Clinical features of cases of seroconversion of anti-glutamic acid decarboxylase antibody during the clinical course of type 2 diabetes: a nationwide survey in Japan

The pathogenesis of type 1 diabetes is different from that of type 2 diabetes, and anti-glutamic acid decarboxylase antibody (GADA) helps to diagnose autoimmune type 1 diabetes. Some studies reported that GADA seroconversion occurs during the clinical course of type 2 diabetes, leading to development of "type 1 on type 2 diabetes". To clarify the clinical characteristics and triggers of GADA seroconversion, we performed a nationwide questionnaire survey for clinical cases identified by literature search, and obtained information on 38 cases (24 with insulin therapy and 14 without it). The diabetes duration up to determination of GADA seroconversion was significantly longer in the group with insulin therapy than that without it. This finding was particularly noted in insulin-treated non-obese patients with lower serum C-peptide levels. In these patients, insulin therapy could have masked sudden increases in plasma glucose and HbA1c levels, possibly leading to delayed determination of GADA seroconversion. In non-obese patients without insulin therapy, an abrupt rise in the plasma glucose and HbA1c levels was observed at immediately before the determination, a finding which may help to predict GADA seroconversion. From the results of the present survey, we could not determine apparent triggers of GADA seroconversion. Thus, physicians may need to consider the possibility of concurrent type 1 diabetes during the therapeutic course of type 2 diabetes; GADA measurement should be considered when non-obese type 2 diabetic patients not receiving insulin therapy experience unexpected abrupt hyperglycemia and when those receiving insulin therapy show low serum C-peptide levels.

Role of vitamin D in energy and bone metabolism in postmenopausal women with type 2 diabetes mellitus: A 6-month follow-up evaluation

AIMS/INTRODUCTION

Resting energy expenditure was associated with a serum bone turnover marker in postmenopausal women with type 2 diabetes (T2DMPW) in the present cross-sectional study. To clarify the fundamental pathological factor for the correlation of bone metabolism and basal metabolism in type 2 diabetes, a 6-month prospective follow-up study was carried out with supplementation of vitamin D.

MATERIALS AND METHODS

A total of 44 T2DMPW were enrolled. The following factors were evaluated at the beginning and the end of the summer: procollagen type 1 N-terminal propeptide, carboxy-terminal collagen crosslinks-1, intact parathyroid hormone and 25-hydroxyvitamin D (25[OH]D), as well as diabetic complications, body composition, respiratory quotient and resting energy expenditure. A total of 23 patients with low 25(OH)D levels (˂20 ng/mL) were instructed to increase vitamin D levels by lifestyle change. Among them, 15 patients with osteoporosis were also administered alfacalcidol.

RESULTS

Serum 25(OH)D increased in 25 patients and decreased in 19 patients. Patients who did not receive the study intervention at the start tended to have a decreased 2525(OH)D level; therefore, the average 25(OH)D level of all patients was not changed. Changes in resting energy expenditure were positively correlated with those of procollagen type 1 N-terminal propeptide/carboxy-terminal collagen crosslinks-1. Changes in the respiratory quotient correlated with the mean glycated hemoglobin levels; procollagen type 1 N-terminal propeptide levels positively correlated with serum 25(OH)D after the intervention. These correlations were prominent in patients with increased 25(OH)D and those with alfacalcidol supplementation.

CONCLUSIONS

Restoration of vitamin D level might be a prerequisite for a normal correlation between bone and basal metabolism in T2DMPW. Lifestyle intervention for retention of vitamin D level is important even in summer, in T2DMPW.

The importance of nonstop treatment after delivery for pregnant women with type 2 diabetes

BACKGROUND

There are no reports of very long follow-up studies of pregnant women with type 2 diabetes after delivery. Here we describe cases of Japanese women whom we treated for 20 to 50 years after deliveries to investigate the relationship between blood glucose control and diabetic complications.

METHODS

In Japan, the prevalence of type 1 diabetes is very low, and we have very few long-term follow-up cases with type 1 diabetes. Therefore, we chose to describe subjects with type 2 diabetes only. We present data on a total of 80 deliveries, 68 cases, treated by one of us (Y.O.) for more than a 50-year period. They are divided into 4 groups based on duration of treatment after delivery: more than 50 years (1 delivery, 1 patient), 40 to 49 years (13 deliveries, 11 patients), 30 to 39 years (19 deliveries, 16 patients), and 20 to 29 years (47 deliveries, 40 patients). Their present average ages in these 4 groups are 77, 72.4, 65.9, and 55.5 years, respectively. Their average HbA1c levels at last visit, in May 2014, are 8.2%, 7.6%.,7.2%, and 8.3%, respectively.

RESULTS

Despite elevated HbA1c levels, they had relatively few complications: 40% (no retinopathy), 43.8% (simple retinopathy), and 12.5% (treated with photocoagulation); 67.5% (no albuminuria), 26.3% (albuminuria), and 6.3% (treated with renal transplantation or hemodialysis). Therefore, even if glycemic control is not ideal, nonstop treatment of Japanese women for type 2 diabetes after deliveries is effective to prevent diabetic complications.

CONCLUSIONS

Long-term attention to care of diabetes after pregnancy may be preventive of diabetic complications in other populations as well.

Four cases of type 1 diabetes mellitus showing sharp serum transaminase increases and hepatomegaly due to glycogenic hepatopathy

Poorly controlled diabetes mellitus (DM) patients sometimes show serum transaminase elevations due to steatohepatitis. However, we experienced four cases with type 1 DM with sharp elevations in serum transaminases that could not be explained by steatohepatitis alone and showed bright liver. They were diagnosed with glycogenic hepatopathy (GH) clinicopathologically. The four patients had a median age of 22.5 years (range, 19-29 years) and 12.5 (4-15)-year histories of type 1 DM and showed marked increases in serum transaminases (aspartate aminotransferase, 698 U/L [469-2763 U/L]; alanine transaminase, 255 U/L [216-956 U/L]). Diabetes mellitus control was poor and hemoglobin A1c was 12.7% (11-16.5%). Three cases had a past history of diabetic ketoacidosis. Hepatomegaly and hyperdense liver were seen on computed tomography scans. Magnetic resonance imaging showed low intensity in T2-weighted images. The pathological findings revealed pale and swollen hepatocytes and glycogenated nuclei. The architecture of the liver was preserved, and steatosis and fibrosis were mild. The cytoplasm of hepatocytes stained densely positive with periodic acid-Schiff, and the positive staining disappeared after diastase digestion, suggesting glycogen deposition. No other cause of hepatitis was evident, and the diagnosis was GH. Elevated transaminases improved within 1 month with good glycemic control. Transaminase elevations were observed several times in three cases with poor glycemic control. Glycogenic hepatopathy is rare, but extremely high serum elevations of transaminases are important to identify clinically. Despite showing a good clinical course in general, GH sometimes recurs and requires strict glycemic control. Clinicians should be aware of and recognize GH when dealing with uncontrolled DM patients.

Diabetes diagnostic thresholds of the glycated hemoglobin A1c and fasting plasma glucose levels considering the 5-year incidence of retinopathy

AIMS

As retinopathy is used as a defining threshold of diabetes, we assessed the glycated hemoglobin A1c (HbA1c) and fasting plasma glucose (FPG) values associated with an increased risk of 5-year incidence of retinopathy.

METHODS

We studied HbA1c, FPG, and optic fundus findings of 2605 individuals without previously diagnosed diabetes annually during a 5-year period. Retinopathy was examined using non-mydriatic, 45° digital fundus photography. Baseline levels were stratified as <5.3 [34], 5.3-5.6 [34-38], 5.7-6.0 [39-42], 6.1-6.4 [43-47], and ⩾6.5% [48mmol/mol] for HbA1c and <5.0, 5.0-5.5, 5.6-6.0, 6.1-6.9, and ⩾7.0mmol/L for FPG. Cox proportional hazard models were used to analyze hazard ratios (HRs) associated with HbA1c or FPG for incident retinopathy.

RESULTS

During a total of 11845 person-years, we identified 50 (1.9%) cases of incident retinopathy. The adjusted HRs for incident retinopathy associated with a one-standard deviation increase in HbA1c and FPG were 1.2 (95% confidence intervals: 1.1-1.4) and 1.2 (1.1-1.4), respectively. These HRs were significantly higher for a HbA1c level ⩾6.5% (48mmol/mol) (3.4 [1.1-10.2]) or FPG level ⩾7.0mmol/L (3.6 [1.1-11.6]) than for a HbA1c level <5.3% (34mmol/mol) or FPG level <5.0mmol/L.

CONCLUSIONS

A HbA1c value of 6.5% (48mmol/mol) and FPG value of 7.0mmol/L might be proper as diabetes diagnostic thresholds that indicate a high risk of future retinopathy.

Relationship between HLA haplotype and BMI change in Japanese slowly progressive type 1 diabetes patients

We investigated the association between susceptible HLA and BMI change rate from diagnosis of diabetes to diagnosis of slowly progressive type 1 diabetes in Japanese diabetic patients. Subjects with the HLA DRB1*04:05-DQB1*04:01 haplotype were more likely to show weight loss than those without. This HLA haplotype might affect weight loss.

Clinicophysiological outcomes after total pancreatectomy

PURPOSE

Total pancreatectomy (TP) for pancreatic neoplasms is associated with high morbidity and mortality rates. However, with recent advances in surgical techniques and improved postoperative management, the number of cases with clinical indications for TP is increasing. Here, we evaluated the clinical outcomes post-TP.

MATERIALS AND METHODS

Patients (n = 41) who underwent TP between 2004 and 2011 at Tokyo Women's Medical University were retrospectively examined. Pre- and postoperative clinicophysiological data were collected up to 12 months post-TP and then analyzed.

RESULTS

Only glycated hemoglobin (HbA1c), percentage of lymphocytes and hepatic Hounsfield unit level on computed tomography (CT) were significantly different between the preoperative state and at 12 months post-TP, while other clinicophysiological parameters remained unchanged. The quantity of the pancreatic enzyme administered significantly influenced glycemic control at 12 months post-TP (p < 0.05).

CONCLUSIONS

All clinicophysiological parameters except for HbA1c were temporarily decreased after TP but normalized by 12 months. Thus, TP is a feasible surgical approach to treating pancreatic neoplasms with the potential to spread across the entire pancreas when adequately supplemented by synthetic insulin and pancreatic enzymes.

Associations of HbA1c and fasting plasma glucose with incident diabetes: Implications for pre-diabetes thresholds in a Japanese population

AIMS

This study assessed pre-diabetes (pre-DM) cutoffs for HbA1c and fasting plasma glucose (FPG) that were associated with an increased risk of incident DM.

METHODS

We evaluated 2267 non-diabetic Japanese health-check examinees (HbA1c: <6.5% [<48mmol/mol] and FPG: <7.0mmol/L) who were 30-79 years old and were followed-up for 5 years. Incident DM was defined as HbA1c of ≥6.5% (≥48mmol/mol), FPG of ≥7.0mmol/L, or physician-diagnosed DM.

RESULTS

During 11047 person-years, we identified 99 incident DM cases (4.3%). The incidence of DM increased with increasing baseline HbA1c or FPG levels, and the change points (95% confidence intervals) were 5.7% (5.6-5.7%; 39mmol/mol [38-39mmol/mol]) for HbA1c and 5.5mmol/L (5.5-5.6mmol/L) for FPG. The adjusted hazard ratios (HRs) for incident DM per one standard deviation-increase in HbA1c and FPG were 5.5 (4.4-6.8) and 4.0 (3.2-4.8), respectively. The adjusted HRs for incident DM were significantly higher at HbA1c of 5.7-6.4% (39-46mmol/mol) or FPG of 5.5-6.9mmol/L, compared to HbA1c of <5.7% (<39mmol/mol) or FPG of <5.5mmol/L.

CONCLUSION

The lower cut-offs for pre-DM may be 5.7% (39mmol/mol) for HbA1c and 5.5mmol/L for FPG in this Japanese population.

Giant retinal pigment epithelial tear associated with fluid overload due to end-stage diabetic kidney disease

Purpose

To report a case of a giant retinal pigment epithelial (RPE) tear associated with fluid overload in a patient with diabetic macular edema (DME) and kidney disease.

Observations

A 60-year-old man with type 2 diabetes mellitus and end-stage diabetic kidney disease who had gained weight because of fluid overload complained of a visual disturbance in the left eye that had started a few days earlier. The left fundus showed a RPE defect in two temporal quadrants under an extensive serous retinal detachment (SRD) with exacerbation of the original DME. Seven days later, he was admitted for severe edema and pleural effusion. No overt signs of congestive heart failure were noted. On admission, the RPE defect had markedly widened to involve the macula. Spectral-domain optical coherence tomography images showed substantial intraretinal fluid and an extensive SRD with rolled edges of the retinal pigment epithelium, which led to the diagnosis of a RPE tear. The fluid under the SRD was absorbed on the fourth hospital day and the substantial intraretinal fluid resolved on the eleventh day after systemic management of fluid overload only without ophthalmic treatment. The change in the appearance of the RPE area was minimal and the visual field defect remained even after 6 months.

Conclusions and importance

A RPE tear may develop in association with fluid overload in patients with diabetes.

Relationships between vitreous levels of soluble receptor for advanced glycation end products (sRAGE) and renal function in patients with diabetic retinopathy

PURPOSE

We investigated the relationship between vitreous levels of soluble receptor for advanced glycation end products (sRAGE) and vascular endothelial growth factor (VEGF) and renal function, and correlations between vitreous sRAGE levels and proliferative diabetic retinopathy (PDR) activity.

METHODS

We examined 33 eyes from 33 patients with diabetes mellitus who underwent a vitrectomy (eight patients in the non-PDR [NPDR] group and 25 in the PDR group). Serum creatinine levels and estimated glomerular filtration rate (eGFR) were measured and classified according to the chronic kidney disease (CKD)-staging method. Enzyme-linked immunosorbent assay (ELISA) was performed to quantify vitreous sRAGE and VEGF levels.

RESULTS

Vitreous sRAGE levels were significantly higher in PDR group compared to NPDR group (p = 0.00003). Vitreous sRAGE levels were significantly higher in patients with CKD stage 5 (end-stage renal failure or hemodialysis) than in patients with CKD stage 1 or 2 (p < 0.01) and 3 or 4 (p < 0.05), and were significantly correlated with eGFR (r = - 0.490, p = 0.007) and creatinine levels (r = 0.484, p = 0.006). Within the PDR group, patients with low (<27 pg/mL) sRAGE levels required repeat vitreous surgeries for early postoperative vitreous hemorrhage significantly more frequently than those with high (≥27 pg/mL) sRAGE levels (p = 0.0067).

CONCLUSIONS

Vitreous sRAGE levels were significantly correlated with renal function, and low vitreous sRAGE levels in patients with PDR were associated with postoperative vitreous hemorrhage. Vitreous sRAGE may be a useful biomarker for renal dysfunction associated with diabetic retinopathy.

Brachial-ankle pulse wave velocity, but not ankle-brachial index, predicts all-cause mortality in patients with diabetes after lower extremity amputation

We examined whether brachial‐ankle pulse wave velocity (baPWV) and ankle‐brachial pressure index (ABI) are predictors for mortality in diabetic patients after lower extremity amputation. This was an observational historical cohort study of 102 Japanese diabetic patients after first non‐traumatic lower extremity amputation, with a mean age of 63 years (standard deviation 12 years). The end‐point was all‐cause mortality. During the mean follow‐up period of 3.3 years, 44 patients reached the end‐point. In both univariate and multivariate analyses, baPWV (m/s) (hazard ratio [HR] 1.05 and 1.04, both P < 0.01, respectively), but not ABI (HR 0.38 and 0.89, P = 0.08 and 0.86, respectively), was a significant predictor for the end‐point. When baPWV (above or below the median [21.8 m/s]) and ABI (normal [0.9–1.4] or not) were analyzed as categorical variables, the results were similar. In conclusion, baPWV, but not ABI, might be a predictor for all‐cause mortality in diabetic patients after lower extremity amputation.

Size effect of engineered islets prepared using microfabricated wells on islet cell function and arrangement

Pancreatic islets are heterogeneous clusters mainly composed of α and β cells, and these clusters range in diameter from 50 to several hundred micrometers. Native small islets are known to have a higher insulin secretion ability in vitro and to provide better transplantation outcomes when compared with large islets. In this study, we prepared microengineered pseudo-islets from dispersed rat islet cells using precisely-fabricated agarose gel-based microwells with different diameters (100, 300, or 500 μm) to investigate the function and survival of islet cell aggregates with well-controlled sizes. We observed that dead cells were rarely present in the small pseudo-islets with an average diameter of ∼60 μm prepared using 100 μm microwells. In contrast, we observed more dead cells in the larger pseudo-islets prepared using 300 and 500 μm microwells. The relative amount of hypoxic cells was significantly low in the small pseudo-islets whereas a hypoxic condition was present in the core region of the larger pseudo-islets. In addition, we found that the small-sized pseudo-islets reconstituted the in vivo-tissue like arrangement of the α and β cells, and restored the high insulin secretory capacity in response to high glucose. These results clearly suggest that precise size control of pseudo-islets is essential for maintaining islet cell function and survival in vitro. The small-sized pseudo-islets may be advantageous for providing a better therapeutic approach for treating type 1 diabetes mellitus via islet reorganization and transplantation.

Clinical and Genetic Characteristics of Non-Insulin-Requiring Glutamic Acid Decarboxylase (GAD) Autoantibody-Positive Diabetes: A Nationwide Survey in Japan

Aims

Glutamic acid decarboxylase autoantibodies (GADAb) differentiate slowly progressive insulin-dependent (type 1) diabetes mellitus (SPIDDM) from phenotypic type 2 diabetes, but many GADAb-positive patients with diabetes do not progress to insulin-requiring diabetes. To characterize GADAb-positive patients with adult-onset diabetes who do not require insulin therapy for >5 years (NIR-SPIDDM), we conducted a nationwide cross-sectional survey in Japan.

Methods

We collected 82 GADAb-positive patients who did not require insulin therapy for >5 years (NIR-SPIDDM) and compared them with 63 patients with insulin-requiring SPIDDM (IR-SPIDDM). Clinical and biochemical characteristics, HLA-DRB1-DQB1 haplotypes, and predictive markers for progression to insulin therapy were investigated.

Results

Compared with the IR-SPIDDM group, the NIR-SPIDDM patients showed later diabetes onset, higher body mass index, longer duration before diagnosis, and less frequent hyperglycemic symptoms at onset. In addition, C-peptide, LDL-cholesterol, and TG were significantly higher in the NIR-SPIDDM compared to IR-SPIDDM patients. The NIR-SPIDDM group had lower frequency of susceptible HLA-DRB1*04:05-DQB1*04:01 and a higher frequency of resistant HLA-DRB1*15:01-DQB1*06:02 haplotype compared to IR-SPIDDM. A multivariable analysis showed that age at diabetes onset (OR = 0.82), duration before diagnosis of GADAb-positive diabetes (OR = 0.82), higher GADAb level (≥10.0 U/ml) (OR = 20.41), and fasting C-peptide at diagnosis (OR = 0.07) were independent predictive markers for progression to insulin-requiring diabetes. An ROC curve analysis showed that the optimal cut-off points for discriminating two groups was the GADAb level of 13.6 U/ml, age of diabetes onset of 47 years, duration before diagnosis of 5 years, and fasting C-peptide of 0.65 ng/ml.

Conclusions

Clinical, biochemical and genetic characteristics of patients with NIR-SPIDDM are different from those of IR-SPIDDM patients. Age of diabetes onset, duration before GADAb-positivity, GADAb level, and fasting C-peptide at diagnosis must be carefully considered in planning prevention trials for SPIDDM.

The relationship between depressive symptoms and diabetic complications in elderly patients with diabetes: Analysis using the Diabetes Study from the Center of Tokyo Women's Medical University (DIACET)

AIMS

To investigate the association between likelihood or severity of depression and symptoms associated with diabetic complications in elderly Japanese patients with diabetes.

METHODS

This single-center cross-sectional study included 4283 patients with diabetes, 65 years and older (mean age was 73 ± 6 years, 38.7% were women, 3.9% had type 1 diabetes). Participants completed a self-administered questionnaire including items on subjective symptoms associated with diabetic microangiopathy, frequency of clinical visits due to vascular diseases (heart diseases, stroke, or gangrene), hospitalization, and the Patient Health Questionnaire-9 (PHQ-9), a simple but reliable measure of depression. The associations between severity of depression and diabetic complications were examined using logistic regression analysis.

RESULTS

According to the PHQ-9 scores, patients were classified into the following 3 categories: 0-4 points (n=2975); 5-9 points (n=842); and 10 or more points (n=466). Higher PHQ-9 scores were associated with increased odds ratios for retinopathy, symptoms related to peripheral polyneuropathy and autonomic neuropathy, and end-stage renal disease requiring dialysis after adjustment for age, gender, smoking status, and HbA1c (all p<0.05).

CONCLUSIONS

Significant relationships were found between depression severity and chronic diabetic complications among elderly Japanese patients with diabetes.

Recurrence of diabetic kidney disease in a type 1 diabetic patient after kidney transplantation

Post-transplant hyperglycaemia of diabetic patients may cause recurrent diabetic kidney disease (DKD) in kidney allografts. We report a patient with slowly progressive DKD with calcineurin inhibitor toxicity (CNI) toxicity after the kidney transplantation. A 28-year-old female with type 1 diabetes mellitus underwent successful kidney transplantation from her mother in April 2003, and the kidney graft survived for more than 10 years. She was treated with combined immunosuppressive therapy consisting of cyclosporine and mycophenolate mofetil. After transplantation, she continued to take insulin injection four times per day, but her glycosylated haemoglobin (HbA1c) was above 10%. Protocol allograft kidney biopsies performed 5 and 10 years after transplantation revealed the recurrence of slowly progressive diabetic kidney disease. In addition, arteriolar hyalinosis partly associated with calcineurin inhibitor toxicity (CNI) was detected with progression. Post-transplant hyperglycaemia causes recurrent diabetic kidney disease (DKD) in kidney allografts, but its progression is usually slow. For long-term management, it is important to prevent the progression of the calcineurin inhibitor arteriolopathy, as well as maintain favourable glycaemic control.

Insulin Autoimmune Syndrome Accompanied by Multiple Myeloma

In 1981, a 48-year old man was diagnosed with insulin autoimmune syndrome. In 2005, he experienced a substantial increase in his monoclonal insulin antibody levels; in 2006 and 2007, serum monoclonal gammopathy and an 11% marrow plasmacyte ratio were confirmed. In 2012, asymptomatic multiple myeloma was diagnosed based on an increased γ-globulin fraction and serum M-protein (IgG) levels. The insulin antibody binding rate was 75.4% in 2005 and 78.8% in 2012. In 2012, he was hospitalized for ileus and died. Autopsy identified multiple myeloma and no endocrinological tumors in the pancreas.

Improved incidence of end-stage renal disease of type 1 diabetes in Japan, from a hospital-based survey

OBJECTIVE

To explore whether the incidence of end-stage renal disease (ESRD) in type 1 diabetes (T1DM) was lowered over time, and how the baseline characteristics and risk factor management during follow-up were associated with the incident ESRD.

RESEARCH DESIGN AND METHODS

An observational cohort study was performed in 1014 patients with T1DM diagnosed from 1961 to 1999, who were admitted to the diabetes center. The incidence of ESRD up to 2010 and the effect of risk factors, including annual mean glycated haemoglobin (HbA1c) and blood pressure, were investigated.

RESULTS

During a mean follow-up of 19.3 years, with 88.3% follow-up rate, the incidence of ESRD was significantly lower in T1DM diagnosed in 1985-1999 than in 1961-1984 (0.8 vs 5.0 per 1000 person-years, p<0.0001), which was not precluded by preceding death. Multivariate Cox regression analysis indicated that the former group (vs the latter) was associated with a significantly reduced risk of ESRD independent of baseline variables of age, duration and gender (p<0.01). The continuous variable of year of T1DM diagnosis remained significant after adjustment for the above variables plus baseline proteinuria and retinopathy (p=0.02). Time-dependent Cox regression analysis indicated that ESRD was associated with annual mean HbA1c (p<0.01), systolic blood pressure (p<0.001) and baseline proteinuria (p<0.001), followed by continuous variable of year of T1DM diagnosis (p=0.09).

CONCLUSIONS

Our data indicate that incidence of ESRD is decreasing over time, coinciding with enhanced glycemic and blood pressure controls. The incidence of ESRD in recently diagnosed T1DM appears to be much lower than previously reported ESRD incidence.

Relationship between diabetic nephropathy and depression: a cross-sectional analysis using the Diabetes Study from the Center of Tokyo Women's Medical University (DIACET)

OBJECTIVE

We conducted this cross-sectional study to investigate the relationship between stage of diabetic nephropathy and likelihood or severity of depression in patients with diabetes.

RESEARCH DESIGN AND METHODS

We studied 2212 patients with diabetes (mean age 60.9 years; 928 women; 1838 patients with type 2 diabetes). Presence and severity of depression was examined using the Patient Health Questionnaire-9 (PHQ-9). Patients were classified into 5 stages of nephropathy, according to albuminuria and estimated glomerular filtration rate (eGFR); patients in stage 5 undergoing dialysis and kidney transplantation were analyzed separately (stages 5D and 5T). The relationship between stage of nephropathy and depression was examined using analysis of covariance and multivariate logistic regression analysis.

RESULTS

Both least square mean PHQ-9 scores and prevalence of patients with PHQ-9 scores ≥5 points (mild depression) and ≥10 points (moderate or severe depression) increased from stage 1 to 5D, and then declined in stage 5T. Multivariate ORs for mild or greater depression increased in patients in stages 3, 4, and 5D in reference to those in stage 1, which declined in patients in stage 5T. Albuminuria was significantly, but eGFR was not, associated with higher PHQ-9 scores and the PHQ-9 scores ≥5 or ≥10 after adjustment for clinical findings.

CONCLUSIONS

In patients with diabetes, progression of nephropathy is likely to be associated with increased risk and severity of depression, which may be reduced after successful kidney transplantation. Albuminuria may be more strongly associated with depression than eGFR.

Differences in risk factors for the onset of albuminuria and decrease in glomerular filtration rate in people with Type 2 diabetes mellitus: implications for the pathogenesis of diabetic kidney disease

AIMS

To determine differences in predictors of albuminuria and decreased estimated GFR in Japanese people with Type 2 diabetes mellitus without chronic kidney disease.

METHODS

This single-centre observational cohort study involved 1802 Japanese people with Type 2 diabetes with normoalbuminuria and estimated GFR ≥ 60 ml/min/1.73 m(2) (740 women; mean ± sd age 58 ± 12 years). Two separate outcomes were evaluated: onset of albuminuria ( ≥ 30 mg/g creatinine, albuminuria cohort; n = 1655) and decrease in estimated GFR ( < 60 ml/min/1.73 m(2) ; estimated GFR cohort; n = 1777). A Cox proportional hazards model was used to identify significant predictors for each outcome.

RESULTS

During a median follow-up period of 6.9 years for the albuminuria cohort and 8.0 years for the estimated GFR cohort, 181 and 316 individuals reached the respective outcome. The 5-year cumulative incidence of albuminuria was 8.3%, and that of decreased estimated GFR was 10.4%. In the multivariate Cox model, greater urinary albumin-to-creatinine ratio, presence of diabetic retinopathy and higher HbA1c levels were associated with both outcomes. Unique risk factors for onset of albuminuria were male gender and higher uric acid levels; those for decreased estimated GFR were older age, greater systolic blood pressure, and lower baseline estimated GFR and HDL cholesterol levels.

CONCLUSIONS

Identification of both common and distinct predictive factors for onset of albuminuria and decreased estimated GFR support the hypothesis that both common and distinct pathophysiological mechanisms are involved in the development of these two manifestations of chronic kidney disease in diabetes.

Changes in the prognosis of Japanese patients who developed type 1 diabetes before the age of 30 years

AIMS

We investigated changes in vital prognosis according to the year at diagnosis of type 1 diabetes mellitus (T1DM) in a hospital-based survey.

METHODS

Of 1054 Japanese subjects diagnosed as T1DM between 1952 and 1999 before the age of 30 and consulted the diabetes center between 1962 and 1999, the survival status up to 2010 or 20 years of follow-up was investigated. Subjects were divided by the year at diagnosis of T1DM: before 1979 (Group A: n = 359), 1980 to 1989 (Group B: n = 400), and 1990 to 1999 (Group C: n = 295). The mortality (/100,000 person years) and standardized mortality ratio (SMR) were calculated, and the effect of year at diagnosis of T1DM was explored by the Cox proportional hazard model.

RESULTS

The survival status was confirmed in 90.0%. The mortality rate (95%CI) and age and sex adjusted SMR (95%CI) were 457 (288-627) and 3.0 (1.9-4.2) in Group A, 265 (143-387) and 2.2 (1.2-3.2) in Group B, and 144 (29-259) and 1.6 (0.3-2.9) in Group C, respectively. The cumulative survival rate was significantly different according to the year at diagnosis of T1DM (p = 0.0239). Cox's proportional hazard model revealed that Groups B and C had significantly lower risks of death than Group A after adjustment for gender and age at diagnosis of T1DM (HR 0.48 [95%CI 0.26-0.87] for Group B and HR 0.25 [95%CI 0.09-0.60] for Group C).

CONCLUSION

This study indicated that vital prognosis is improving according to the year at diagnosis of T1DM and suggested the need of a nationwide survey.