title: Diabetes increases the risk of acute hepatic failure.
abstract: OBJECTIVE
  It is unclear whether patients with diabetes are at an increased risk of developing acute liver failure (ALF). We performed a large cohort study to examine the occurrence of ALF by using the databases of the Department of Veterans Affairs.
  
  
  METHODS
  We identified all patients with a hospital discharge diagnosis of diabetes (ICD-9 codes: 250 [1-9][0-4]) from 1985 to 1990 and randomly assigned patients without diabetes for comparison (3:1 ratio). We excluded patients with concomitant liver disease as far back as 1980. After excluding the first year of follow-up, the remaining patients were observed through 2000 for the occurrence of ALF (ICD-9 570). The cumulative risk and the relative risk of ALF were determined by Kaplan-Meier and Cox Proportional Hazard survival analysis, respectively.
  
  
  RESULTS
  We included 173,643 patients with diabetes and 650,620 patients without diabetes. Patients with diabetes were significantly older (62 vs. 54 years) and were less likely to be white (28% vs. 24%). The cumulative risk of ALF was significantly higher among patients with diabetes (incidence rate, 2.31 per 10,000 vs. 1.44 per 10,000 person-years; P < 0.0001). In the Cox proportional hazard model, diabetes was associated with a relative risk of 1.44 (95% CI, 1.26-1.63; P < 0.0001) for ALF while controlling for comorbidity index, age, sex, ethnicity, and period of service. This risk remained significantly increased after excluding patients with liver disease or viral hepatitis recorded during follow-up or those with ALF recorded after the introduction of troglitazone (relative risk = 1.40; P < 0.0001).
  
  
  CONCLUSIONS
  Diabetes increases the risk of ALF. The increase in ALF is independent of recognized underlying chronic liver disease or viral hepatitis.
authors.affiliation: Section of Gastroenterology, Houston Department of Veterans Affairs Medical Center, Texas 77030, USA. hasheme@bcm.tmc.edu
authors.forename: Hashem B
authors.initials: HB
authors.lastname: El-Serag
authors.forename: James E
authors.initials: JE
authors.lastname: Everhart
mesh_terms: D000208:Acute Disease; D000368:Aged; D016022:Case-Control Studies; D048909:Diabetes Complications; D005260:Female; D006787:Hospitals, Veterans; D006801:Humans; D017093:Liver Failure / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis