Follow-up survey of all participants at the first and second juvenile diabetes summer camp in Japan in 1963 and 1964

This report documents the status of all 10 participants in the first (1963) and second (1964) summer camp in Japan as of 31 December 2008. The eight living participants continue to function as adults in society without hemodialysis.

Comparison of the prevalence of chronic kidney disease in Japanese patients with Type 1 and Type 2 diabetes

AIMS

The relationship between type of diabetes and risk of chronic kidney disease has not been studied in detail. We conducted this study to determine the prevalence of chronic kidney disease in Japanese adults with diabetes, with a particular emphasis on the comparison of Type 1 and Type 2 diabetes.

METHODS

We studied 3,575 Japanese patients with diabetes, 504 with Type 1 (mean +/- SD age 38 +/- 13 years; 350 women and 154 men) and 3071 with Type 2 diabetes (60 +/- 13 years; 1187 women and 1884 men). Prevalence rates of albuminuria [urinary albumin/creatinine ratio (> or = 30 mg/g], decreased estimated glomerular filtration rate (eGFR < 60 ml/min/1.73 m(2)) and chronic kidney disease (defined as albuminuria and/or decreased eGFR) were compared between the two diabetic groups.

RESULTS

The prevalence of albuminuria was higher in Type 2 than Type 1 diabetic patients by both Fisher's exact test (36.1 vs. 15.9%, P < 0.001) and multivariate logistic regression analysis [adjusted odds ratio (OR) = 1.482, 95% confidence interval (CI) = 1.050-2.091, P = 0.025]. The prevalence of decreased eGFR was also higher in Type 2 diabetic patients (25.2 vs. 7.9%, P < 0.001); however, the statistical significance disappeared after adjusting for covariates, including age (OR = 0.656, 95% CI = 0.395-1.088, P = 0.102). The prevalence of chronic kidney disease was also higher in Type 2 diabetic patients (46.0 vs. 19.1%, P < 0.001); however, the statistical significance disappeared in the multivariate analysis. CONCLUSIONS Type 2 diabetic patients are more than twice as likely as Type 1 diabetic patients to have chronic kidney disease due to an age-independent higher prevalence of albuminuria and age-dependent decreased eGFR.

Incidence and development of diabetic microangiopathy of fulminant type 1 diabetes--comparison with non-fulminant type 1 diabetes

OBJECTIVE

The data from the Fulminant Type 1 Diabetes Committee suggested that patients with fulminant type 1 diabetes are a subgroup at high risk for diabetic microangiopathy in the first 5 years after diagnosis associated with the lack of endogenous insulin secretion from the onset of diabetes. The aim of this study was to assess the development of microangiopathy in patients with fulminant type 1 diabetes followed in our diabetes center.

METHODS

Sixteen patients with fulminant type 1 diabetes and 60 age-matched patients with non-fulminant type 1 diabetes were recruited as subjects. The existence or lack of diabetic retinopathy and nephropathy, average HbA(1C) level, serum C-peptide level, average blood pressure, insulin level, whether or not they were taking antihypertensive agents, and smoking history were investigated retrospectively based on medical records.

RESULTS

The 5-year incidence of microangiopathy was lower in fulminant than in non-fulminant type 1 diabetes patients; retinopathy cases occurred in 0% vs. 8.3% of patients, and nephropathy occurred in 0% vs. 1.7% of patients. The 10-year incidence of retinopathy was 0% vs. 24.1%, and that of nephropathy was 11.1% vs. 3.4%. The cumulative incidence of microangiopathy did not differ between the fulminant and non-fulminant type 1 diabetes patients. Mean HbA(1C) levels and systolic blood pressure were significantly lower in fulminant type 1 diabetes patients.

CONCLUSION

No difference between the patients visiting the center with fulminant type 1 diabetes and those with non-fulminant type 1 diabetes was observed in the development of microangiopathy complications.

Drug-induced insulin autoimmune syndrome

Although insulin autoimmune syndrome (IAS) was found to be strongly related with methimazole, rapidly increasing numbers of cases with alpha lipoic acid-induced IAS have been confirmed to be reported since 2003. As alpha lipoic acid has gained popularity as a supplement for dieting and anti-aging, a warning should be issued.

Uniformity in clinical and HLA-DR status regardless of age and gender within fulminant type 1 diabetes

To clarify the detailed clinical features and HLA subtype in the patients with fulminant type 1 diabetes, we investigated consecutive 250 case records registered to the committee of the Japan Diabetes Society between 2000/7/15 and 2006/6/30. After the classification with age at onset or gender, clinical data and HLA DR were evaluated. As a result, the prevalence of male patients, BMI, HbA(1c) and ALT levels at the onset increased significantly according to the elder quartile, but no other data showed any significant difference. Only age at onset and blood glucose level were significantly higher in male patients than in female patients without pregnancy by multivariate analysis. The distribution of HLA DR was not different in any subtype by gender or age at onset. Our present study revealed common feature in clinical and HLA-DR status regardless of age and gender within fulminant type 1 diabetes except pregnant women.

Time-course changes in clinical features of early-onset Japanese type 1 and type 2 diabetes: TWMU hospital-based study

Using a database of patients with type 1 (n=1675) and type 2 (n=2259) diabetes diagnosed before the age of 30 years at the Diabetes Center, Tokyo Women's Medical University (TWMU), in which such Japanese patients have been registered at the time of first visit since the 1960s, we performed a hospital-based study over the last 40 years to clarify time-course changes in clinical features of type 1 and type 2 diabetes diagnosed before the age of 30 years. Type 2 diabetes had a male dominancy, while there has been a female dominancy in patients with type 1 diabetes as in previous reports of Japanese childhood-onset type 1 diabetes. Such dominances had been continued over the last 40 years. The number of patients with type 2 diabetes and with a past history of obesity increased with time. The age at which type 2 diabetes was diagnosed was suggested to have been getting lower with time, whereas that of type 1 diabetes has been higher with time. There was no marked difference in family history of diabetes in the first-degree relatives of patients with type 2 diabetes, regardless of the presence or absence of a past history of obesity. More female patients with type 2 diabetes diagnosed before the age of 15 years had mothers with type 2 diabetes compared to corresponding male patients.

Differences in the contribution of the CTLA4 gene to susceptibility to fulminant and type 1A diabetes in Japanese patients

OBJECTIVE

To examine the contribution of the CTLA4 gene in the susceptibility to fulminant type 1 diabetes and compare it with classic type 1A diabetes.

RESEARCH DESIGN AND METHODS

We genotyped the +49G>A and CT60G>A variants of the CTLA4 gene in fulminant type 1 diabetic patients (n = 55), classic type 1A diabetic patients (n = 91), and healthy control subjects (n = 369). We also assessed serum levels of the soluble form of CTLA4 (sCTLA4).

RESULTS

The +49GG and CT60GG genotypes were associated with type 1A diabetes (P < 0.001). In contrast, the CT60AA genotype, but not the +49G>A variation, was associated with fulminant type 1 diabetes (P < 0.05), especially in patients carrying HLA-DR4 (P < 0.01). Serum levels of sCTLA4 were significantly decreased in patients with fulminant type 1 diabetes (P < 0.05).

CONCLUSIONS

These results suggest that CTLA4 CT60 affects the genetic susceptibility to fulminant type 1 diabetes. Furthermore, the contribution of CTLA4 to disease susceptibility is distinct between fulminant type 1 diabetes and classic type 1A diabetes.

[Latest overview of type 1 diabetes mellitus]

Type 1 diabetes mellitus (T1DM) was defined as a heterogeneous disorder characterized by severe beta-cell loss. The subtype 1A is characterized by abnormal autoimmue-mediated response and 1B is idiopathic etiology, and most of patients with T1DM are classified in 1A. There are three subtypes characterized by onset, fulminant, acute onset and slowly progressive in T1DM. Among these three subtypes, there are differences in genetic etiology, pathogenesis and prevalence of autoantibodies. Glutamic acid decarboxylase-65 (GAD65), insulinoma-associated antigen-2 (IA-2) and insulin are major autoantigens in T1DM and autoantibodies for former two are frequently used for clinical diagnosis. Also novel autoantibodies for T1DM have been found and clinical characteristics of the patients with each antibody will be made clearer. There have been eager efforts to develop immunotherapies to prevent islet destruction and to cure the disorder with islet transplantation, and new treatment with inhaled insulin regimen. Continuous glucose monitoring system(CGMS) has been established to make clearer the daily profile of blood glucose of the patients and to improve the metabolic control. Most efficient treatment for T1DM is a still insulin injection. However, the development of new medical devices and novel treatment rather than insulin injection has been done and the progression will promise improved prognosis of vascular complications.

The duration of severe insulin omission is the factor most closely associated with the microvascular complications of Type 1 diabetic females with clinical eating disorders

OBJECTIVE

To investigate which features of eating disorders are associated with retinopathy and nephropathy in Type 1 diabetic females with clinical eating disorders.

METHOD

Participants were 109 Type 1 diabetic females with clinical eating disorders diagnosed by the structured clinical interview for DSM-IV (bulimia nervosa [n = 70], binge-eating disorder [n = 28], anorexia nervosa [n = 7], and eating disorder not otherwise specified [n = 4]). Retinopathy and nephropathy were screened and demographic, medical, and eating disorder related factors were investigated. To identify the factors associated with each complication, logistic regression analysis was done.

RESULTS

Duration of severe insulin omission and duration of Type 1 diabetes were significantly associated with retinopathy (odds ratios = 1.35 and 1.23, respectively) and nephropathy (odds ratio = 1.35 and 1.21, respectively) in multivariate regression analyses.

CONCLUSION

Of the various problematic behavioral factors related to eating disorders, the duration of severe insulin omission was the factor most closely associated with the retinopathy and nephropathy of Type 1 diabetic females with clinical eating disorders by multivariate analysis. This finding may help patients who deliberately omit insulin become aware of medical risk of insulin omission.

Nationwide survey to compare the prevalence of transient elevation of liver transaminase during treatment of diabetic ketosis or ketoacidosis in new-onset acute and fulminant type 1 diabetes mellitus

BACKGROUND AIMS

A mild increase in liver enzyme levels is sometimes observed in patients with diabetic ketosis or ketoacidosis. The aim of the present study was to assess the cause and prevalence of the elevation of liver transaminase levels in fulminant and acute-onset type 1 diabetic patients experiencing diabetic ketosis or ketoacidosis.

METHODS

We analyzed data on the liver transaminase levels of 108 patients over 18 years of age with newly diagnosed type 1 diabetes complicated by ketosis or ketoacidosis. The data were collated from a nationwide survey on fulminant type 1 diabetes and retrospective medical records.

RESULTS

Thirty-two (60.4%) out of the 53 patients suffering from fulminant type 1 diabetes were detected with transient elevation of liver transaminase (TELT) levels during the first month after initiation of insulin therapy; in the case of acute-onset type 1 diabetes, such an observation was noted in 16 (29.1%) out of 55 patients. Fatty liver was diagnosed in 20% of the patients, and 65% of these patients exhibited TELT. The dosage of insulin injected in these patients was significantly high.

CONCLUSIONS

High blood glucose and fatty liver may influence the elevation of liver transaminase levels during the treatment of new-onset type 1 diabetes.

Severe hypoglycaemia in a person with insulin autoimmune syndrome accompanied by insulin receptor anomaly type B

AIMS

A rare case of the insulin autoimmune syndrome (IAS) accompanied by insulin receptor anomaly is reported.

METHODS

Antibodies to insulin and insulin receptor were determined in the patient with severe hypoglycaemia before and after the treatment with prednisolone.

RESULTS

Titers of antibody to insulin and insulin receptors were 73.0% and 41.5%, respectively. Drug-induced lymphocyte stimulation tests were all negative for the suspicious drugs. Her HLA-DR was DRB1*0403/04051. Following steroid therapy, the formation of antibodies was suppressed and alleviated her symptoms. Scatchard analysis yielded findings specific to polyclonal antibodies.

CONCLUSIONS

The changes in autoantibodies resulted in alleviation of the hypoglycemic symptoms as a result of steroid therapy.

Survey of dietary habits in obese patients with type 2 diabetes treated with either OHA or insulin injections in Japan

A questionnaire survey on meal/snack intake and timing in obese patients with type 2 diabetes treated with either oral hypoglycemic agents (OHA) or insulin injections was performed in order to elucidate their dietary habits, using a method independent of the treating physician. The OHA and insulin groups recruited from all over Japan showed no differences in any factors except the duration of diabetes. Daily calorie intake was not correlated with gender, BMI, medication or HbA1c. However, calorie intake was the highest at dinner, followed by lunch and breakfast. Only for dinner was the calorie intake significantly higher for the OHA group than for the insulin group. Of the patients, 8.6, 4.2 and 1.3% skipped breakfast, lunch or dinner, respectively. However, there was no significant difference in the abstention ratio for the three meals or between the two treatment groups. It was remarkable that at least 90% or more reported the habitual ingestion of snacks. The snack time ranged from 6:00 a.m. to midnight. There was no marked difference in the proportion of patients having snacks between the two treatment groups. The outcomes such as deviations in calorie intake among the three meals, skipping meals and snacking in this survey may reflect the current dietary habits of obese patients with type 2 diabetes, especially under medical treatment.

De-N-glycosylation or G82S mutation of RAGE sensitizes its interaction with advanced glycation endproducts

Interactions between advanced glycation endproducts (AGE) and the receptor for AGE (RAGE) have been implicated in the development of diabetic vascular complications. RAGE has two N-glycosylation sites in and near the AGE-binding domain, and G82S mutation in the second N-glycosylation motif was recently reported in human. In this study, we examined whether de-N-glycosylation or G82S of RAGE affect its ability to bind AGE and cellular response to AGE. Recombinant wild-type, de-N-glycosylation and G82S RAGE proteins were produced in COS-7 cells, purified and assayed for ligand-binding abilities. De-N-glycosylation at N81 and G82S mutation decreased Kd for glycolaldehyde-derived AGE to three orders of magnitude lower levels compared with wild-type. AGE-induced upregulation of VEGF mRNA was significantly augmented in endothelial cell-derived ECV304 cells expressing de-N-glycosylated and G82S RAGE when compared with wild-type expressor. Exposure to low glucose resulted in the appearance of RAGE proteins of deglycosylated size in wild-type RAGE-expressing cells and significantly enhanced glycolaldehyde-derived AGE-induced VEGF mRNA expression. De-N-glycosylation or G82S mutation of RAGE increases affinity for AGE ligands, and may sensitize cells or conditions with it to AGE.

Fulminant type 1 diabetes as a high risk group for diabetic microangiopathy--a nationwide 5-year-study in Japan

AIMS/HYPOTHESIS

The aim of the present study was to assess the development of microangiopathy in patients with fulminant type 1 diabetes, a novel subtype of type 1B diabetes.

MATERIALS AND METHODS

In a nationwide survey, we followed 41 patients with fulminant type 1 diabetes and 76 age- and sex-matched patients with type 1A diabetes for 5 years. The following data were recorded every 12 months after the onset of diabetes: seven-point blood glucose concentrations, HbA1c level, urinary albumin excretion, serum C-peptide level, blood pressure, daily dosages of insulin, frequency of severe hypoglycaemic episodes, and neurological and fundoscopic examination.

RESULTS

The 5-year cumulative incidence of microangiopathy was 24.4% in fulminant type 1 diabetes and 2.6% in type 1A diabetes. In longitudinal studies using the Kaplan-Meier method, the cumulative incidence of each form of microangiopathy was significantly higher in fulminant type 1 diabetes than in type 1A diabetes; retinopathy was 9.8% vs 0% (p=0.014), nephropathy 12.2% vs 2.6% (p=0.015) and neuropathy 12.2% vs 1.3% (p=0.010), respectively. Mean HbA1c levels were similar in the fulminant and type 1A diabetes groups during the follow-up periods. However, the mean M-value, mean insulin dosages and the frequency of severe hypoglycaemic episodes were significantly higher, and the mean postprandial C-peptide level was significantly lower in the fulminant type 1 diabetes group.

CONCLUSIONS/INTERPRETATION

These data suggest that patients with fulminant type 1 diabetes are a high-risk subgroup for diabetic microangiopathy associated with the lack of endogenous insulin secretion from the onset of diabetes.

Development of an ELISA for esRAGE and its application to type 1 diabetic patients

We recently identified a naturally occurring soluble form of RAGE (the receptor for advanced glycation endproducts, receptor for AGE) in cultured human vascular cells, and named it endogenous secretory RAGE (esRAGE). esRAGE is generated by alternative RNA splicing and is able to capture AGE, and exerts protection against AGE-induced endothelial cell injury. In the present study, the presence of esRAGE in human circulation was demonstrated for the first time, and a highly sensitive and specific sandwich ELISA system for esRAGE was developed to see whether esRAGE could be related to an individual resistance to the development of diabetic vascular complications. Sera from 47 type 1 diabetic subjects without clinical nephropathy (urinary albumin excretion <300mg/g creatinine) and 55 healthy controls were analyzed by the ELISA. Circulating esRAGE concentrations in diabetic patients with simple and proliferative retinopathy (0.09+/-0.02ng/mL, n=16 and 0.08+/-0.02ng/mL, n=8, respectively) were significantly lower than in those without retinopathy (0.13+/-0.06ng/mL, n=23). The results indicate that esRAGE can be a useful biomarker to indicate individual variations in susceptibility to diabetic retinopathy.