General Medicine.

Prof. Dr.
Professor of General Medicine,
Govt. Kilpauk Medical College,
Chennai - 600 010

Date :
Place : Chennai
 PLAGARISIM CERTIFICATE

This is to certify that the dissertation titled “ASSOCIATION OF

SERUM URIC ACID LEVEL WITH SEVERITY OF CHRONIC

LIVER DISEASE - A CROSS SECTIONAL STUDY” of the candidate

PRASANNA.R. with registration number –for the award of MD Post

Graduate Degree in the branch MD General Medicine-I. I personally

verified the urkund.com website for the purpose of plagiarism check. I

uploaded the thesis file containing from introduction to conclusion pages

and the result shows 20% of plagiarism I the dissertation.

Prof.,
Professor of General Medicine,
Govt. Kilpauk Medical College,
Chennai - 600 010

Place : Chennai
Date :
 ACKNOWLEDGEMENT

At the outset, I would like to thank my beloved Dean,

Kilpauk Medical College & Hospital, Prof. Dr. P.

VASANTHAMANI, M. D., D.G.O., MNAMS., DCPSY., MBA for

her kind permission to conduct the study in Kilpauk Medical College.

I express my indebtedness to PROF. DR.P.PARANTHAMAN M.D,

Professor & HOD of Medicine, Department of General Medicine, Kilpauk

Medical College & Hospital for permitting me to carry out this study and

for his constant encouragement and guidance.

I owe my sincere thanks and gratitude to my Guide, Prof.

DR.K.E.GOVINDARAJALU M.D, Professor of Medicine, Kilpauk

Medical College & Hospital for her continuous motivation, affectionate

guidance, valuable suggestions, sympathetic, helping nature and

encouragement enabled me to complete the dissertation.

I also thank my Assistant Professors DR.BATHRAGIRI M.D,

Dr. R. POONGUNDRAN M.D and Dr.VIJAYA KUMAR M.D for their

constant support.

I also thank the Almighty and my Parents for their everlasting

support.
 ABBREVIATIONS

CLD – Chronic liver disease

CPS – Child Pugh score

NASH – Non alcoholic steatohepatitis

ALD – Alcoholic liver disease

NAFLD – Non alcoholic fatty liver disease

PNPLAP3. – Patatin-like phospholipase domain containing protein 3

SREBP1c – Sterol regulatory element binding protein 1c

PPAR alpha – Peroxisome proliferator activated receptor alpha

MCP 1 – Monocyte chemoattractant protein

MELD – Model for End stage liver disease

PHBA – Polyhalogenated benzoic acid

4 AAP – 4 aminoantipyrine
 CONTENTS

S.No Title Page No

1 INTRODUCTION
2 AIMS AND OBJECTIVES
3 REVIEW OF LITERATURE
4 MATERIALS AND METHOD
5 RESULTS
6 DISCUSSION
7 SUMMARY
8 CONCLUSION
9 BIBLIOGRAPHY
10 ANNEXURES
11 MASTER CHART
 INTRODUCTION

Chronic liver disease (CLD) is known to cause significant morbidity and

mortality all over the world. Because of greater alcohol consumption which has

led to increased epidemic of diabetes and obesity and because of increased

hepatitis B and C infections there is increasing incidence of chronic liver

disease.

Chronic liver disease is defined as progressive deterioration of liver

functions for a period of more than six months. Deterioration of function

includes deterioration in synthesis of clotting factors, proteins, decreased

detoxification of harmful metabolic product and decreased excretion of bile. It

is a continuous process which involves inflammation, destruction, and

regeneration of liver parenchyma, which at the end leads to fibrosis and

cirrhosis.

Liver diseases alone contributes to about 2 million deaths worldwide per

year. Globally, Cirrhosis is the 11th most common cause of death and liver

cancer is the 16th most common cause of death.

The major complications of chronic liver disease is cirrhosis and

hepatocellular carcinoma and these two accounts for about 3.5% of total deaths.

According to UK National statistics , liver diseases is ranked as the fifth

common cause of death.

Chronic liver disease can be caused by alcoholic liver disease(ALD) ,non

alcoholic fatty liver disease(NAFLD) and hepatitis B , C viral infections,

1
autoimmune hepatitis and hepatocellular carcinoma. Cirrhosis is an end stage

result of many different types of liver diseases which is characterized by fibrosis

and liver architectural distortion which is accompanied by generation of

regenerative nodules and they can have varied clinical presentations and

complications.

Alcohol consumption mainly in males is increasing every year in India .

According to WHO, alcohol consumption contributes to 3.8% of global

mortality and 4.6% of Diasbility adjusted life year (DALYs). Liver disease

accounts for 9.5% of alcohol associated DALY’s worldwide. Currently,

alcoholic Liver disease is identified as the most common cause for most

cirrhosis related deaths in Europe. Alcohol associated Liver Disease consists of

alcoholic steatosis, hepatitis, steatohepatitis, and fibrosis or cirrhosis.

The prevalence of NASH varies from 6% to 35%, with an average of

20%. NAFLD comprises of a spectrum of presentations including hepatic

steatosis, nonalcoholic steatohepatitis and cirrhosis. Viral hepatitis contributes

to about 1.5 million deaths per year and also it affects the quality of life of more

than hundred millions of people.

Systemic inflammation, Oxidative stress and insulin resistance are now

considered as the most important risk factors which leads to the development

and progression of chronic liver disease. Hyperuricemia can cause endothelial

dysfunction, systemic inflammation insulin resistance and oxidative stress.

These pathologies are considered as the central pathogenesis involved in the

development of non alcoholic fatty liver disease and non alcoholic

2
steatohepatitis. They have also known to contribute to the pathogenesis of

alcoholic liver disease and hepatitis C virus.

Uric acid causes oxidative stress and inflammatory action adipose tissue.

Hyperuricemia is present along with other disorder like obesity, insulin

resistance, hypertension. Insulin resistance induces hepatic lipogenesis and

reduces lipolysis in adipose tissue. This causes adipose tissue dysfunction which

in turn causes changes in release of adipokines and cytokines. Fat deposition in

liver parenchyma causes increased secretion of reactive oxygen species (ROS)

with dysfunction of mitochondria. Since chronic liver disease exerts an

immense burden, it has become essential to develop a more accurate estimate

of prognosis in chronic liver disease survivors and so it becomes a very

important goal. In addition identification of factors responsible for the

progression of chronic liver disease is also very essential so that we can

introduce many therapeutic measures to prevent progression and to improve

disease outcome.

As per studies done earlier, high serum uric acid level may contribute to

oxidative stress and damageto liver , so serum uric acid may be a vita

prognostic indicator for assessing the severity of chronic liver disease.

Hence, this study is done to compare the association of serum uric acid

with severity of chronic liver disease by using Child Turcotte Pugh scoring and

aetiology of chronic liver disease.

AIM OF THE STUDY:

3
 To find the association of serum uric acid level with severity of chronic

liver disease by using child turcotte Pugh scoring and also association with

aetiology of chronic liver disease (alcoholic and non-alcoholic).

OBJECTIVES OF THE STUDY:

1) To find a statistically significant association of serum uric acid

level with different severity of chronic liver disease by using child

turcotte Pugh severity scoring.

2) To find association of serum uric acid level with aetiology of

chronic liver disease ( alcoholic and non-alcoholic ).

REVIEW OF LITERATURE

ANATOMY OF THE LIVER

The liver is a large solid organ situated in the right upper quadrant of the

abdominal cavity. The liver is reddish brown in color, consistency is soft,

friable. It weighs about 1300g in females and about 1600 g in females.

The liver is present in the entire right hypochondrium, epigastrium, and

extends into the left hypochondrium reaching upto the left lateral margin. Most

of the liver is covered by ribs and coastal cartilage, except part of epigastrium

where it is beneath the anterior abdominal wall. The liver is the largest organ in

the body. It performs various metabolic function and also secretes bile.

4
 Liver has five surfaces: Anterior, Posterior, Superior, Inferior and Right.

Out of them inferior surface is well demarcated. The other surfaces are

continuous with each other and are not demarcated well. The anterior part of

inferior border is marked by: A. an interlobar notch for ligamentum teres. B. a

cystic notch for fundus of gall bladder.

Lobes

Liver consists of two lobes right and left based on falciform ligament

anteriorly and superiorly, by fissure for ligamentum teres inferiorly, fissure for

ligamentum venosum posteriorly.

The right lobe is larger than the left lobe about five sixth of total liver.

Caudate and quadrate lobe is present in the right lobe

The caudate lobe is present on the posterior surface and is bounded by

inferior vena cava on right, fissure for ligamentum venosum on left and by porta

hepatis inferiorly. Behind the porta hepatis it is connected to right lobe by

caudate process. Papillary process is a small rounded elevation below and to the

left of caudate lobe.

The quadrate lobe is rectangular in shape and is present on the inferior

surface. It is bounded by inferior border anteriorly, by porta hepatis posteriorly,

by fossa for gall bladder on right, and by fissure for ligamentum venosum on

left.

The porta hepatis is a 5 cm long deep transverse fissure present on the

inferior surface of right lobe of liver. It is present between caudate lobe above

and quadrate lobe below. The structures which enters the liver through porta

5
hepatis are portal vein, hepatic artery, hepatic plexus of nerves and the

structures which leaves are right and left hepatic duct and few lymphatics. In the

porta hepatis, portal vein is present posteriorly and hepatic artery and hepatic

duct present anteriorly.

The left lobe is smaller than the right and forms one sixth of total liver.

Tuber omentale is a rounded elevation present on the inferior surface of left

lobe near ligamentum venosum.

Peritoneal Relations

Majority of liver is covered by peritoneum except: 1. Bare area on the

posterior of right lobe. 2. Groove for inferior vena cava on the posterior surface

of right lobe. 3. Fossa for gall bladder on the inferior surface of right lobe. 4.

Lesser omentum.

Surfaces of liver

Anterior surface

The anterior surface is convex and triangular. It is related in the median

plane to xiphoid and anterior abdominal wall and to diaphragm on either side.

The diaphragm is separating this surface from pleura at the level 10 th rib in the

midaxillary line and from lung at the level of 8 th rib. A little right to the

median plane this surface gives attachment to falciform ligament.

Posterior surface

It is triangular. It shows deep concavity in the middle part for vertebral

column. It has bare area which is related to the diaphragm, and to the right

suprarenal gland. There is a groove for the inferior vena cava and its floor is

6
pierced by hepatic veins. The caudate lobe is present in the superior recess of

lesser sac. It is related to crura of diaphragm, to the inferior phrenic artery, and

to the coeliac trunk. The fissure for ligamentum venosum extends to the front of

caudate lobe. The posterior surface of the left lobe has oesophageal impression.

Superior surface

The superior surface is quadrilateral. It has a concavity in the middle for

cardiac impression. On either side of this concavity the surface is convex to fit

the dome of diaphragm. The diaphragm separates this surface from pleura and

lung on either side and from pericardium and heart in the middle.

Inferior surface

This surface is approximately quadrilateral and is directed backward,

downward and to the left. There is a concave gastric impression on the inferior

surface of the left lobe. The left lobe also has omentale tuber which comes in

contact with the lesser omentum. Fissure for ligamentum teres passes from this

border to the left of porta hepatis. Ligamentum teres contains the obliterated left

umbilical vein. The quadrate lobe is related to lesser omentum, first part of

duodenum, pylorus. To the right of quadrate lobe there is fossa for gall bladder.

There is colic impression for hepatic flexure of colon, renal impression and

duodenal impression.

Right surface

The right surface is convex and quadrilateral. It lies opposite to 7-11 ribs

in the midaxillary line. It is separated by the diaphragm from the lung upto 8th

rib and from the pleura upto 10th rib. Upper third is related to the diaphragm

7
lung and pleura, middle third is related to the diaphragm, cost diaphragmatic

recess of the pleura and the lower third is related to diaphragm alone.

Blood supply of the liver

The liver has a dual blood supply. About 80% of blood supply of liver is

through portal vein and 20% is through hepatic artery. Both hepatic artery and

portal vein divide into right and left branches before entering the liver. They

then divide into segmental vessels in the liver which then divides into

interlobular vessels which is present in portal canals. Further branches open into

hepatic sinusoids. Since there is no anastamosis between hepatic arterial

territories, each branch is an end artery.

Venous drainage

Hepatic sinusoids drain into interlobular veins. These interlobular veins

join to form sublobular veins. They join together to form hepatic veins which

drain into inferior vena cava. The hepatic veins are arranged as upper and lower

group. The upper group consists of right, left and middle veins. They emerge

through the upper part of the groove for inferior vena cava and opens into the

vena cava. The lower group consists of number of veins from right lobe and

caudate lobe. They emerge through the lower part of groove for inferior vena

cava and opens into it.

Nerve supply of the liver

8
 The liver receives its nerve supply from hepatic plexus which contains

both sympathetic and parasympathetic fibres. The sympathetic ganglia has

nerve fibres from T7 to T10. Parasympathetic fibres consists of left vagus and

right vagus nerves .

Lymphatic drainage of liver

Superficial lymphatics runs beneath the peritoneum on the surface of liver

and terminate in hepatic, caval, paracardiac and coeliac lymph nodes. Some

lymphatic vessel from the coronary ligament may directly join the thoracic duct.

Deep lymphatics end in the hepatic nodes and in the nodes along the

inferior vena cava.

Segments

Based on distribution of hepatic artery, portal vein and biliary duct, the

liver is divided into right and left functional lobe. They are different from

anatomical lobe. They are separated by a plane passing along the line joining

the cystic notch to the groove for inferior vena cava. Inferiorly the plane passes

through fossa for gall bladder and posteriorly it passes through the middle of

caudate lobe.

There are four segments a) right anterior (V and VIII) b) right posterior

(VI and VII) c) left lateral (II and III) d) left medial (I and IV). These segments

are of surgical importance

DEVELOPMENT OF THE LIVER

Liver develops from hepatic bud during 4 th week of intrauterine life.

Endodermal in origin. It arises from the ventral margin of foregut. Hepatic bud

9
consists of rapidly proliferating cells which grows cranially and ventrally into

ventral mesogastrium and into septum transversum.

The hepatic bud divides into large cranial part pars hepatica and small

caudal part pars cystica. Pars hepatica forms the liver and pars cystica forms

gall bladder. Pars hepatica in turn divide into right and left hepatic duct. The

terminal part of duct contributes to lobes of liver. During early development the

lobes are of the same size but in later stages the size of left lobe reduces

gradually.

The terminal part of right and left hepatic duct on reaching the septum

transversum break into interlacing columns called hepatic trabeculae. Sinusoids

is present in between hepatic trabeculae. The vitelline and umbilical establish

connection with hepatic sinusoids. The hepatic duct canalise to form

intrahepatic biliary passages within the substance if liver.

The hepatic trabaculae forms the liver parenchyma- liver cells and cells

lining the biliary system. Septum transversum contributes to kupffer cells,

connective tissue cells. Reorganization of connective tissue cells and cells of

hepatic bud and blood vessels forms portal triad and sinusoids.

The mesoderm of septum transversum between liver and foregut forms

the lesser omentum, and between liver and ventral abdominal wall it forms the

coronary, falciform and triangular ligament. Lesser omentum and falciform

ligament together forms the ventral mesogastrium.

HISTOLOGY OF LIVER

10
 The liver is covered by glisson’s capsule made up of connective tissue.

The connective tissue surrounds the portal triads. Sinusoids are surrounded by

reticular fibres. The substance of the organ appears to be made up of hexogonal

areas which constitute the hepatic lobule. Each lobule is made up of cords of

liver cells separated by sinusoids. These cells branch and anastamose with one

another.

Portal canal

In the periphery of each lobule there are intervals filled by connective

tissue. They are called portal canals. Each canal contains a branch of portal

vein, hepatic artery, bile duct. These are called as portal triad. Blood from portal

vein, hepatic artery enters the sinusoid in the periphery and passes towards the

centre. The central vein drains into hepatic vein. Portal traid is surrounded by an

interval called space of mall.

Portal lobules

The blood vessels in the portal triad give branches to parts of three

adjoining lobules. This functional unit of liver is referred to as portal lobule. It

is a diamond shaped area supplied by one hepatic arteriole. Two central veins

lie at the ends of acinus. The liver is divided into 3 zones. Zone I is close to

preterminal branch and is better supplied by oxygen, nutrients and toxins. The

cells in zone II is hypoxic whereas cells in zone III is more hypoxic and they are

close to central vein.

Duct system

11
 The biliary canaliculi form hexagonal networks around the liver cells.

The interlobular ductules are lined by cuboidal epithelial cells. In the walls of

larger ducts smooth muscle is present.

Hepatocytes

Each hepatocytes is a large cell with round open faced nucleus, with

prominent nucleoli. The cytoplasm contains numerous mitochondria, abundant

rough endoplasmic retinaculum, lysosomes, golgi complex. Glycogen is present

in relation to smooth endoplasmic retinaculum.

The surface of hepatocyte shows three kinds of specialization. 1)

sinusoidal surface- the cells in sinusoids has microvilli whuch projects into

space of Disse. They are also concerned with exocytosis. About 70% of surface

is of this type. 2) Canalicular surface- longitudinal depression on adjacent

hepatocytes to form bile canaliculus. Irregular microvilli present. It constituted

15% of surface. 3) Intercellular surface- adjacent hepatocytes are united to each

other. About 15% are intercellular.

Space of disse

Liver cell is separated from the endothelial lining of sinusoid by a space

called space of Disse. Microvilli extend into this space. Fat cells are also seen

here.

12
13
 Functions of liver include producing clotting factors and other proteins

detoxifying harmful metabolic product, formation and excretion of bile.

CHRONIC LIVER DISEASE

Chronic liver disease is a gradual process which takes place for more than

6 months and there is progressive deterioration of liver function. There is

inflammation, destruction, and regeneration of liver parenchyma, which

ultimately leads to cirrhosis and fibrosis.

14
 The final stage of chronic liver disease is cirrhosis where there is

disruption of architecture, deposition of extracellular matrix and fibrosis due to

activation of stellate cells. Regeneration of parenchyma is due to activation of

hepatic stem cells. The critical point of transmission from reversible to

irreversible fibrosis is not completely delineated.

Major etiology of chronic liver disease includes alcoholic liver disease,

non-alcoholic fatty liver disease, viral hepatitis like hepatitis B and C and

hemochromatosis. Fibrosis in alcoholic and non-alcoholic fatty liver starts in the

centrilobular area and the fibrosis has a sinusoidal distribution

Alcoholic liver disease

Alcoholic liver disease consists of wide range of disorder ranging from

fatty liver to alcoholic hepatitis to alcoholic cirrhosis. Alcoholic cirrhosis is the

most irreversible and advanced injury.

There are three stages of alcoholic liver disease. 1)Hepatic steatosis -

accumulation of fat in parenchyma. 2) Steatohepatitis - characterized by

inflammation which depends on the disease severity. 3) Cirrhosis - irreversible

and leads to complication. Characterised by fibrosis and nodules

Increased consumption of alcohol leads to deterioration of metabolic

function of liver. Amount and duration of alcohol consumption are the most

important factor which decides the risk of development of liver disease. Other

important risk factors are concurrent hepatitis C infection. Patatin-like

phospholipase domain containing protein 3 (PNPLAP3).

PATHOPHYSIOLOGY

15
 Alcoholic dehydrogenase and aldehyde dehydrogenase are the two

enzyme involved in metabolism of alcohol. Alcohol is converted to

acetaldehyde by alcohol dehydrogenase. Acetaldehyde is in turn converted to

acetate by aldehyde dehydrogenase.

During this metabolism there is increased production of NADH which in

turn leads to the formation of triglycerides. Triglycerides starts accumulating in

the liver. Excessive alcohol consumption leads to inhibition of lipoysis, so fat

accumulates in the liver and this leads to fatty liver.

Increased generation of NADH by both alcohol and aldehyde

dehydrogenase decreases the NAD+ /NADH ratio which is known as the redox

potential. This is the main shift which leads to the synthesis of fatty acid leading

to fatty liver.

Histopathology

Hepatic steatosis- fat droplets accumulates in the liver parenchyma which

starts in the centrilobar zone. It is a reversible condition. Further fat

accumulation leads to inflammation. This stage is known as steatohepatitis.

Mallory hyaline bodies accumulates in liver, these are eosinophilic material.

Extensive infiltration of neutrophils occurs.

End stage is called alcoholic cirrhosis. Fibrosis with regenerating nodules

can be seen. Collagen deposits around the central vein. This ultimately leads to

characteristic chicken wire pattern of fibrosis.

Increased lipid synthesis takes place through enzymes encoded by genes

which in turn is regulated by transcription factors. Main transcription factors are

16
sterol regulatory element binding protein 1c (SREBP-1c) and early growth

response1. The free fatty acid from the adipose tissue is taken up by the liver

and converted to triglycerides.

Alcohol decelerated breakdown of lipid in liver. It is by three mechanism

1) it inhibits mitochondrial beta oxidation. 2) acetaldehyde inactivates

peroxisome proliferator activated receptor alpha (PPAR-alpha), a transcription

factor which governs fatty acid transport and beta oxidation. 3) alcohol

decreases adiponectin produced by fat cells.

17
18
URIC ACID IN ALCOHOLIC LIVER DISEASE

Alcohol can cause hyperuricaemia. This is mainly due to high urate

production. There is also decrease in urinary uric acid excretion. When alcohol

is metabolised NADH2 is being produced. As the concentration of NADH2

increases and NAD decreases. There is a shift of NADH2/NAD ratio.

Metabolism of alcohol is coupled with reduction of pyruvate to lactate where

the NADH2 is being used.

This results in increased hepatic lactate production, increased lactate in

blood. Another mechanism is due to renal retention of uric acid .

NON-ALCOHOLIC FATTY LIVER DISEASE INTRODUCTION

Non-alcoholic fatty liver disease consists of a group of condition which

causes hepatic steatosis and there is absence of secondary cause of hepatic

steatosis like alcohol, medication use or hereditary disorders. It is usually an

incidental diagnosis found in imaging or when there is complications.

19
 The incidence of NAFLD is found to be 20-30% in Western countries and

5-15% in Asia. There is an increasing trend for prevalence due to dietary

changes and sedentary lifestyle.

PATHOGENESIS

Accumulation of free fatty acid and triglycerides is the hallmark feature.

Two hit theories has been proposed for understanding the development of

NAFLD. First hit consists of lipid accumulation, high fat diet, insulin resistance,

obesity. Second hit consists if inflammatory events and fibrogenesis. This

theory is not widely accepted as it is too simple. Now insulin resistance is

identified as one of the main factors involved in NAFLD development.

Insulin resistance causes hepatic lipogenesis and decrease lipolysis of

adipose tissue. This adipose tissue dysfunction causes alteration in secretion of

adipokines and cytokines. Fat accumulation in liver causes increased production

of reactive oxygen species with mitochondrial dysfunction.

Gut micro bacterium also plays an important role by supplying toll like

receptor ligands which stimulates liver to produces proinflammatory cytokines.

HISTOPATHOLOGY

It shows a range if histological manifestation ranging from mild steatosis

to severe portal/ lobular inflammation. More than 5% of steatosis is considered

as clinically significant.

Macro vesicular steatosis occurs where lipid droplets covers majority of

the cytoplasm pushing the nucleus to the periphery. Micro vesicular steatosis is

rare in NAFLD. On the surface of lipid droplets inactive PNPLA3 accumulates.

20
 Based on the percentage of liver parenchyma involved steatotic liver is

divided into 3 groups. 1) mild 5%-33% 2) moderate 34%-66% 3) severe >66%.

steatosis is usually centered around zone 3.

In steatohepatitis stage there is chronic inflammatory mononuclear

infiltration with few plasma cells. Kupffer cells plays an important role in

NAFLD as it mediates inflammatory activity and hepatocyte injury. Ballooned

hepatocytes can be seen. It is mainly due to oxidative stress, loss of intermediate

filament, fluid retention and dilatation of endoplasmic retinaculum. Mallory

denk bodies, lipogranulomas, acidophilic bodies are also seen.

Fibrosis in NAFLD has a unique appearance with early lesion involving

the perisinusoidal zone 3. In later stages collagen deposition occurs. After

perisinusoidal fibrosis, periportal fibrosis occurs where there is trapping of

hepatocytes and collagen extends into parenchyma.

Eventually bridging fibrosis occurs connecting portal area with central

vein. Massons trichrome can identify the collagen deposits. Late complication

of NAFLD include hepatocellular carcinoma.

Progression of NAFLD

33% of patient with non-alcoholic steatohepatitis progress to fibrosis and

20% shows regression of disease. The development of complication like portal

hypertension is 17% at one year, 23% at 3 years, 52% at 10 years. In case of

decompensated disease, the median survival is two years.

21
22
1
2
3
4
RISK FACTORS

1) Metabolic syndrome and type 2 diabetes mellitus

Insulin resistance. It consists of spectrum of risk factors which

predisposes the patient to type 2 diabetes mellitus and cardiovascular disease.

Diagnostic criteria for metabolic syndrome: 3 out of 5 of the following

criteria should be present:

Triglycerides 150 mg/dl or greater.

HDL Cholesterol less than 40mg/dl in men & 50mg/dl in female.

Hyperglycemia- fasting glucose more than 100g/dl

Increased waist circumference

Hypertension >130/85 mmhg.

Type 2 diabetic patient have liver fat content 80% higher than non-

diabetic. T2DM have high risk for developing Non-alcoholic steatohepatitis.

They have four-fold increased risk of developing fatty liver associated

complication.

2) Ethnic differences

Greatest rate fir NAFLD is seen in Hispanic patients. Asian population

have an increasing trend for NAFLD. Hispanic patients have two-fold higher fat

content in liver. They possess homogygous PNPLA3. Mutation in PNPLA3

leads to more severe histological features .

5
 3) GENDER AND AGE

NAFLD is more common in male. There is increase in trend among

younger to middle aged people. Obesity is an important risk factor for NAFLD.

About one-third of obese children have NAFLD.

4) LIFESTYLE

Diet is an important risk factor. Taking a proper balanced diet with less of

carbohydrate, monounsaturated fat can reduce metabolic syndrome. Diet rich in

red meat, sugar loaded beverages, refined grains are associated with high risk.

Smoking is an independent risk factor. Tobacco can lead to insulin resistance.

Balanced diet with weight reduction leads to decrease in NAFLD parameters,

improvement in liver enzymes, decreased inflammation of liver and decreased

level of fibrosis.

5) POLYCYSTIC OVARIAN SYNDROME

It is an endocrine disorder in reproductive age group characterized by

insulin resistance and obesity. They are hyperandrogenic and insulin resistance.

Hyperandrogenism is due to ovarian androgen production and due to

decreased sex hormone binding globulin production. This makes the patient

more prone for developing NAFLD.

6) OBSTRUCTIVE SLEEP APNEA.

Is partial or complete obstruction of pharyngeal airway. OSA is

associated with diabetes mellitus, metabolic syndrome, cardiovascular disease.

6
Severe OSA is found to be more insulin resistant and they were found to give

higher percentage if steatosis with increased necrosis and fibrosis.

The mechanism behind this is due to intermittent hypoxia which causes

increase in inflammatory cytokines, oxidative stress, metabolic dysregulation

and insulin resistance.

7) GENETICS

Mutation in bardet-biedl syndrome 1 gene and melanocortin 3 receptor

gene is associated with NAFLD. Hepatic triacylglycerol accumulation is more

severe in patients having mutation of HTAG and PNPLA3 gene.

GRADING OF NAFLD

GRADE 1(mild) : steatosis involving 66% of total parenchyma, ballooning in

zone 3, mild or no portal inflammation with polymorph.

GRADE 2(moderate) : prominent ballooning in zone 3, intralobular

inflammation, mild to moderate portal inflammation.

GRADE 3(severe) : ballooning and disarray involving zone 3, panacinar

steatosis, intralobular inflammation with moderate portal inflammation.

7
 STAGES OF NAFLD

STAGE 0: no fibrosis

STAGE 1: mild fibrosis in zone 3. Perisinusoidal fibrosis. Asymptomatic,

incidental diagnosis. Steatosis is reversible with dietary restriction and exercise.

STAGE 2: mild to moderate fibrosis in zone 3. Perisinusoidal fibrosis and

periportal fibrosis. Non-alcoholic steatohepatitis develops in this stage.

This occurs due to fat accumulation which stimulated the

proinflammatory cytokines. Dull pain is seen in right hypochondrium.

STAGE 3: bridging fibrosis. It extends across lobules, between portal areas and

between portal area and central vein. The hepatic architecture remains intact.

Moderate to severe fibrosis.

STAGE 4: cirrhosis. Hepatic architecture is lost. The liver gets shrunken. There

is extensive fibrosis with regenerating nodules in between them. This stage is

irreversible, patient often requires liver transplantation. They have high

probability of developing decompensated liver disease. Patient have ascites,

splenomegaly, variceal bleeding and hepatic encephalopathy. The 5 year

survival rate for NASH cirrhosis is 40%.

Stages of hepatic encephalopathy:

Stage 1: mild confusion, agitation, irritability, decreased attention.

Stage 2: lethargy, disorientation, behaviour change, drowsiness.

8
Stage 3: slurred speech, aggressive, confused, somnolent but arousable.

Stage 3: coma.

EPIDEMOLOGY OF NAFLD

It is increasing in the western countries because of increase in obesity,

sedentary lifestyle. The prevalence in the general population is, about 25%.

Non-alcoholic steatohepatitis is seen about 2-3% of general population.

They may progress to cirrhosis and carcinoma. The prevalence of

NAFLD is 90% in obese individual, 50% in diabetes, 90% in hyperlipidemia.

NAFLD is more common in male than in female and increases with

increase in age. About 60% of people with NAFLD have normal

aminotransferase levels. This shows that liver enzymes is not a good marker for

detecting NAFLD in general population.

The prevalence among children is 10% whereas, the prevalence among

obese children is 40-70%. Majority of individual with NAFLD do not develop

non-alcoholic steatohepatitis.

INSULIN RESISTANCE

Insulin resistance plays an important role in development of NAFLD.

This can be seen by the data that 80% of diabetic patient have NAFLD. Kupffer

cells, specialised macrophages in liver and macrophages from bone marrow are

the main cells involved in development of non-alcoholic steatohepatitis. These

cells secrete tumour necrosis factor and interleukin 1beta leading to NASH.

9
 Macrophages are of two types- 1) classically activated M1 which is

inflammatory. 2) alternatively activated M2 which is non inflammatory.

Alternatively activated macrophages increases insulin sensitivity by

secreting anti-inflammatory cytokines like IL-13 and IL-4. classically activated

macrophages increases insulin resistance by secreting pro inflammatory

cytokines like TNF alpha, IL-6 and IL-1 beta.

Any shift in ratio between M1 and M2 can be due to metabolic

disturbance like obesity, insulin resistance. They ultimately lead to NASH and

cirrhosis. Oxidative stress is another theory which is known to cause NASH.

Obesity and diabetes mellitus induces lipogenesis, so there is more fatty

acid synthesis. This excess fatty acid especially oxidised fatty acid accumulates

in the peripheral tissue like liver and adipose tissue causing insulin resistance.

Adipose is a storage organ for lipid and it also secretes hormones and

cytokines. One such group is adipokines which includes adiponectin and leptin.

Adiponectin is an important adipokine which regulates fatty acid breakdown

( lipolysis) and inhibits accumulation of lipid in liver and adipose tissue.

Adiponectin also plays a vital role in maintaining blood glucose levels.

They also increase insulin sensitivity. Low level of adiponectin can lead to

NAFLD by increased fatty acid synthesis and by increased insulin resistance.

So, by maintaining high adiponectin level in blood can prevent the development

of NAFLD.

10
 High fat diet and sedentary lifestyle can lead to more adipose tissue

formation. They in turn secrete inflammatory cytokine which leads to steatosis,

hepatitis and cirrhosis. Macrophage marker like F4/89, CD11b and CD68 are

expressed on Kupffer cells.

Main pathogenesis involved in insulin resistance mediated steatosis

formation is by M1 mediated Kupffer cell derived cytokine synthesis. M1

Kupffer cell produces chemoattractant protein which increases lipid

accumulation.

M2 Kupffer cell helps in reversing the inflammatory process in NAFLD.

They mediate apoptosis of M1 cells by activating caspase 3 and protects against

NAFLD. So M1/M2 ratio is very important.

11
 MCP-1( monocyte chemoattractant protein ) is an important cytokine

which is increased in obese patient. It occurs due infiltration of macrophages in

adipose tissue. It plays an important role in insulin resistance.

OXIDATIVE STRESS AND NAFLD

Mitochondria plays an important role in electron transport

chain, oxidation of fatty acid and is more prone for attack by reactive oxygen

species. Proper balance is required between pro and antioxidant. Any

abnormality in mitochondria leads to inhibition of fatty oxidation, so fatty acid

accumulates in cytoplasm and there is induction of reactive oxygen species.

Mitochondrial dysfunction can be seen as changes in electron

microscopy. The changes include amorphous inclusion bodies in the

mitochondrial matrix.

Primary mitochondrial dysfunction can occur due to various

mechanism. Increase in oxidative stress can cause damage to mitochondrial

DNA and genes coding various proteins. Mutations of enzyme isobutyryl CoA

dehydrogenase caused by reactive oxygen species can lead to fat accumulation

in liver and thus NAFLD.

Sitruins also plays an important role in the development of NAFLD.

These are group of NAD dependant deacetylase which is involved in oxidative

damage. SIRT1 has a regulatory action on oxidative stress. They activate the

12
transcription factors involved in transcription of genes which produce anti-

oxidant enzyme and has a detoxifying effect.

SIRT3 induces oxidation of free fatty acid by activation of acyl CoA

dehydrogenase. SIRT3 activity is reduced in patient with NAFLD. By this

mechanism NAD depletion can lead to mitochondrial dysfunction leading to

high fat content in liver .

High free fatty acid in mitochondria either by increased dietary intake or

by insulin resistance can lead to increased permeability of inner mitochondrial

membrane. The electrical gradient is lost which causes reduction of ATP

synthesizing capacity. This leads to impairment of mitochondria.

The generation of reactive oxygen species is increased. It us accompanied

by electron leakage due to increased flux in ETC. Thus, there is a direct relation

between electron and oxygen which leads to formation of reactive oxygen

species. This reaction is mediated by cytochrome C oxidase.

If cytochrome C is lost hydrogen peroxide production is increased by

three-fold. Mitochondrial cytochrome P450 is a main source of reactive oxygen

species. Its activity is high in patient with NAFLD. CYP2E1 is also known to

produce free radicals.

Polymorphism of CYP2E1 is related to the development of non-alcoholic

steatohepatitis in obese patient.

13
 Uncommon causes of NAFLD

DISORDERS OF LIPID METABOLISM

1) Abetalipoproteinemia

2) Hypobetalipoproteinemia

3) Familial combined hyperlipidemia

4) Glycogen storage disorder

5) Weber Christian syndrome

6) Lipodystrophy

14
 7) TOTAL PARENTRAL NUTRITION

8) HEPATITIS C INFECTION

9) SEVERE WEIGHT LOSS

MEDICATIONS

1) Amiodarone

2) Tamoxifen

3) Methotrexate

4) Corticosteroid

5) HAART

6) Tetracycline

7) Antiviral drugs

STARVATION

HIV INFECTION

WILSONS DISEASE

ENVIRONMENTAL TOXICITY

CELIAC DISEASE

INFLAMMATORY BOWEL DISEASE

INFECTION LIKE BACILLUS CEREUS

CHILD PUGH SCORE

15
 It is used for determining the prognosis of patient with cirrhosis.it has

three categories: A- good hepatic function, B- moderately impaired hepatic

function, C- advanced hepatic dysfunction.

Modified child pugh score consists of:

ENCEPHALOPATHY: None = 1point, Grade1&2 = 2points, Grade3&4

= 3points.

ASICTES: None = 1point, Slight = 2points, Moderate = 3points.

BILIRUBIN: Under 2 mg/ml = 1point, 2-3 mg/ml = 2points, over 3

mg/ml = 3points.

ALBUMIN: Greater than 3.5mg/ml = 1point, 2.8 - 3.5mg/ml = 2points,

less than 2.8mg/ml = 3points.

PROTHROMBIN TIME: Less than 4 sec = 1point, 4 to 6 sec = 2points,

over 6 sec = 3points.

Sometime INR can be used instead of PT, INR under 1.7 = 1point, 1.7 -

2.2 = 2points, above 2.2 = 3points.

SEVERITY OF CIRRHOSIS:

Child pugh A: 5-6 points

Child pugh B: 7-9 points

Child pugh C: 10-15 points

16
 The other score that can be used to evaluate the patient is MELD score

( model for end stage liver disease ). It uses patient’s creatinine level, bilirubin

level, INR and cause if liver disease.

Child pugh score is used as a prognostic indicator after shunt surgery and

after other major surgery. After an abdominal surgery class A have a mortality

rate of 10%, class B have about 30% and class have about 80%.

It is also used to predict risk of development of complication of liver

disease like variceal bleeding, hepatic encephalopathy and its mortality rate.

One year mortality rate of class A is 0%, class B is 20% and class C is 55%.

ASSESSMENT OF CHRONIC LIVER DISEASE

CLINICAL PRESENTATION

Clinical symptoms cannot be used for diagnosis since they are

nonspecific and unreliable. Presentations include abdominal pain, nausea,

general malaise and other vague symptoms.

Examination reveals hepatomegaly, splenomegaly, ascites, spider

agiomas, caput medusae, jaundice.

For the diagnosis of metabolic syndrome body mass index, waist

circumference, triglyceride level is needed.

17
COMMON INVESTIGATION

Serum aminotransferase is mildly elevated. However, in about 75% of

patient with NAFLD liver enzymes is normal. So, liver enzyme is not a very

sensitive marker for diagnosis.

Gamma glutamyl transferase is elevated in people with NAFLD. But, it

cannot be used for diagnosing NAFLD.

Alkaline phosphatase can be elevated on rare occasion. In advanced

disease with complication hypoalbuminemia, hyperbilirubinemia,

thrombocytopenia may be seen.

NOVEL MARKERS

Inflammation - sensitivity and specificity is very limited. The markers

that can be used are TNF-alpha, adiponectin, C reactive protein, IL-6

Fibrosis - type IV collagen, hyaluronic acid. The platelet count can also

be used as a predictive biomarker for cirrhosis. Serum laminin can also be used

as a marker for fibrosis. Fibro Test for assessment of fibrosis consists of alpha2

microglobulin A1, GGT, ALT, haptoglobulin and total bilirubin. Tissue

inhibitor of metalloproteinase 1 can also be used.

Oxidative stress - vitamin E levels, lipid peroxidation products,

superoxide dismutase, glutathione peroxidase are markers for non-alcoholic

steatohepatitis.

18
 Hepatocyte apoptosis - cytokeratin 18 which is measured ysing ELISA is

elevated in NASH. Other markers are homocysteine level, pentraxin 3 level,

tissue polypeptide specific antigen.

IMAGING

Ultrasound - most common method used for screening NAFLD suspects.

Common findings in ultrasound includes hepatomegaly, hyperechoic areas in

liver and blunting of vasculature. USG is cost effective.

Disadvantages of USG are it is operator dependent and there is observer

variability, not quantitative and it cannot be used to diagnose NASH and

fibrosis.

Computer tomography - non contrast CT is more accurate than contrast

CT for identifying steatosis. It has a sensitivity of 75-100% and specificity 95 -

100%. Exposure to radiation of CT has limited the use of CT.

Magnetic resonance imaging - less sensitivity as compared to US and CT.

It is more expensive and less accessible than other imaging technique.

Transient elastography - it a non-invasive method for identified liver

fibrosis. It is a bed side investigation. It measures liver stiffness. It uses

ultrasound technology.

Liver biopsy - gold standard for diagnosis as it also distinguishes steatosis

and hepatitis. It helps to determine the severity of NAFLD and helps in ruling

out other liver pathology.

19
 NAFLD Activity Score (NAS) is used to differentiate steatosis from

steatohepatitis. Score of more than 5 indicates NASH, score of 3-4 is

indeterminate, score of 0-2 indicates absence of NASH.

Due to varied pattern of disease, there is no proper correlation between

NAS and disease severity.

Limitations of liver biopsy includes development of complication like

pain , bleeding. It is prone for sampling error. The interpretation of biopsy is

more prone for subjective error as there can be observer variability.

Serum uric acid

Uric acid is produced in liver, intestine, muscle, kidney and vascular

endothelium. It is the end product of purine metabolism. Adenine and guanine

upon degradation they form uric acid. Normally uric acid is excreted by kidney.

Human lack the enzyme uricase so they cannot oxidise uric acid to allantoin.

MECHANISM OF FORMATION OF NUCLEOTIDE

Adenosine monophosphate is converted to inosine by two different

pathways. First pathway is by deaminase which removes amino group and

forms inosine monophospate. Later dephosphorylation occurs and inosine is

formed. In second pathway, dephosphorylation occurs first which leads to

adenosine formation, later deamination occurs and inosine is formed.

Purine nucleoside phosphorylase converts inosine and guanosine is

converted to hypoxanthine and guanine. Hypoxanthine forms xanthine by

20
xanthine oxidase. Guanine forms xanthine by guanine deaminase. The final

product of guanine and hypoxanthine is xanthine which acted upon by xanthine

oxidase again to form uric acid.

Uric acid has a pKa of 5.8, so at pH 7.4 it is a weak acid. Majority of uric

acid exist as urate crystals. Normal value of uric acid in men is 1.5-6.0 mg/dl

and in female it is 2.5-7.0 mg/dl.

As the concentration increases solubility decrease. When the

concentration of uric acid is more than 6.8mg/dl, it forms monosodium urate

crystals.

Uric acid can be measured on serum, plasma, in exhaled air and in urine.

The production and catabolism of purines is relatively constant of about 300-

400 mg per day. About 70% of uric acid is eliminated by kidney and remaining

30% is eliminated by gastrointestinal tract.

Most of the uric acid is filtered by glomeruli and there is tubular secretion

and reabsorption which regulates the body uric acid concentration. About 90%

of uric acid reabsorption and secretion takes place in the proximal convoluted

tubule.

S1 segment of proximal convoluted tubule is mainly involved in majority

of reabsorption. Secretion of uric acid into tubule takes place in S2 segment.

Secretion is usually more than resorption.

21
 Important uric acid transporters include URAT1, GLUT9 and ABCG2.

They regulate the serum uric acid. One of the main causes of urate transport

disorder is mutation of ABCG2 which causes hyperuricemia and gout.

URAT1 is an organic anion transporter encoded by SLC22A12 and

GLUT9 is a glucose transporter encoded by SCL2A9.

22
23
 Hyperuricemia is defined as a uric acid concentration more than 6.0

mg/dl in women and 7.0 mg/dl in men. It is a risk factor for development of

gout, renall failure, obesity, diabetes, hyperlipidemia and hypertension. It occurs

due to increased production or decreased excretion or by both mechanisms.

Impaired uric acid secretion can occur due to urate transporter

dysfunction. It can also occur from increased production of uric acid. Diet rich

in fructose or purine can lead to increased uric acid level. Fructose rapidly

depletes ATP which degrades to form uric acid.

Mutation and subsequent deficiency of enzyme can lead to high uric acid

level. Most common enzyme deficient is hypoxanthine guanine phosphoribosyl

transferase. Deficiency of this enzyme can lead to Lesch- Nyhan syndrome.

Lesch-Nyhan syndrome is a x-linked inherited syndrome which leads to

accumulation of purine and purine phosphoribosyl phosphate.

Hypoxanthine guanine phosphoribosyl transferase enzyme is used in

salvage pathway. This leads to accumulation of guanine and hypoxanthine.

They then leads to uric acid accumulation in blood.

Excess phosphoribosyl pyrophosphate increases the denovo synthesis of

purine whose end product is uric acid. Lesch Nyhan syndrome causes severe

gout, mental retardation, compulsive self-mutilation, neurological disturbance

and renal stones.

24
 Gouty arthritis is acute inflammatory arthritis which presents as red hot,

tender and swollen joint. It is linked to hypertension, coronary artery disease

and metabolic syndrome. It is also related to cerebrovascular disease,

preeclampsia, kidney disease and vascular dementia.

URIC ACID IN DEFENSE MECHANISM.

ANTIOXIDANT -

50% antioxidant property of blood comes from uric acid. Uric acid is an

important scavenger of ROS and peroxynitrite. It reduces the heme oxidant

formed in haemoglobin by peroxidation reaction. It protects erythrocyte against

peroxidative damage.

Plasma uric acid level is more than ascorbic acid level suggests that it is

more important as antioxidant. In liver vascular endothelium and nasal secretion

uric acid acts as an anti-oxidant.

ENDOTHELIAL FUNCTION

Low level of uric acid is known to cause endothelium dysfunction. So

uric acid helps to maintain the integrity of endothelium. It plays an important

role in tissue repair and healing.

IMMUNE REGULATION

Uric acid plays an important role in inducing protective immune response

against various vaccine where alum is used as an adjuvant. Uric acid is also

demonstrated in asthmatic patient and is linked to bronchial hyperactivity.

25
IMMUNITY AGAINST PARASITE

Type 2 immune response is mounted and helminth parasite. Presence of

uric acid mount immune response against cysteine peptidase.

Because of the powerful anti-oxidant property, uric acid interferes with

lipoxygenase activity and it acts as a substrate for cyclooxygenase. It plays an

important role in protecting against schistosome infection.

PROTECTION AGAINST NEUROLOGICAL DISEASES

Low uric acid level is associated with multiple sclerosis, parkinsonism,

Alzheimer’s. It is also associated with autoimmune condition like pemphigus

vulgaris and lichen planus.

ESTIMATION OF URIC ACID

Uric acid structure- it is dibasic acid so it can form mono sodium salt and

disodium salt. It depends on the pH. In plasma, uric acid exist mainly as

monosodium crystals.

26
 Uric acid concentration can be determined by phosphotungistic acid

method, high performance liquid chromatography method, uricase method, dry

chemistry method and biosensor method.

Uricase method is most commonly as lab diagnosis used to determine

the uric acid concentration. Since uric acid has a unique property of showing

absorbance at 293 nm so it is easy to quantify uric acid

Uric acid can also be quantified by quantifying hydrogen peroxide level

which is a product of a uricase enzyme reaction. Uric acid can be identified

directly by decrease in absorbance at 293 nm as uric is acted upon by uricase

enzyme and indirectly by identifying the amount of hydrogen peroxide.

The direct method is by measuring the difference between initial UV and

UV after completion of uricase enzyme. Michaelis menten equation is used for

identifying UV absorbance.

Advantage of this method is that it is cheaper and it no prone for any

common errors.

Principle:

Uric acid is oxidized by the enzymes uricase to form allantoin and

hydrogen peroxide.

Hydrogen peroxide in the presence of peroxidase enzyme reacts with

polyhalogenated benzoic acid (PHBA) and 4 amino antipyrine (4-AAP) to form

quinoneimme dye which is a chromogen.

27
 The intensity of chromogen is measured and it is proportional to the

amount of uric acid in the specimen.

Materials needed-

1) URIZYME BUFFER- polyhalogenated benzoic acid in Tris buffer

2) URIZYME REAGENT- 4-aminoantipyrine, peroxidase, uricase.

3) URIC ACID STANDARD- an aqueous solution which contains

5mg/dl uric acid.

4) TOW SAMPLE SERUM

Calculations -

Concentration of uric acid in normal serum sample 1 = (absorbance of sample/

absorbance of standard)*5 = mg/dl

Concentration of uric acid in normal serum sample 2 = (absorbance of sample/

absorbance of standard)*5 = mg/dl

RANGE OF EXPECTED VALUES IN SERUM- 3.4-7.0 mg/dl

URIC ACID AND VARIOUS DISEASE

1) GOUT- it is an acute and chronic inflammatory and uric acid is a known

etiologic agent. It is due to deposition of monosodium urate crystals.

These crystals get bounded by protein in plasma and then they acted upon by

articular cells which initiate the innate immunity

28
 Innate immunity causes formation of inflammasome which causes the

release of IL-1. Neutrophil are recruited which produces reactive oxygen

species, extracellular trap and they activate macrophage.

Gout is due to interaction between monosodium urate crystal ,

inflammasome, IL-1 release and neutrophil release.

In most patient with hyperuricemia, they remain asymptomatic and don’t

develop gout. Urate crystals gets deposited in peripheral connective tissue like

joint, tendon kidney and heart.

Deposition of monosodium urate crystal recruit neutrophil and

macrophages. These cells phagocytes the crystals and leads to release of

hydrolytic enzyme, activation of reactive oxygen species and innate immunity.

Toll like receptor gets activated and they activate the release of IL-1 and

tumour necrosis factor.

29
 In addition, the phagocytosed cell leads to increase in sodium content

intracellularly, water influx, swelling of cells and decrease in potassium content

intracellularly.

IL-1 causes fever by changing the hypothalamic thermostat, destruction

of cartilage and muscle. Uric acid also increases the risk for development of

osteoarthritis through inflammasome. Osteoarthritis is also directly linked to the

concentration of uric acid in plasma.

RENAL DISORDER

Kidney plays a vital role in maintaining the plasma uric acid level. In

kidney filtration of uric acid occurs followed by secretion and reabsorption.

Tubular regulation of uric acid is handled by several organic anion transporter.

Hyperuricemia can cause acute kidney injury. It impairs the activity of

mesangial cells and also activates toll like receptor and also causes damage to

tubules and mesangium.

Excess uric acid can lead to stone formation. Most common problem is

urinary tract infection.

Kidney stone is second most common urinary stones. Acid pH of urine

causes crystallization of uric acid and subsequent stone formation. Causes for

low urine pH includes diarrhea, dehydration and diabetic ketoacidosis.

30
CARDIOVASCULAR DISORDER

Correlation gas been noted between serum uric acid cardiovascular

disease. Majority of risk factors of heart disease correlates with serum uric acid

level.

There is a positive correlation between high uric acid level and obesity,

hypertension, diabetes. High mortality is seen in patient with hyperuricemia. It

is also associated with severity if atherosclerosis.

Extracellular uric acid in serum contributes to antioxidant property

whereas intracellular uric acid leads to oxidative stress and it also known to

contribute to the development of heart failure.

Assessment of uric acid is cost effective and can be used to determine the

severity, prognosis of heart failure.

HYPERTENSION

Patient with primary hypertension with high uric acid upon treatment

with allopurinol resulted in decrease of blood pressure. Hyperuricemia can

interfere with nitric oxide synthesis and causes reduction in nitric oxide and thus

endothelial dysfunction and vasoconstriction

High uric acid level is also known to cause activation of renin angiotensin

system, vascular smooth muscle proliferation. Impaired kidney function is also

involved in development of hypertension.

31
ASSOCIATION OF URIC ACID AND NAFLD

Uric acid can cause oxidative stress and inflammatory effect on adipose

tissue. Hyperuricemia coexist with other condition like obesity, hypertension,

insulin resistance.

High xanthine oxidase level is seen in patient is, seen in patient with non-

alcoholic fatty liver disease. So, xanthine oxidase inhibitor can be used for

treating NAFLD. Uric acid increases the endoplasmic retinaculum stress and

increases fatty acid accumulation

Uric acid is an independent risk factor for development of metabolic

syndrome which in turn is the root cause for non-alcoholic fatty liver disease.

Uric acid is related to diabetes, cardiovascular.

Uric acid activates growth factors, cytokines, autocoids. It causes

proliferation of vascular smooth muscle. It alters the cell proliferation, induces

apoptosis, triggers reactive oxygen species and activates renin angiotensin

system.

Uric acid level is found to be proportional to the development of

complication of diabetes like diabetic retinopathy and grade of albuminuria.

Increased consumption of carbonated drinks, junk food leads to increase

in uric acid, weight gain, fat accumulation in liver and adipose tissue and leads

to metabolic syndrome.

32
 Uric acid produces reactive oxygen species, increases the expression of

thioredoxin related protein resulting in release of IL- 1, IL-18. Accumulation of

fat occurs due to oxidative stress, endoplasmic retinaculum dysfunction.

Histological study to establish the difference between uric acid and

NAFLD showed that increased severity of NAFLD is associated with

hyperuricemia. Hyperuricemia is an independent risk factor for advanced

lobular inflammation.

Serum uric acid level is found to be directly proportionate to degree of

steatosis. Increased uric acid level is linked to greater severity of inflammation

and NASH. Uric acid is also known to contribute to lipid oxidation.

Treatment with allopurinol and benzbromane has decreased the

cholesterol level and prevents the further progression of steatosis.

33
34
35
MECHANISM OF ASSOCIATION BETWEEN URIC ACID AND CLD

Uric acid is a strong oxidant, it activates NADPH dependant oxidase

followed by activation of redox mediated inflammatory signal through

adipocyte differentiation.

Uric acid induces infiltration of inflammatory cells in the liver

parenchyma. Uric acid increases the expression of inflammatory agent like

MCP-1 and decreases the expression of anti-inflammatory like adiponectin.

Lowering uric acid can decrease the expression of xanthine oxidase, so

this results in increase in expression of adiponectin and decrease in expression

of MCP-1.

Uric acid activates NALP-3 inflammasomes which in turn tiggers innate

immunity in NAFLD. NALP-3 inflammasome activates caspase 1, IL-1and IL-

18 which contributes to inflammation and insulin resistance.

Hyperuricemia can be used as a marker for hepatic necro-inflammation.

36
 MATERIALS AND METHODS

STUDY DESIGN:

 Cross sectional study

STUDY POPULATION:
 Patients of chronic liver disease both male and female, above 18 years of

age

STUDY PERIOD:

 Six months from the date of approval from ethical committee.

INCLUSION CRITERIA:

 Patients of chronic liver disease both male and female, above 18 years

of age.

EXCLUSION CRITERIA:

 Age <18 years

 Patient with known history of Hyperuricemia, Gout

 Patient who are currently acute alcoholic intoxication

 Patient who are under Chemotherapy

 Malignancy

 Patient who are taking Drugs like Allopurinol , Febuxostat , Thiazides

Frusemide which may cause altered serum uric acid level.

37
SAMPLE SIZE:

Sample size was determined based on the study “Chronic liver

disease – Etiological spectrum in adults”.

Authored by Vijay kundal

In this study, the prevalence of alcoholic among all subjects is 51.

n = 4pq /L2
p = prevalence
q = 100 – p
L = Allowable absolute error
Here , assuming prevalence is 51 and absolute error is 10
n = 4 × 51 × 49 / 10 × 10
n = 99
Total sample size is 99.

METHODOLOGY:

HISTORY TAKING:

 Detailed history has to be taken from the patients.

 Age (>18 years)

 Sex (both male and female)

 Old medical records (history of diabetes/ hypertension/chronic liver

disease/ coronary artery disease/ dyslipidemia/ haematological diseases/

stroke in past)

 Drug intake (anti-hypertensives, anti-diabetics, drugs causing

hyperuricemia, chemotherapy, diuretics, drugs for ischemic heart

disease, drugs for hypercholesterolemia)

38
  Smoking and Alcohol history.

CLINICAL EXAMINATION:

 Level of consciousness

 Orientation to time, place and person

 Icterus, pallor, clubbing, dilated veins over abdomen

 Testicular atrophy, gynaecomastia in males

 Astrexis

 Thorough clinical physical examination

 special attention to abdomen and central nervous system

LABARATORY ASSESSMENT:

 Serum uric acid level using Uricase enzyme method.

 Serum Bilirubin, Albumin, Prothrombin time.

 Radiological imaging with ultrasonography (USG) of

abdomen was done to know the degree of ascites.

ETHICAL ISSUES:

The study is initiated after obtaining clearance from the institutional

ethical committee. The written informed consent will be obtained from the

patients who are included in this study; after explaining to them objectives of

the study and role of the study participants in this study in local language.

39
Statistical Analysis

Data were entered into Microsoft Excel and statistical analysis was

carried out in SPSS software version 17.0. Qualitative variables were presented

as frequency and percentages. Quantitative variables were presented as mean

(standard deviation) or median (range) depending upon the distribution of data.

Bar diagram and pie charts were used for graphical representation of data.

Serum uric acid levels were compared across Child Pugh categories (A,

B, C) using ANOVA. Bonferroni correction was applied for post-hoc analysis

while interpreting the P values. Normality of data was assessed using

histogram. Uric acid levels were compared with those with and without history

of alcohol use by Students t-test (Independent t-test) and a p value of less than

0.05 was considered as statistically significant.

40
 Results

Table-1 Age distribution

Age groups
Number Percentage
(years)

31-40 28 28.3

41-50 51 51.5

>50 20 20.2

Total 99 100.0

A total of 99 proven cases of chronic liver disease was included in the

study. The mean age of the patients was 45 years with a standard deviation of

6.4 years. More than 50% of patients were in the age group of 41-50 years and

20% were above 50 years of age.

Age distribution
60
51
50

40

30 28
20
20

10

0
31-40 41-50 >50

41
Table-2 Gender distribution

Gende
Number Percentage
r

Male 84 84.9

Female 15 15.1

Total 99 100.0

Of total 99 patients, 84 were males and 15 were females.

Gender distribution

15

84

Male Female

42
Table-3 Co-morbidities

Co-morbidities Number Percentage

Type 2 DM

Yes 66 66.7

No 33 33.3

Hypertension

Yes 47 47.5

No 52 52.5

Sixty-six patients had type 2 diabetes mellitus and 47 patients had

hypertension.

Type 2 DM

33

66

Yes No

43
 Hypertension

47
52

Yes No

Table-4 Type of CLD

Male Female Total

Alcohol
N % N %
Yes
73 86.9 1 6.7 74 74.8
No
11 13.1 14 93.3 25 25.2
Total
84 100.0 15 100.0 99 100.0

Overall, 74 patients had history of alcohol use compared to 25 patients

who did not report alcohol use. Among males, 86.9% (73/11) reported alcohol

use compared to 6.7% (1/15) in females.

44
 Alcohol use
80
73
70
60
50
40
30
20 14
11
10
1
0
Male Female

Yes No

Table-5 Ascites in USG

Ascites Number Percentage

Absent 27 27.3

Mild 45 45.4

Moderat
27 27.3
e

Total 99 100.0

In USG, mild ascites was detected in 45 patients and moderate ascites

in 27 patients.

45
 Ascites in USG

27 27

45

Absent Mild Moderate

Table-6 Hepatic encephalopathy

Hepatic
Number Percentage
encephalopathy

No 30 30.3

Grade 1 28 28.3

Grade 2 18 18.2

Grade 3 19 19.2

Grade 4 4 4.0

Total 99 100.0

Of total, 30 patients did not have hepatic encephalopathy. Grade 1

encephalopathy was seen in 28 patients, grade 2 in 18 patients, grade 3 in 19

patients and four patients had grade 4 encephalopathy.

46
 Hepatic encephalopathy
35
30
30 28

25

20 19
18

15

10

5 4

0
No Grade 1 Grade 2 Grade 3 Grade 4

Table-7 Descriptive statistics of selected parameters

Minimu
Parameter Mean SD Maximum
m
Total bilirubin 3.7 1.5 1.4 7.2
Serum albumin 3.4 0.7 1.6 5.1
PT over normal 2.6 2.1 0.2 8
CPS score 9.9 3.0 5 15
Serum uric acid 5.1 1.3 2.9 8.1

The above table provides the descriptive statistics. Mean (SD) total

bilirubin level was 3.7 (1.5) mg/dl. Mean serum albumin level was 3.4 with a

standard deviation of 0.7 gm/dl. Mean (SD of PT over normal was 2.6 (2.1)

seconds. Mean CPS score was 9.9 with a SD of 3.0. Mean serum uric acid level

was 5.1 units with a SD of 1.3. Minimum uric acid level was 2.9 and maximum

in our study participant was 8.1 units.

47
 Descriptive statistics
12

10

6
9.9
4

5.1
2 3.7 3.4
2.6
0
Total bilirubin Serum albumin PT over normal CPS score Serum uric acid

Table-8 CPS categories

CPS
Number Percentage
categories

A 18 18.2

B 43 43.4

C 38 38.4

Total 99 100.0

Eighteen patients were in Child Pugh Score A category, 43 in B

category and 38 in C category.

48
 CPS categories

18

38

43

A B C

Table-9 CPS categories and Serum uric acid levels

CPS
Total Mean SD P value*
categories
A 18 3.7 0.4

B 43 4.7 0.8 <0.001

C 38 6.2 1.1

P value-significant (ANOVA)

The mean (SD) of uric acid levels was 3.7 (0.4), 4.7 (0.8) and 6.2 (1.1)

units in CPS categories A, B and C respectively. The difference in mean levels

of uric acid across the CPS categories was statistically significant (P<0.001).

The post-hoc analysis showed that all three possible comparisons between the

groups/categories were significant (P<0.001).

49
 CPS categories and Serum uric acid levels
7

3 6.2
4.7
2 3.7
1

0
A B C

Post-hoc analysis: CPS categories and uric acid level

Comparison P value*

A vs B <0.001

B vs C <0.001

A vs C <0.001

*Bonferroni correction

50
 Table-10 Alcohol use and serum uric acid levels

Mea P value
Alcohol use Number SD
n

Yes 74 4.9 1.1

0.02

No 25 5.8 1.7

Independent t-test, p value-significant

Mean uric acid levels in those patients reporting alcohol use was 4.9

units compared to 5.8 units in those who did not report alcohol use. The

difference in uric acid levels between the two groups was statistically

73
significant (P=0.02)

Alcohol use and serum uric acid levels

6

5.8

5.6

5.4

5.2
5.8
5

4.8
4.9
4.6

4.4
Yes No

74
 H/O
S.N AG SE ALCOHOL ASCITES IN Hepatic Sr PT CPS CPS Sr Uric
o E X T2DM SHT INTAKE USG encephalopathy Bilirubin Sr Albumin INR class CPS score acid

1 42 M No yes yes absent no 2.3 5 1.1 A 1 6 3.6

2 47 M No yes yes absent no 2.6 4.5 0.2 A 1 6 3.8

3 42 M Yes no yes absent no 2.1 4.6 0.5 A 1 6 3.7

4 51 M Yes no yes absent no 2.1 4 0.4 A 1 6 3.5

5 40 M Yes no yes absent no 2 3.9 0.4 A 1 6 3.5

6 50 M Yes no yes absent no 2.1 4.1 0.2 A 1 6 3.6

7 40 F Yes yes No absent No 1.8 3.7 1.4 A 1 6 3.4

8 52 M Yes yes yes absent no 2.4 4.8 0.2 A 1 6 3.9

9 41 M No no yes absent no 2.1 4.8 1 A 1 6 3.8

10 43 F Yes yes No absent No 1.9 4.2 1 A 1 5 3.6

11 49 M Yes no yes absent no 2 5.1 0.4 A 1 6 4.1

12 52 M Yes no yes absent no 2.6 4.2 0.4 A 1 6 3.5

13 46 F Yes yes No absent No 1.6 4 1.1 A 1 5 2.9

14 41 F Yes yes No absent No 1.9 4.1 0.5 A 1 5 3

15 41 M No yes yes absent no 2 4.5 0.4 A 1 6 3.8

16 44 M Yes yes No absent No 1.4 3.9 0.4 A 1 5 4.8

17 38 M No no yes absent no 2.4 5 1.1 A 1 6 3.7

18 41 M No no yes absent no 2.4 4.8 1 A 1 6 3.8

19 55 M Yes yes yes absent no 2.1 4.9 0.8 B 2 7 3.8

20 42 M Yes yes yes absent no 2.4 4.6 0.4 B 2 7 3.3

21 35 M No no yes mild grade 1 2.4 3.2 1 B 2 9 4.5

22 50 M Yes no yes mild grade 2 2.9 3.4 0.8 B 2 9 4.2

23 46 F Yes yes No mild grade 1 2.1 3.1 1.2 B 2 9 4.1

24 50 M Yes no No mild grade 1 2.6 4 1.4 B 2 8 6.6

25 50 F Yes yes No mild grade 2 3 3.4 1.3 B 2 9 5.2

26 43 M Yes no yes mild No 5.5 3.2 1 B 2 9 6.3

27 43 M No no yes mild grade 1 2.9 3.4 0.5 B 2 9 4.5

28 55 M Yes yes No absent grade 1 2.7 3 1 B 2 8 5.9

29 40 M Yes no yes mild grade 1 2.9 3.6 1.1 B 2 8 4.5

30 35 M No no yes absent grade 1 4.5 2.9 1.6 B 2 9 4.1

31 40 M Yes yes No mild grade 2 4.5 3 1.5 B 2 9 6.4

32 47 M Yes no yes mild grade 1 3 3.6 2 B 2 9 4.5

33 51 M Yes no yes mild grade 2 2.5 3.3 1.6 B 2 9 6.3

34 45 M Yes no yes mild grade 1 2.8 2.9 1.1 B 2 9 4

35 40 M Yes yes No mild grade 1 2.4 3.6 1.9 B 2 9 6.2

36 60 M Yes yes yes mild grade 2 3.5 3.6 1.1 B 2 9 4.2

37 50 M Yes no yes mild grade 1 2.9 3.4 1.5 B 2 9 4.3

38 62 M Yes yes yes mild grade 2 2.9 3.4 1.7 B 2 9 4.3

39 38 M No no yes absent grade 1 4.1 3.6 2 B 2 9 4.1

40 50 M Yes yes No mild No 2.3 3.1 2 B 2 9 6.2

41 40 M No yes yes absent grade 1 4.1 3.4 1 B 2 9 4.1

42 45 M No no yes mild grade 2 3 2.9 1.6 B 2 9 4.4

43 49 M No yes yes mild grade 1 2.9 4.5 1 B 2 8 3.9

44 52 F Yes no No absent No 4.5 3.2 1.2 B 2 8 4.8

45 59 M Yes yes yes mild grade 1 2.9 3.4 2 B 2 9 4.3

46 50 F Yes yes No mild grade 1 2.5 1.6 1.8 B 2 9 4.9

74
47 43 M Yes no yes mild no 4.2 4.1 2 B 2 9 4.4

48 40 M No no yes mild grade 1 4 3.6 1.4 B 2 9 4.6

49 42 M Yes no yes mild No 5.5 4.6 1.1 B 2 8 4.5

50 49 M Yes no yes mild grade 2 3 3 1.1 B 2 9 4.6

51 41 M No yes yes mild grade 1 3 2.9 1.3 B 2 9 4.1

52 35 M No no yes mild grade 1 2.7 3.3 1.1 B 2 9 4.7

53 44 M No yes yes mild grade 1 3 3.4 1.6 B 2 9 5

54 39 F Yes yes No mild grade 1 1.9 2.9 2.2 B 2 9 4.8

55 57 M Yes no yes mild grade 1 3 3.4 1.6 B 2 9 4.5

56 46 F Yes yes No mild grade 1 2.8 3.6 2.2 B 2 9 4.7

57 55 M No no yes mild no 3 3.3 2 B 2 9 4.6

58 47 M Yes no yes mild no 3.3 3.1 1.6 B 2 9 4.4

59 51 M No yes yes mild no 3.1 3.6 2 B 2 9 4.5

60 52 F Yes yes No mild grade 2 5.5 3.6 1.6 B 2 9 5

61 48 M Yes no yes mild grade 1 3 3.4 1.2 B 2 9 4.9

62 40 M Yes no yes mild grade 2 2.7 3.2 1.8 C 3 10 4.2

63 55 M No no yes moderate grade3 5.2 2.4 6.2 C 3 15 6.4

64 52 M Yes yes yes absent grade 1 5 3.6 3.2 C 3 10 4.4

65 49 M No no yes moderate grade2 7.2 2.4 5 C 3 14 6.5

66 39 M No yes yes moderate grade 3 5.8 2.9 4.5 C 3 14 6.7

67 38 M Yes no yes mild No 5.1 2.9 2.1 C 3 10 4.3

68 52 M Yes yes yes moderate grade 4 7.2 2.7 6.2 C 3 15 6.6

69 41 M No no yes mild grade2 2.8 2.9 3.2 C 3 11 6.2

70 37 M No no yes mild grade 1 4.2 3.6 2 C 3 10 4.9

71 43 M Yes yes yes mild no 5.4 3.2 1.7 C 3 10 4.2

72 34 M No yes yes absent grade 1 3.5 3.4 2.3 C 3 11 4.3

73 35 M No yes yes moderate grade 3 5.5 2.8 6.2 C 3 14 6.6

74 49 M Yes no yes mild grade 1 1.9 2.7 2 C 3 10 4.8

75 38 M No yes yes moderate grade 4 6.5 2.4 7.2 C 3 15 5.9

76 50 M Yes yes yes moderate grade 3 5.5 3.1 5.2 C 3 14 6

77 39 M No yes yes moderate grade 3 6.7 3 4.5 C 3 14 6.3

78 38 M No no yes moderate grade 3 5.8 3.4 4.5 C 3 14 5.8

79 47 M Yes yes yes moderate grade 3 6.3 2.9 6 C 3 14 6.2

80 40 M Yes yes yes moderate grade 3 5.9 3.2 6.2 C 3 14 6.5

81 47 M Yes no yes moderate grade3 5.1 2.7 6 C 3 15 6.1

82 34 M No no yes moderate grade3 4.5 3 4 C 3 14 6.3

83 43 M Yes yes No moderate grade 2 3.5 2.9 4.5 C 3 13 7.5

84 50 F Yes no yes moderate grade 3 4 3.1 4 C 3 14 5.5

85 51 M Yes no yes moderate grade 3 5.7 2.7 4.3 C 3 15 6.3

86 40 M Yes no yes moderate grade 3 4.3 3.4 5.2 C 3 14 6.4

87 32 M No no yes moderate grade 2 6 2.4 7 C 3 14 6.3

88 41 M Yes yes No mild grade 2 5.5 2.7 5 C 3 13 7.9

89 51 M Yes no yes moderate grade 4 6.8 2.3 8 C 3 15 6.7

90 46 M Yes no No moderate grade 3 4.2 3.4 4.6 C 3 14 8.1

91 36 M No no yes moderate grade 3 6 3.4 4 C 3 14 5.9

92 49 M Yes yes No moderate grade 2 4.2 3.3 6.1 C 3 13 7.6

93 54 M Yes yes yes moderate grade 3 6.3 3.1 5 C 3 14 6.3

94 42 F Yes no No mild grade 2 5.1 2.6 6 C 3 13 7.4

75
95 50 M Yes no yes moderate grade 3 4.7 2.4 5.3 C 3 14 6.2

96 40 F Yes yes No mild grade 2 3.2 2.6 6.2 C 3 13 7.5

97 49 M Yes yes No moderate grade 3 5.2 3 6.4 C 3 14 8.1

98 43 M No yes yes moderate grade 4 7.1 2.2 7.8 C 3 15 6

99 49 F Yes no No moderate grade 3 3.5 3.1 4.5 C 3 14 7.1

76
 DISCUSSION

Present study was done to evaluate the relationship between serum uric

acid and chronic liver disease. A total of 99 patients were enrolled, among

them 84 were male and 15 were female. Mean age was found to be 45+/- 6.4

year.

More than 50% of patient were in the age group of 41-50 years and

20% were above 50 years.

While in the study conducted by Bobi singh M, a total of 66 patient

were enrolled of which 48 were female and 18 were female. Alcohol was

identified as the most common cause of CLD among all causes. About 46

patients were alcoholic out of which 39 were male and 7 were female.

In our study, 74 patients had history of alcohol out of which 73 were

male ( 86.9%) and 1 female ( 6.7%). In ultrasonogram, mild ascites were

detected in 45 patients(45.4%) and moderate ascites were detected in 27

patients( 27.3%).

About 66 patient (66.6%) had type 2 Diabetes Mellitus and 47

patient(47.5%) had hypertension.

77
 Hepatic encephalopathy was identified in about 69 patients. Grade 1

encephalopathy was seen in 28 patients, grade 2 in 18 patients, grade 3 in 4

patients. 30 patients did not have hepatic encephalopathy.

Noel S. Weiss conducted a study where National Health and Nutrition

Examination survey cohort study was done. The result of NHANES 1 cohort

study showed that increased serum uric acid level was associated with

increased age, obesity, sr. Creatinine, alcohol intake, male gender, diabetes.

They are linked together and they contribute independently to the development

of cirrhosis.

In NHANES studies, mean ALT and GGT levels are increased with

increase in level of serum uric acid. Increased uric acid is associated with

increased level of hepatic necro inflammatory markers (ALT and GGT).

In our study, mean serum uric acid was 5.1 mg/dl with standard

deviation of 1.3. Minimum uric acid level was 2.9 mg/dl and maximum uric

acid level was 8.1 mg/dl.

In our study, 18 patients were in category A of child Pugh score, 43

patients were in category B of child Pugh score and 38 patient were in category

C of child Pugh score. Mean CPS score was 9.9 with SD of 3.0.

In the study conducted by Bobi singh M, 16 patients were in class A

CPS, 30 patients were in class B CPS and 20 patients were in class C CPS. The

78
mean uric acid level was higher in CPS class C than in class A and B. The

mean uric acid level in category A was 4.4 mg/dl while in B it was 5.53 mg/dl

and in C it was 8.26 mg/ dl.

In the study conducted by Bobi singh M, the mean uric acid level in

alcoholic liver disease was 4.44 mg/dl and in Non-alcoholic fatty liver disease,

it was 7.04 mg/dl. NAFLD patients had higher uric acid level than alcoholic

liver disease patients.

In our study the mean serum Uric acid level was 3.7 in CPS category

A, 4.7 in CPS category B and 6.2 in CPS category C . The difference in mean

uric acid levels across the CPS categories were statistically significant

( P<0.001).

The mean uric acid levels in alcoholic liver disease patients was 4.9

mg/dl while in patients with non-alcoholic liver disease it was 5.8 mg/dl. The

difference in uric acid between these two groups was statistically significant.

So, we find in our study that uric acid levels are high in Non-alcoholic fatty

liver disease than in alcoholic liver disease.

To summarise we find in our study that uric acid level is higher with

higher Child Pugh grading. Thus, Uric acid was higher in patient with CPS

class C than class B and class A. These studies show that severity of liver

disease is increased with higher uric acid level.

79
STRENGTHS:

1) Various studies have proven that serum uric acid level is associated with

chronic liver disease in different etiology of chronic liver disease. But only few

studies have done to compare serum uric acid level in different severity of

chronic liver disease by using scoring system.

LIMITATIONS:

 As a hospital-based study, only the patients admitted in Government

Kilpauk Medical College and hospital in department of General

medicine were included; A single centre study; limiting the geographical

distribution of study participants

1) Relatively smaller sample size, to draw inferences from the study that can

be attributed to general population.

CONCLUSION

In this study , serum uric acid level has statistically significant

association with chronic liver disease .while comparing serum uric acid level

with different classes (A,B,C) of child pugh scoring ,Class C patients have

higher value of mean serum uric acid than class B and class B patients have

higher value than class A. This indicate that greater severity of chronic liver

disease is associated with higher value of serum uric acid. In etiology, non-

80
alcoholic patients have higher value of mean serum uric acid than alcoholic

patients. All these indicates serum uric acid is higher in non-alcoholics and

patients with greater severity of chronic liver disease. Hence, serum uric acid

can be taken as prognostic marker to predict and prevent disease progression

in chronic liver disease .In future, serum uric acid can be taken as one of

parameter like albumin and bilirubin, prothrombin time, ascites , hepatic

encephalopathy in child pugh score. However, there is need for more studies to

evaluate and validate these findings.

SUMMARY

 The aim of the study to find out association of serum uric acid level with

different severity of chronic liver disease patients.

 A hospital based prospective study was conducted at a Tertiary health care

centre; Department of General Medicine, Govt. Kilpauk Medical College,

Chennai for 6 months from the date of approval of ethical committee among

99 study participants who met the inclusion, exclusion criteria and were

willing to participate in the study.

 To study the association of serum uric acid with severity of chronic liver

disease, relevant statistical test was applied.

81
 In this study, we observed significant association between serum uric acid

with different severity of chronic Liver disease by child pugh scoring; p

value <0.05

 This study concludes that serum uric acid is useful as prognostic marker to

predict severity of chronic liver disease. However, there is need for more

studies to evaluate and validate this association.

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87
 QUESTIONNAIRE :

YES NO
DIABETES
HYPERTENSION
SMOKER
ALCOHOLIC
PREVIOUS STROKE
HEART DISEASE
DRUG ABUSE
KNOWN
HAEMATOLOGICAL
DISEASES

PROFORMA:

NAME
DATE
AGE
SEX
ADDRESS
CONTACT NUMBER
COMPLETE DIAGNOSIS
IP NUMBER
 PATIENT CONSENT FORM

Study detail:“TO COMPARE THE CORRELATION OF HAEMATOLOGICAL

PARAMETERS WITH THE MORTALITY OF ACUTE ISCHEMIC STROKE - A
PROSPECTIVE STUDY.”
Study centre :GOVT. KILPAUK MEDICAL COLLEGE, CHENNAI
Patient Name :
Patient Age :
OP number :

Patient may check in ( ) these boxes

I confirm that I have understood the purpose of procedure for the above study. I have the
opportunity to ask question and all my questions and doubts have been answered to my
complete satisfaction.
I understand that my participation in the study is voluntary and that I am free to withdraw at
any time without giving reason, without my legal rights being affected.
I understand that sponsor of the clinical study, others working on the sponsor’s behalf, the
ethical committee and the regulatory authorities will not need my permission to look at my
health records, both in respect of current study and any further research that may be
conducted in relation to it, even if I withdraw from the study I agree to this access. However,
I understand that my identity will not be revealed in any information released to third parties
or published, unless as required under the law. I agree not to restrict the use of any data or
results that arise from this study.
I agree to take part in the above study and to comply with the instructions given during the
study and faithfully cooperate with the study team and to immediately inform the study staff
if I suffer from any deterioration in my health or well-being or any unexpected or unusual
symptoms.
I hereby consent to participate in this study.
I hereby give permission to undergo complete clinical examination and diagnostic tests
including haematological, biochemical, radiological tests.

Signature/thumb impression:

Patient Name and Address: Place: Date:

Signature of investigator :

Study investigator’s Name : Place: Date :

 ேநாயாள� ஒப்�த ப�வம
ஆய் வ�வரம: " க�ைமயான ஸ்ட்ேர இறப் �லம பல்ேவ ஹமேடாலாஜிகல
அள்�க்க ெதாடர் ஒபப�்�-ஒ� வ�ங்கா ஆய்." ஆய் ைமயம:
அர�
கீ ழ்ப்பாக ம�த்வர கல்�, ெசன்ை
ேநாயாள� ெபயர:
ேநாயாள� வய்:
OP எண:

இந்தப் ெபட்�லபடநாயாள�( √) ேசாதிக்கப்படல

ேமேல உள் ஆயவ�ன நைட�ைறய�ன ேநாக்கத் நான ்�ந்ெகாணடடன என
உவதிபப�த்கிடறன. ேகள்வ ேகட்பதற எனக் வாய்ப உள்ள, என் ��
தி�ப்திக என் ேககவ�ககம சந்ேதகங்க பதிலள�க்கப்பட.
இநதபஆயவ�லபநானபபஙடகதப்பதனனாரவதன்னார்வத்திலான்பச்ட�ம்
உ�ைமகள் பாதிக்கப்படாமல் எந்த ேநமபஎநதரபகாரந்தக் காரண
வ�லகிரெகாகவததறபநானப�தநதிரமாகபஉகடளனபஎனபைதபநானப்�ந்ெகாணடடன.
ம�த்வ ஆய்ை வழஙறம நிவவனம, ஆய்ை வழஙறம நிவவனத்தி சார்பா
பண�்��ம மற்றவர், ெநறி�ைறக ற� மதவம ஒ�ங்�ைற அதிகா�கள, நான
ஆயவ�லி�ந் வ�லகினாநம ்ட, நான இந் அ�கநரற சம்மதிக்கிே என்
உடல்நல பதிேவ�கைளப பார்ப்பத என் அ�மதி ேதைவய�ல்ை. என��ம,
சட்டத்த கீ ழேதைவப்பட்ட ஒழிய, �ன்றா தரபப�ன�ரற ெவள�ய�டபப�ம அல்ல
ப�ர��க்கப்ப எந்த தகவலகள�ல என் அைடயாளம ெவள�பப�தத்தப்ப என்பை
நான ்�ந்ெகாணடடன. இந் ஆயவ�லி�ந் எ�ம தர்கள அல்ல �ப்கள�ன
பயன்பாட் க்�பப�ததாமல இ�க் நான ஒப்ரெகாகாள்கி.
ேமேல உள் ஆயவ�ல பங்ேகற நான ஒப்ரெகாகாள்கி, ஆயவ�ன ேபா் அள�க்கப்ப
அறி்ைரககரற இணங் ேவண�ம மதவம ஆய்ரற�்டன வ��வாசத்டன ஒத்ைழரக்க,
என் உடல்நல அல்ல நல்வாழ் அல்ல எதிர்பாரா அல்ல வழக்கத்தி மாறான அறிறறிகள�ல
ஏேத�ம சீர்ேக ஏற்பட்ட உடனபயாக ஆய்ப பண�யாள�ரறத ெத�யபப�தத
ேவண�ம..

இந் ஆயவ�ல பங்ேகற்பத நான ஒப்தல அள�க்கிேற.

��ைமயான ம�த்வ ப�ேசாதைன மதவம ேநாயறிதல ப�ேசாதைனகள, உய�ர
ேவதிய�யல, ேரபடயாலாஜிக்க ப�ேசாதைனகள உகள�்ட ப�ேசாதைனககரகாக
நான அ�மதி அள�ப்ேப.

ைகெயாப்ப/க்ைடவ�ரலபடரைக:

ேநாயாள� ெபயரபமதவமப�கவ�: இடம: ேத

தி:

ஆயவாள�னபைகெயாபபம:

ஆய்பஆயவாளரபெபயர:

இடம:

ேததி: