Vous êtes sur la page 1sur 7

Clinical Gastroenterology and Hepatology 2017;15:927–933

Clinical, Biochemical, and Histopathology Features of Patients

With Glycogenic Hepatopathy
Saurabh Mukewar,*,a Ayush Sharma,*,a Kandace A. Lackore,‡ Felicity T. Enders,‡
Michael S. Torbenson,§ Patrick S. Kamath,* Lewis R. Roberts,* and Yogish C. Kudvak

*Division of Gastroenterology and Hepatology, ‡Division of Biomedical Statistics and Informatics, §Department of Laboratory
Medicine and Pathology, and kDivision of Endocrinology, Mayo Clinic, Rochester, Minnesota

BACKGROUND & AIMS: Glycogenic hepatopathy, a syndrome characterized by hepatomegaly and increased liver
transaminases in patients with type 1 diabetes, has not been well characterized in adults. We
describe the clinical, biochemical, and histopathology profile of a cohort of patients with
glycogenic hepatopathy. We also examined differences between patients with type 1 diabetes
with versus without glycogenic hepatopathy.

METHODS: We performed a case–control study of patients with type 1 diabetes diagnosed with glycogenic
hepatopathy and patients with type 1 diabetes without glycogenic hepatopathy (control
subjects). Cases were identified in the database of electronic medical records at Mayo Clinic,
Rochester from January 1, 1998, through January 1, 2014. Age- and sex-matched control
subjects were identified from a Mayo Clinic registry of patients with type 1 diabetes who had
normal levels of liver enzymes. Demographic, clinical, laboratory, and histopathology data were
collected and compared between cases and control subjects. The primary outcome was
difference in frequency of diabetic ketoacidosis episodes and hemoglobin (Hb) A1c levels
between cases and control subjects.

RESULTS: Among the 36 patients diagnosed with glycogenic hepatopathy, 20 had undergone liver biopsy
analysis. Most cases were female (n [ 28; 77.8%). Abdominal pain was the most common
symptom (n [ 23; 63.9%); 28 patients (77.8%) had hepatomegaly. All patients had poor control
of diabetes (mean HbA1c level, 11.2 – 2.4%). A higher proportion of cases had recurrent
episodes of diabetic ketoacidosis (61%) than control subjects (9%) (P [ .009), and cases had a
higher mean level of HbA1c (11.2 – 2.4% vs 9.0 – 2.2% in control subjects; P [ .0004). Adult
cases had higher levels of aspartate transaminase (312.5 IU/L; range, 245.5–775 IU/L) than
pediatric cases (157; range, 104–267 IU/L; P [ .02) and lower serum levels of albumin (3.7 –
0.5 g/dL vs 4.3 – 0.4 g/dL for pediatric cases; P [ .008). Only 16.7% of pediatric patients with
glycogenic hepatopathy had growth retardation. Levels of liver transaminases were normalized
at follow-up examinations of 18 of 21 adult or pediatric patients with glycogenic hepatopathy.

CONCLUSIONS: More than half of patients with glycogenic hepatopathy and type 1 diabetes have recurrent
episodes of diabetic ketoacidosis, and these patients have higher levels of HbA1c than patients
with type 1 diabetes without glycogenic hepatopathy. We observed growth retardation in only
about 17% of pediatric patients with glycogenic hepatopathy.

Keywords: DKA; AST; Mauriac Syndrome; Glycogen Deposition.

auriac syndrome or glycogenic hepatopathy although there are conflicting observations.1 GH seems
M (GH) is characterized by elevated serum trans-
aminases in patients with type 1 diabetes (T1D) sec-
to be most prevalent in patients with poorly controlled

ondary to glycogen deposition in the liver.1 In the classic a

Authors share co-first authorship.
description by Mauriac, the patients were children with Abbreviations used in this paper: AST, aspartate transaminase; BMI, body
mass index; DKA, diabetic ketoacidosis; GH, glycogenic hepatopathy;
poorly controlled T1D in the pre-long-term-acting insulin HbA1c, hemoglobin A1c; T1D, type 1 diabetes.
era who presented with growth retardation and cushin-
Most current article
goid features.2
© 2017 by the AGA Institute
Some recent studies have suggested that the pheno- 1542-3565/$36.00
type of patients presenting today may be milder,3,4 http://dx.doi.org/10.1016/j.cgh.2016.11.038
928 Mukewar et al Clinical Gastroenterology and Hepatology Vol. 15, No. 6

T1D, but there have been no comparative studies findings including presence of inflammation, mega
confirming worse glucose control in these patients mitochondria, and fibrosis were also noted. Follow-up
compared with T1D without GH. The aim of the current transaminase levels were also recorded and were clas-
study was to describe the clinical, biochemical, and sified as “resolved liver enzymes” or “resolving liver
histopathologic profile of patients with GH and to enzymes.”
conduct a matched case-control study to determine
whether T1D with GH had more frequent diabetic Outcomes
ketoacidosis (DKA) episodes and elevated hemoglobin
A1c (HbA1c) concentrations compared with those The primary outcome was to compare frequency of
without. recurrent DKA episodes and HbA1c levels between cases
(T1D þ GH) and control subjects (T1D þ normal liver
Materials and Methods enzymes). Secondary outcomes were to assess differ-
ences in clinical presentation, imaging findings, and
laboratory investigations between adult (>18 years) and
Study Design
pediatric (18 years) patients diagnosed with GH.
This was a case-control study. Cases were patients
with T1D diagnosed with GH and control subjects were Statistical Analysis
patients with T1D without GH. Cases were identified by
searching the terms “glycogenic hepatopathy” and Descriptive statistics were calculated using fre-
“Mauriac syndrome” in electronic medical records at quencies and percentages for categorical variables and
Mayo Clinic, Rochester from January 1, 1998 to January either mean and standard deviation or median and
1, 2014. Age and gender matched control subjects were interquartile range for continuous variables. P values
identified from a Mayo Clinic registry of patients with were generated using Fisher exact tests for categorical
T1D who had normal liver enzymes. The study was variables and Kruskal-Wallis tests for continuous vari-
approved by the Mayo Foundation Institutional Review ables. All statistical analyses were performed using SAS
Board. version 9.3 (SAS Institute Inc, Cary, NC).
“Cases” of GH were identified as patients with T1D
and a liver biopsy suggestive of glycogenic GH (patho- Results
logic overloading of hepatocytes with glycogen); or a
clinical diagnosis of GH based on hepatomegaly on clin- Thirty-six patients were diagnosed with GH; 20 had
ical examination or hepatic imaging and transaminases liver biopsy and 16 were clinically diagnosed. Hepato-
elevation >2 times the upper limit of normal. Patients megaly was present in 32 of the 36 patients (88.9%), in
with known chronic liver disease or patients in whom 18 (50%) on both clinical examination and imaging, in 10
elevated transaminases could be attributed to other (27.8%) on imaging only, and in 4 (11.1%) on clinical
causes were excluded. examination only. Most of the cases were female (28 of
36; 77.8%). Abdominal pain was the most common
Study Variables symptom (23; 63.9%). All patients had poor diabetes
control (HbA1c, 11.2  2.4).
Demographic, clinical, laboratory, and histopathology
variables were abstracted including age at presentation Patients With Type 1 Diabetes With and Without
with GH (for cases), age when transaminases were Glycogenic Hepatopathy
normal (for control subjects), sex, height (cm), weight
(kg), body mass index (BMI), percentile height for age, Table 1 shows the comparison between patients
percentile weight for age, and BMI for age. Clinical with T1D with and without GH. In the GH group, a
features comprised history of recurrent episodes of greater frequency of patients had history of recurrent
DKA, duration of T1D, age at diagnosis of T1D, symp- DKA episodes (61% vs 32%; P ¼ .02) and the GH group
toms at presentation (abdominal pain, abdominal had higher HbA1c levels (11.2  2.4 vs 9.0  2.2;
distention, vomiting), and findings of hepatomegaly P ¼ .003). In pediatric patients with GH, median
and/or splenomegaly on physical examination and/or percentile height for age was 30.5 (range, 1–79) and
abdominal imaging. Laboratory findings included HbA1c median percentile weight for age was 64.5 (range,
(percentage), aspartate transaminase (AST; IU/L), 1–91). In those without GH, median percentile height for
alanine transaminase (IU/L), alkaline phosphatase (IU/ age was 54 (range, 4–86) and median percentile weight
L), g-glutamyltransferase (IU/L), total bilirubin (mg/ for age was 77.5 (range, 3–96). There was no difference
dL), direct bilirubin (mg/dL), serum albumin (g/dL), in the frequency of pediatric patients with low (<5)
total cholesterol (mg/dL), low-density lipoprotein percentile height and weight for age between the 2
cholesterol (mg/dL), high-density lipoprotein choles- groups (16.7% vs 18.2%; P ¼ 1.00). Cases had higher
terol (mg/dL), and triglycerides (mg/dL). Liver biopsy total cholesterol (266.4  95.3 vs 175.0  39.4;
June 2017 Glycogenic Hepatopathy 929

Table 1. Comparison Between Type 1 Diabetics With Glycogenic Hepatopathy and Type 1 Diabetes With Normal Liver

Type 1 diabetes with glycogenic Type 1 diabetes with normal liver

hepatopathy (cases) enzymes (control subjects) P valuea

Male, n (%) 8 (22.0) 7 (20.6) 1.00

BMIb 23.5  3.5 24.0  5.3 .97
Percentile height for agec 30 (8–52) 47 (36–67) .18
Percentile weight for agec 77 (58–81.5) 71 (48–76) .36
Clinical features, n (%)
Abdominal pain 23 (63.9) 13 (38.2) .055
Vomiting 6 (16.7) 5 (14.7) 1.00
Abdominal distention 6 (16.7) 0 (0) .025
Splenomegaly 2 (5.6) 0 (0) .49
Hepatomegaly 22 (61.1) 1 (2.9) < .0001
Age at diagnosis of DM, yc 8.5 (5–12) 8 (5–12) .75
Episodes of recurrent DKA, n (%) 22 (61.1) 10 (29.4) .009
Imaging findings, n (%)
Splenomegaly 0 (0) 0 (0) —
Hepatomegaly 28 (84.8) 0 (0) < .0001
Laboratory studies
HbA1c, %b 11.2  2.4 9.0  2.2 .0004
AST, U/Lc 289 (135–604) 23.5 (18–30) < .0001
ALT, U/Lc 245 (123–386) 18 (15–27.5) < .0001
Alkaline phosphatase, U/Lc 196.5 (142–289) 113 (78–145) .0003
GGT, U/Lc 97 (66–426) 11 (11–20) .0006
Total bilirubin, mg/dLb 0.5  0.3 0.5  0.3 .80
Direct bilirubin, mg/dLb 0.2  0.3 0.1  0.0 .33
Serum albumin, g/dLb 3.9  0.6 4.2  0.6 .22
INRb 0.9  0.1 1.0  0.0 .022
Total cholesterol, mg/dLb 266.4  95.3 175.0  39.4 < .0001
LDL cholesterol, mg/dLb 112.5  37.7 95.2  42.0 .072
HDL cholesterol, mg/dLb 51.5  23.7 61.3  18.7 .21
Triglycerides, mg/dLc 291.5 (180–509) 88.0 (58–126) < .0001

ALT, alanine transaminase; DM, diabetes mellitus; GGT, g-glutamyl transferase; HDL, high-density lipoprotein cholesterol; INR, international normalized ratio; LDL,
low-density lipoprotein cholesterol.
Kruskal-Wallis for continuous, Fisher exact for categorical.
Mean  standard deviation.
Median (interquartile range).

P < .0001) and triglyceride levels (291.5 [range, bilirubin, total cholesterol, high-density lipoprotein
180–509] vs 88.0 [range, 58–126]; P < .0001) cholesterol, low-density lipoprotein cholesterol, or tri-
compared with control subjects. There were no glycerides between the 2 groups.
differences in BMI, abdominal pain, abdominal disten-
tion, vomiting, splenomegaly, total bilirubin, albumin, Clinical Versus Histopathologic Diagnosis of
high-density lipoprotein cholesterol, or low-density Glycogenic Hepatopathy
lipoprotein cholesterol between the 2 groups.
The only difference found in the clinical versus
Adult and Pediatric Patients With histopathologically diagnosed GH cases was in AST
Glycogenic Hepatopathy levels, which were greater in biopsy proven than in
clinically diagnosed cases (301 [range, 245.5–775] vs
There were 24 adult and 12 pediatric patients with 150 [range, 69–465.5]; P ¼ .02) (Table 3). Among those
GH (Table 2). Adults had longer duration of diabetes with biopsy-confirmed GH, 3 (15%) patients had mega
(13.3  5.8 vs 8.7  3.6; P ¼ .02), higher AST levels mitochondria observed on histopathology.
(312.5 [range, 245.5–775] vs 157 [range, 104–267];
P ¼ .02), and lower serum albumin levels (3.7  0.5 Follow-up
vs 4.3  0.4; P ¼ .008) than pediatric patients. There
was no difference in sex, BMI, abdominal pain, abdominal Median duration of follow-up was 8 months (range,
distention, vomiting, splenomegaly, hepatomegaly, 1–72) with data available for 21 of the 36 patients. For
history of recurrent DKA, HbA1c, alanine transaminase, 18 of the patients the transaminases eventually
alkaline phosphatase, g-glutamyltransferase, total normalized; in the other 3 patients they were trending
930 Mukewar et al Clinical Gastroenterology and Hepatology Vol. 15, No. 6

Table 2. Comparison Between Adult and Pediatric Patients With Glycogenic Hepatopathy

Adults (n ¼ 24) Pediatric (n ¼ 12) P valuea

Male, n (%) 5 (20.8) 3 (25.0) 1.00

Age at presentation, yb 23.2  5.6 16.1  2.0 < .0001
Clinical features, n (%)
Abdominal pain 14 (58.3) 9 (75.0) .47
Vomiting 6 (25.0) 0 (0) .08
Abdominal distention 2 (8.3) 4 (33.3) .15
Splenomegaly 0 (0) 2 (16.7) .10
Hepatomegaly 12 (50.0) 10 (83.3) .08
Age at diagnosis of DM, yc 9.5 (5–13) 7.5 (5–9.5) .21
Duration of DM, yb 13.3  5.8 8.7  3.6 .02
Requires insulin, n (%) 23 (95.8) 12 (100) 1.00
Episodes of recurrent DKA, n (%) 13 (54.2) 9 (75.0) .29
Imaging findings, n (%)
Splenomegaly 0 (0) 0 (0)
Hepatomegaly 19 (86.4) 9 (81.8) 1.00
Laboratory studies
HbA1c, %b 11.5  2.6 10.7  2.1 .48
AST, U/Lc 312.5 (245.5–775) 157 (104–267) .02
ALT, U/Lc 315 (188–386) 144.5 (76.5–349) .10
Alkaline phosphatase, U/Lc 193 (142–297) 243 (131–289) .77
GGT, U/Lc 181 (66–552) 77 (66–426) .56
Total bilirubin, mg/dLb 0.5  0.4 0.5  0.2 1.00
Direct bilirubin, mg/dLb 0.2  0.3 0.2  0.1 .81
Serum albumin, g/dLb 3.7  0.5 4.3  0.4 .008
INRb 0.9  0.1 0.8  0.0 .04
Total cholesterol, mg/dLb 281.7  112.0 242.0  56.3 .40
LDL cholesterol, mg/dLb 116.6  38.7 106.9  38.2 .56
HDL cholesterol, mg/dLb 52.1  24.3 50.5  23.9 .72
Triglycerides, mg/dLc 318 (180–593) 259.5 (173.5–407.5) .35

ALT, alanine transaminase; DM, diabetes mellitus; GGT, g-glutamyl transferase; HDL, high-density lipoprotein cholesterol; INR, international normalized ratio; LDL,
low-density lipoprotein cholesterol.
Kruskal-Wallis for continuous, Fisher exact for categorical.
Mean  standard deviation.
Median (interquartile range).

down on follow-up. The decrease in transaminases was hepatopathy” was recently coined by Torbenson et al4 to
associated with improvement in glycemic control. None describe this condition. Hepatic glycogenosis occurs
of the patients developed any apparent long-term secondary to a combination of 2 main factors: elevated
adverse liver outcomes. glucose levels and elevated insulin levels. Glucose diffuses
into hepatocytes and is converted to glucose-6-phosphate
by the enzyme glucokinase. Glucose-6-phosphate is
Discussion converted to glycogen by the enzyme glycogen synthase.
Glycogen synthase exists in an active dephosphorylated
This study constitutes the largest series of patients form and an inactive phosphorylated form. The active
with T1D and GH. The typical clinical presentation was dephosphorylated form of glycogen synthase is produced
abdominal pain, hepatomegaly, recurrent DKA, elevated by the action of a phosphatase enzyme, which is stimu-
HbA1c levels, and hypercholesterolemia. Growth retar- lated by elevated glucose and insulin levels. Glycogen is
dation was infrequently seen in pediatric patients with mobilized by glycogen phosphorylase typically in the
GH. When compared with patients with T1D with normal postabsorptive state. Thus, mechanistically, elevated
liver enzymes, patients with GH more frequently had glucose and insulin levels and decreased glycogen
recurrent DKA and elevated HbA1c levels. Adult patients phosphorylase activity in the hepatocyte could lead to
with GH had higher AST levels and lower albumin levels deposition of glycogen in hepatocytes (Figure 1).
compared with pediatric patients. On follow-up, patients DKA can be considered as a surrogate marker for
had fluctuating liver enzymes, which eventually poor glycemic control with elevated insulin and glucose
normalized in most cases. levels in T1D. Thus, patients with a history of DKA can be
GH, or Mauriac syndrome, was described by Pierre expected to have a higher risk of developing GH. An
Mauriac in patients with T1D as hepatomegaly autopsy study evaluating the glycogen content in the
and elevated liver function tests caused by glycogen liver of patients dying from DKA showed significantly
accumulation in hepatocytes.2,5 The term “glycogenic more glycogen deposition in the liver compared with the
June 2017 Glycogenic Hepatopathy 931

Table 3. Comparison Between Biopsy Proven and Clinically Diagnosed Cases of Glycogenic Hepatopathy

Biopsy-proven glycogenic Clinically diagnosed glycogenic

hepatopathy (n ¼ 20) hepatopathy (n ¼ 16) P valuea

Male, n (%) 4 (20) 4 (25) 1.00

Age at presentation, yb 20.4 (18.6–23.8) 18.4 (16.7–21.5) .13
BMIc 23.1  2.3 24.0  4.6 .23
Percentile height for ageb 46 (26.5–52) 12.5 (5–55.5) .50
Percentile weight for ageb 77.5 (71.5–79.5) 77 (25–86) .93
BMI for ageb 77.5 (71.5–87.5) 82.5 (37–90.5) .93
Clinical features, n (%)
Abdominal pain 14 (70.0) 9 (56.3) .49
Vomiting 5 (25.0) 1 (6.3) .20
Abdominal distention 2 (10.0) 4 (25.0) .37
Splenomegaly 1 (5.0) 1 (6.3) 1.00
Hepatomegaly 12 (60.0) 10 (62.5) 1.00
Age at diagnosis of DMb 9.5 (7–13) 7 (5–11) .16
Duration of DMc 11.9  6.1 11.4  5.1 .80
Episodes of recurrent DKA, n (%) 11 (55.0) 11 (68.8) .50
Imaging findings, n (%)
Splenomegaly 0 (0) 0 (0) —
Hepatomegaly 16 (88.9) 12 (80.0) .64
Laboratory studies
HbA1c, %c 11.4  2.6 10.9  2.2 .54
AST, U/Lb 301 (245.5–775) 150 (69–465.5) .02
ALT, U/Lb 308 (191–386) 166 (76–446) .11
Alkaline phosphatase, U/Lb 170 (127–248) 243 (142–306) .28
GGT, U/Lb 66 (63–552) 117 (66–26) .42
Total bilirubin, mg/dLc 0.5  0.4 0.5  0.3 1.00
Direct bilirubin, mg/dLc 0.2  0.3 0.2  0.1 .56
Serum albuminc 3.9  0.4 4.1  0.7 .20
INRc 0.9  0.1 0.9  0.1 .77
Total cholesterol, mg/dLc 294.5  114.2 239.9  66.7 .28
LDL cholesterol, mg/dLc 111.4  21.6 113.4  47.3 .93
HDL cholesterol, mg/dLc 49.5  27.7 53.5  19.8 .55
Triglycerides, mg/dLb 315 (250–593) 231 (102–500) .11

ALT, alanine transaminase; DM, diabetes mellitus; GGT, g-glutamyl transferase; HDL, high-density lipoprotein cholesterol; INR, international normalized ratio; LDL,
low-density lipoprotein cholesterol.
Kruskal-Wallis for continuous, Fisher exact for categorical.
Median (interquartile range).
Mean  standard deviation.

livers of persons dying from natural causes.6 In one of hepatomegaly were reported of whom nearly half were
the largest series of GH published by Marble5 in 1938, dwarfs. Cushingoid features were frequently seen in
nearly 70% of patients with suspected GH had a history earlier reports of GH in the era before the availability of
of severe DKA. In comparison, a more recent study long-acting insulin, purportedly secondary to prolonged
showed lower rates of frequent DKA of about 30%.4 hypercortisolism during periods of hypoglycemia.2,7 Such
However, none of the previous studies compared the findings are infrequently observed today because of use
rate of DKA with that in T1D without GH. Our current of long-acting insulin and probably the decreased fre-
study showed a higher frequency of DKA episodes in quency of hypoglycemic events in this patient cohort. As
patients with GH compared with T1D with normal described in a more recent study by Torbenson et al,4
transaminases. In addition, patients with GH also had only 1 of the 5 pediatric patients with GH exhibited
greater HbA1c levels than control subjects. This suggests classic features of Mauriac syndrome. In another study,
that poor glycemic control may be associated with the none of the 3 patients with GH had such features.8 In
glycogen accumulation seen in GH. contrast, a recent large study from the United Kingdom
There has been a change in clinical presentation of GH showed that overall these patients appeared to be lighter
over the last century. In the classic description by and shorter than UK reference data.1 However, the
Mauriac in 1931, the patient was a 10 year old with authors did not describe what percentage of patients
poorly controlled T1D with protuberant abdomen, liver presented with “classic Mauriac” features. Our findings
enlargement, dwarfism, delayed puberty, cushingoid are similar to those of Torbenson et al4 and Olsson et al,3
features, and hypercholesterolemia.2 In a subsequent because only 2 of the 12 pediatric patients had growth
large series by Marble,5 60 children with diabetes and retardation and cushingoid features. Thus, it seems that
932 Mukewar et al Clinical Gastroenterology and Hepatology Vol. 15, No. 6

In a previous study by Taskinen,10 glycemic control

improved lipid values, with the cholesterol concentration
decreasing by 0.1 mM (3.87 mg/dL; 2.2%) and the
plasma triglyceride level decreasing by 0.08 mM
(7.1 mg/dL; 8%) for each percentage-point decrease in
the glycohemoglobin in a randomly selected insulin-
dependent diabetes mellitus population.11 As in our
series, patients with T1D with GH had significantly higher
values of HbA1c than patients with T1D without GH; this
could have contributed to higher triglycerides and
cholesterol levels. Furthermore, the higher risk of DKA in
GH may indicate unique alterations in lipolysis that may
account for changes in the lipid tests. Visceral white ad-
ipose tissue secretes adipokines that mediate the
inflammatory response associated with central obesity
and its complications, including nonalcoholic fatty liver
Figure 1. High power view of slide showing classic features
of glycogenic hepatopathy with diffuse pale, swelling of the disease and steatohepatitis.12 It is possible that patients
hepatocytes. with GH have defects in fat biology and adipokines that
may mediate the unique metabolic state and cause liver
injury similar to nonalcoholic liver disease. However, this
currently pediatric patients appear to present with a needs to be investigated further to better understand the
milder phenotype compared with the initial descriptions pathophysiologic mechanisms in patients with GH.
of this syndrome. This study confirms the association of recurrent DKA
More recently, GH has been described in young adults with GH. GH could be considered a surrogate marker of
with T1D.3,4,9 Interestingly, two-thirds of the patients in poor glycemic control. Fortunately, GH does not lead to
our study were T1D adults presenting with transaminase adverse long-term outcomes and the liver enzymes
elevations. Chatila and West9 compared 8 adults with GH eventually normalize in most patients on follow-up. None
with 3 pediatric patients and found no differences in of the patients had advanced hepatic fibrosis. It is
presentation. By contrast, adult patients with GH in our important to note that GH can be seen in young adults
study had higher AST and lower albumin levels than with T1D and most patients do not present with the
pediatric cases. In all patients with elevated amino- classic Mauriac syndrome features, such as dwarfism and
transferase levels, tests for chronic liver disease were cushingoid features. The presentation of adults is quite
negative. Therefore, high index of suspicion for GH and similar to that of children except for higher AST and
negative testing for chronic liver disease were criteria for lower albumin levels. The study describes one of the
GH for our cohort of patients. Interestingly, we observed largest single-center series of GH, with a significant
higher levels of AST than alanine transaminase in our proportion of young adult patients.
study; this has not been reported in prior studies. Further The limitations of the study are its retrospective
studies are warranted to investigate the relevance if any nature and the loss to follow-up of nearly 40% of the
and the mechanistic basis for this observation. patients. Also information on some laboratory tests, such
In people with diabetes, hepatomegaly can occur as lactose dehydrogenase and glutamate dehydrogenase,
secondary to fat or glycogen deposition. Although, fatty was not available in all the patients. Glycogen storage
liver is generally seen in obese adults with type 2 dia- disorders, such as von Gierke disease, may have similar
betes, it is infrequently reported in liver biopsies from biopsy findings. However, the age of presentation,
T1D with GH. In a study by Chatila and West,9 moderate clinical history of T1D, lack of developmental delay, or
steatosis was seen in 25% of biopsies with GH, but none severe lactic acidosis made the diagnosis of von Gierke
had steatohepatitis. Torbenson et al4 noted mild steatosis disease unlikely.
in 14%, mild steatohepatitis in 7%, and mild fibrosis in In conclusion, patients with T1D with GH frequently
14% of cases with GH. In contrast, Fitzpatrick et al1 had a history of recurrent DKA and elevated HbA1c levels.
observed steatohepatitis in 42% and fibrosis in 74% of Growth retardation was uncommon in GH. Compared
these patients. Interestingly, 6% of cases in that study with pediatric patients with GH, adult patients had
had bridging fibrosis. By comparison, in our study 15% similar clinical imaging and laboratory features, except
of GH cases had mild inflammation and 10% had mild for higher AST and lower albumin levels. On follow-up,
fibrosis. None of the patients had bridging fibrosis. On liver enzymes normalized in most patients.
follow-up, most patients had fluctuation of the liver
enzymes, which eventually normalized in most of the References
patients as glycemic control improved. None of the 1. Fitzpatrick E, Cotoi C, Quaglia A, et al. Hepatopathy of Mauriac
patients developed long-term sequelae of liver disease syndrome: a retrospective review from a tertiary liver centre.
secondary to glycogen accumulation. Arch Dis Child 2014;99:354–357.
June 2017 Glycogenic Hepatopathy 933

2. Mauriac P. Gros ventre, hepatomegalie, troubles de la crois- 9. Chatila R, West AB. Hepatomegaly and abnormal liver tests due
sance chez les enfants diabetiques: Traites depuis plusiers to glycogenosis in adults with diabetes. Medicine (Baltimore)
annes par l’insuline. Gaz Hebl Sci Med Bordeaux 1930; 1996;75:327–333.
26:402–410. 10. Taskinen M-R. Quantitative and qualitative lipoprotein abnor-
3. Olsson R, Wesslau C, William-Olsson T, et al. Elevated amino- malities in diabetes mellitus. Diabetes 1992;41:12–17.
transferases and alkaline phosphatases in unstable diabetes 11. Taskinen M-R. 3 Hyperlipidaemia in diabetes. Baillières Clin
mellitus without ketoacidosis or hypoglycemia. J Clin Gastro- Endocrinol Metab 1990;4:743–775.
enterol 1989;11:541–545. 12. Wree A, Schlattjan M, Bechmann LP, et al. Adipocyte cell size,
4. Torbenson M, Chen YY, Brunt E, et al. Glycogenic hepatopathy: free fatty acids and apolipoproteins are associated with
an underrecognized hepatic complication of diabetes mellitus. non-alcoholic liver injury progression in severely obese patients.
Am J Surg Pathol 2006;30:508–513. Metabolism 2014;63:1542–1552.
5. Marble A. Enlargement of the liver in diabetic children. Arch
Intern Med 1938;62:740–750.
6. Vallance Owen J. Liver glycogen in diabetes mellitus. J Clin Reprint requests
Pathol 1952;5:42–53. Address requests for reprints to: Lewis R. Roberts, MD, Mayo Clinic, 200 First
Street SW, Rochester, Minnesota 55905. e-mail: roberts.lewis@mayo.edu; fax:
7. Mandell F, Berenberg W. The Mauriac syndrome. Am J Dis Child (507) 284–0762; and Yogish C. Kudva, MBBS, Mayo Clinic, 200 First Street
1974;127:900–902. SW, Rochester, Minnesota 55905. e-mail: kudva.yogish@mayo.edu; fax: (507)
8. Munns CF, McCrossin RB, Thomsett MJ, et al. Hepatic glyco-
genosis: reversible hepatomegaly in type 1 diabetes. J Paediatr Conflicts of interest
Child Health 2000;36:449–452. The authors disclose no conflicts.