Non alcoholic fatty liver disease (NAFLD) is a condition where there is excess accumulation of triglycerides in the liver in absence of excess alcohol consumption usually defined as less than 20 g of ethanol per day.1 It ranges from simple steatosis to non alcoholic steatohepatitis (NASH), which can progress to fibrosis, cirrhosis, and hepatocellular carcinoma (HCC).2 NAFLD is more common in men than in women. Thus it has been suggested that sex steroids do have a role in the development of NAFLD.3

The diagnosis of NAFLD requires evidence of hepatic steatosis (on imaging or histology) in the absence of secondary causes of steatosis or other liver disease like excessive alcohol intake, hepatitis C, Wilson disease, and hepatotoxic medications.

Male hypogonadism is a condition in which the body does not produce enough of testosterone. It plays a key role in masculine growth and development during puberty.4.

NAFLD is considered to be associated with increased visceral adipose tissue (VAT), insulin resistance and dyslipidemia. In males, testosterone deficiency is associated with increased VAT and insulin resistance. Testosterone replacement found to reduce fat deposition.5

The majority of NAFLD will not progress, but a minority of patient will develop cirrhosis of liver and its complications. The gold standard for diagnosing and staging NAFLD and assessment of fibrosis is liver biopsy (LB). But it has sample error issues and subjectivity in the interpretation, apart from other risk of complications.6

Liver biopsy to all patients of NAFLD is not practical. It should be advised in patients with diabetes, metabolic syndrome, raised liver enzymes or obesity. So an easy, rapid, accurate, and noninvasive screening test is required for the small fraction of NAFLD patients who needed liver biopsy. Fibroscan (transient elastography) measures liver stiffness through the estimation of velocity of propagation of a shear wave through liver tissue. The values depend on the viscoelastic properties of the liver.7

Therefore, the present study was conducted to assess the correlation between NAFLD patients having liver stiffness measured by Fibroscan and testosterone level in male population.

After approval of the ethics committee of Calcutta National Medical College & Hospital and permission of West Bengal University of Health Sciences, Kolkata, the present institute based observational cross sectional study was carried out under the department of General Medicine, Calcutta National Medical College, Kolkata between January 2018 to March 2019.

Study Population: Patients of NAFLD attending MOPD or endocrinology OPD.

Sample Size: 139 patients of NAFLD who were attended MOPD or endocrinology OPD of Calcutta national Medical College and Hospital and fulfilled the inclusion criteria were included in the study.

Inclusion Criteria: Patients with Non alcoholic fatty liver disease (Age between 30-50 years).

Exclusion Criteria: Alcoholic, Type 2 Diabetes Mellitus, HIV, CLD, Malignancy, Malnourished, Acute illness, CKD, any other chronic disease.

Parameters like Fibroscan of liver, Basal metabolic index (BMI), HB%, TLC, ESR, LFT, USG- upper abdomen, Lipid profile total testosterone, LH, FSH were analyzed.

Statistical analysis: For statistical analysis data were entered into a Microsoft excel spreadsheet and then analyzed by SPSS (version 20.0; SPSS Inc., Chicago, IL, USA). Data had been summarized as mean and standard deviation for numerical variables and count and percentages for categorical variables. Correlation was calculated by Pearson correlation analysis. The Pearson product- moment correlation coefficient was a measure of the linear dependence between two variables X and Y. Once a t value is determined, a p-value was found using a table of values from Student's t-distribution. If the calculated p-value is below the threshold chosen for statistical significance (usually the 0.10, the 0.05, or 0.01 level), then the null hypothesis is rejected in favour of the alternative hypothesis. P-value ≤ 0.05 was considered for statistically significant.

Ethical considerations: Study was initiated after obtaining the informed consents from the participants and ethical clearance from the institutional ethical committee.

Table-1: Distribution of participants according to age and BMI. (n – 139)

Above table shows distribution of age among study population. The maximum value for age was 51, minimum value 30, mean 36.31 and standard deviation was 5.4. Maximum value of Body Mass Index (BMI) Was 29.9, minimum value 19.7, mean 24.06, standard deviation 2.43 (Table 1) 

Table-2: Table showing comparison between the age, BMI, urea and creatinine of normal and hypogonadal male

The above table shows the comparison of mean ages, BMI, urea and creatinine between the hypogonal and normal NAFLD patients. Independent samples T test was done. There is no difference in mean age between hypogonadal and eugonadal NAFLD patients (p value= 0.565). There is no difference in mean BMI between hypogonadal and eugonadal NAFLD patients (p value= 0.431). There is no difference in mean serum Urea between hypogonadal and eugonadal NAFLD patients (p value= 0.135). There is no difference in mean serum creatinine between hypogonadal and eugonadal NAFLD patients (p value= 0.836). (Table 2)

Table-3: Table showing comparison between the serum fasting blood sugar (FBS), serum post prandial blood sugar (PPBS) and Fibroscan of Liver of normal and hypogonadal male.

The above table shows the comparison between serum fasting blood sugar (FBS), serum post prandial blood sugar (PPBS) and Fibroscan of Liver of normal and hypogonadal male. Independent samples T test was done. There is no difference in mean FBS between hypogonadal and eugonadal NAFLD patients (p value= 0.236). There is no difference in mean PPBS between hypogonadal and eugonadal NAFLD patients (p value= 0.268). There is significant relation in between fibroscan of liver and serum total testosterone level among hypogonadal and eugonadal NAFLD patients (p value= 0.001). (Table 3)

Table 4: Table showing correlation between testosterone level and Fibroscan of Liver value.

Table showing a negative correlation between serum testosterone level and Fibroscan of Liver value in NAFLD patients. (Table 4)

Non alcoholic fatty liver disease (NAFLD) is the most common chronic liver disease in many parts of the world. The subjects of NAFLD deny hazardous level of alcohol consumption (defined as greater than one drink per day in women and two drink per day in men). NAFLD encompasses a spectrum of liver pathology with different clinical prognosis. Accumulation of triglyceride within the hepatocytes (hepatic steatosis) is the most common benign clinical presentation. On the other hand cirrhosis and primary liver cancer are the extreme presentation of NAFLD. Though the development of cirrhosis is extremely low in hepatic steatosis, the risk increases when it is complicated with histologically conspicuous hepatocyte death and inflammation i.e. non alcoholic steatohepatitis (NASH). In the year 1980, Ludwig and colleagues from the Mayo clinic coined the term non alcoholic steatohepatitis (NASH) to describe a form of liver disease observed in middle aged patients with abnormal liver function test with no history of alcohol abuse.

NAFLD is the hepatic component of the metabolic syndrome (MetS). It is associated with increased visceral adipose tissue (VAT), insulin resistance, and dyslipidemia. In many studies have shown that testosterone deficiency is also associated with increased VAT and insulin resistance in males and hyperandrogenemia is associated with increased risk of insulin resistance and VAT in females.8

In men, it has seen that testosterone deficiency is associated with an increased accumulation of visceral adipose tissue and insulin resistance. These are the factors contributing to the metabolic syndrome. Higher levels of testosterone are associated with decreased central obesity. it has seen that testosterone replacement causes reduce insulin resistance in hypogonadal men with type 2 diabetes and/or MetS and also reduce fat accumulation.9

In our study we investigated 139 patients of non alcoholic fatty liver disease who visited our general medicine OPD and endocrine OPD by detailed history, through clinical examination, biochemical examination and as well as ultrasonography and fibroscan of liver. After application of inclusion and exclusion criteria we included them in the final analysis. In this study we want to assess the correlation between NAFLD patients having liver stiffness measured by fibroscan and testosterone level in male population. There are several studies showing values of testosterone ranging from 300- 400 ng/ml as cut off for hypogonadism2.5.10 but in this study we have taken 350 ng/ml. categorical variables are expressed as number of subjects and percentage of subjects having serum testosterone level >=350 ng/ml and <350 ng/ml and compared across the groups using Pearson’s Chi Square test for independence of attribute. Variables are expressed as mean, median and standard deviation and compared across the groups. The statistical software SPSS version 20 has been used for analysis. An alpha level of 5% has been taken i.e. if any p value is less than 0.05 it has been considered as significant.

In the present study maximum age of the population found to be 51 and minimum is 30 with mean age is 36.31. Maximum population is the middle aged. It has been found that there is statistically insignificant relationship in mean age between hypogonadal and eugonadal persons. Similar type of study seen in study by Hübscher SG.10

In our study the BMI of the population has a maximum value of 29.9, minimum value of 19.7 with mean value of 24.06. it has been found that there is statistically insignificant relation mean BMI between hypogonadal and eugonadal NAFLD patients. This is against the value seen in Farid Saad et al.11 This may be due to small sample size of our study population.

In this study we assessed the correlation between renal parameters measured by serum urea and creatinine and hypogonadism. We have excluded chronic kidney disease patients from the study population. The maximum value of serum urea is measured as 66, minimum value is found as 13, mean is 32.19. Maximum and minimum value for serum creatinine are 1.1 and 0.12 respectively, mean is measured as 0.64. we found no significant relation between renal parameters measured by serum urea and creatinine and hypogonadism as the p value found to be 0.135. this is found to be against in the conducted by P Paschos and K Paletas.12 This may be due to small sample size of our study population.

In the present study the correlation between glycaemic parameters and hypogonadism has been studied. The maximum value of fasting blood glucose in our population of study is 143, minimum is 85, mean calculated as 109.14. The post prandial blood glucose shows 212 as maximum value, 116 as minimum value, 151.99 is the calculated mean. It has also been seen that there is statistically insignificant relation between glycaemic parameters (Fasting blood sugar and post prandial blood sugar) and hypogonadism as p value are 0.236 and 0.268 respectively in both the cases. Similar type of results found in study by Alita Mishra and Zobair M Younossi13 and Bharat K Puchakayala et al.14

In our study we have measured liver stiffness by non invasive method like fibroscan of liver. Liver biopsy as the confirmatory test for liver stiffness was not done due to its complications. It has found that the maximum value of fibroscan of liver is 14.3 kpa, the minimum value is 4.2, mean is 6.61 among study population. We also found that there is a statistically significant relation between liver stiffness measured by fibroscan and hypogonadism measured by serum testosterone level as the p value found to be 0.001 (i.e. <0.05). Similar type of study done by Avni Mody et al. showed that there was an association between lower levels of total testosterone and the development of NAFLD. In our study NAFLD patients was diagnosed by Fibroscan and testosterone level measured in male population. Here also we got statistically significant relation between NAFLD and hypogonadism in male subjects.

In this study we do not found any significant relation between hypogonadism and other parameters like age, BMI, renal parameters, glycemic parameters which is found in some previous studies. So we conclude that fibroscan of liver could be done to assess the liver stiffness in non alcoholic fatty liver disease patients who also have hypogonadism. So that we can assess the progression of liver stiffness by non invasive methods and treat hypogonadism accordingly.

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