101
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Hugo CJ, van der Merwe M. South African adolescents with cystic fibrosis: a qualitative exploration of their bio-psychosocial fields. J Child Adolesc Ment Health 2014; 26:177-91. [PMID: 25533405 DOI: 10.2989/17280583.2014.898643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This qualitative case study explored risk factors and protective factors in the bio-psychosocial fields of adolescents living with cystic fibrosis (CF). METHOD Semi-structured interviews were conducted with adolescents in the middle and late adolescent years (15-22 years) who had the defining characteristics of CF and were living in Gauteng province. FINDINGS Themes emerged from individual interviews. The fundamental human need to be understood and to understand was negatively affected as the illness affected socialisation and learning. Participants experienced an array of emotions including loss and bereavement linked to their illness and when friends with CF died. Constructive internal dialogue and positive thinking emerged as protective variables. Participants generally showed awareness of how they regulated their contact with the illness and how they self-regulate. Despite the severity of their symptoms and the taxing demands of managing CF, participants expressed hope for the future and could find some meaning in the illness. CONCLUSION Adolescents with CF who participated in this study indicated that they felt different from their peers. Apart from the general developmental tasks typical to adolescence they faced the challenge of managing a severe chronic and potentially terminal illness.
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Affiliation(s)
- Carina Jacobie Hugo
- a At the time of research - MA Psychology student, Centre for Child, Youth and Family Studies , Faculty of Health Sciences, North-West University , Potchefstroom
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102
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Garnett JP, Braun D, McCarthy AJ, Farrant MR, Baker EH, Lindsay JA, Baines DL. Fructose transport-deficient Staphylococcus aureus reveals important role of epithelial glucose transporters in limiting sugar-driven bacterial growth in airway surface liquid. Cell Mol Life Sci 2014; 71:4665-73. [PMID: 24810961 PMCID: PMC4232747 DOI: 10.1007/s00018-014-1635-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/11/2014] [Accepted: 04/28/2014] [Indexed: 02/05/2023]
Abstract
Hyperglycaemia as a result of diabetes mellitus or acute illness is associated with increased susceptibility to respiratory infection with Staphylococcus aureus. Hyperglycaemia increases the concentration of glucose in airway surface liquid (ASL) and promotes the growth of S. aureus in vitro and in vivo. Whether elevation of other sugars in the blood, such as fructose, also results in increased concentrations in ASL is unknown and whether sugars in ASL are directly utilised by S. aureus for growth has not been investigated. We obtained mutant S. aureus JE2 strains with transposon disrupted sugar transport genes. NE768(fruA) exhibited restricted growth in 10 mM fructose. In H441 airway epithelial-bacterial co-culture, elevation of basolateral sugar concentration (5-20 mM) increased the apical growth of JE2. However, sugar-induced growth of NE768(fruA) was significantly less when basolateral fructose rather than glucose was elevated. This is the first experimental evidence to show that S. aureus directly utilises sugars present in the ASL for growth. Interestingly, JE2 growth was promoted less by glucose than fructose. Net transepithelial flux of D-glucose was lower than D-fructose. However, uptake of D-glucose was higher than D-fructose across both apical and basolateral membranes consistent with the presence of GLUT1/10 in the airway epithelium. Therefore, we propose that the preferential uptake of glucose (compared to fructose) limits its accumulation in ASL. Pre-treatment with metformin increased transepithelial resistance and reduced the sugar-dependent growth of S. aureus. Thus, epithelial paracellular permeability and glucose transport mechanisms are vital to maintain low glucose concentration in ASL and limit bacterial nutrient sources as a defence against infection.
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Affiliation(s)
- James P. Garnett
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Daniela Braun
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Alex J. McCarthy
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Matthew R. Farrant
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Emma H. Baker
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Jodi A. Lindsay
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
| | - Deborah L. Baines
- Institute for Infection and Immunity, St George’s, University of London, Tooting, London, SW17 0RE UK
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103
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Perano S, Rayner CK, Couper J, Martin J, Horowitz M. Cystic fibrosis related diabetes--a new perspective on the optimal management of postprandial glycemia. J Diabetes Complications 2014; 28:904-11. [PMID: 25060530 DOI: 10.1016/j.jdiacomp.2014.06.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 06/16/2014] [Accepted: 06/16/2014] [Indexed: 02/07/2023]
Abstract
As the average life expectancy of patients with cystic fibrosis (CF) improves, the long term co-morbidities assume increasing importance. CF related diabetes (CFRD) has adverse effects on both nutrition and pulmonary function, and is associated with increased mortality. Abnormalities of glucose metabolism in CF represent a continuum; however the predominant abnormality is postprandial, not pre-prandial, glycemia. Insulin is currently recommended as the treatment of choice for CFRD, but its use is associated with a number of limitations, including hypoglycemia. Both the rate of gastric emptying and the consequent release of the 'incretin' hormones, glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like-peptide-1 (GLP-1), from the gut are important determinants of overall glycemic control, particularly postprandial glycemia. Both are abnormal in conditions associated with exocrine pancreatic insufficiency. Incretin based therapies that have the capacity to slow gastric emptying and/or modulate the release of 'incretin' hormones, are now used widely in type 2 diabetes (T2D). This paper explores the determinants of glycemic control in CF, with a particular focus on the roles of gastric emptying and 'incretin' hormones, providing a rationale for the use of therapies that delay gastric emptying, including incretin mimetics, to minimize postprandial glycemia and improve nutritional status.
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Affiliation(s)
- S Perano
- Department of Diabetes and Endocrinology, Women's and Children's Hospital, South Australia, Australia; Discipline of Paediatrics and Medicine, University of Adelaide, South Australia, Australia.
| | - C K Rayner
- Discipline of Paediatrics and Medicine, University of Adelaide, South Australia, Australia; Department of Gastroenterology and Hepatology, Royal Adelaide Hospital, South Australia, Australia
| | - J Couper
- Department of Diabetes and Endocrinology, Women's and Children's Hospital, South Australia, Australia; Discipline of Paediatrics and Medicine, University of Adelaide, South Australia, Australia
| | - J Martin
- Department of Respiratory Medicine, Women's and Children's Hospital, South Australia, Australia
| | - M Horowitz
- Discipline of Paediatrics and Medicine, University of Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, South Australia, Australia
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104
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Moran A, Pillay K, Becker DJ, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2014. Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2014; 15 Suppl 20:65-76. [PMID: 25182308 DOI: 10.1111/pedi.12178] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/11/2014] [Indexed: 12/17/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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105
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Polymorphonuclear leukocytes restrict growth of Pseudomonas aeruginosa in the lungs of cystic fibrosis patients. Infect Immun 2014; 82:4477-86. [PMID: 25114118 DOI: 10.1128/iai.01969-14] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Cystic fibrosis (CF) patients have increased susceptibility to chronic lung infections by Pseudomonas aeruginosa, but the ecophysiology within the CF lung during infections is poorly understood. The aim of this study was to elucidate the in vivo growth physiology of P. aeruginosa within lungs of chronically infected CF patients. A novel, quantitative peptide nucleic acid (PNA) fluorescence in situ hybridization (PNA-FISH)-based method was used to estimate the in vivo growth rates of P. aeruginosa directly in lung tissue samples from CF patients and the growth rates of P. aeruginosa in infected lungs in a mouse model. The growth rate of P. aeruginosa within CF lungs did not correlate with the dimensions of bacterial aggregates but showed an inverse correlation to the concentration of polymorphonuclear leukocytes (PMNs) surrounding the bacteria. A growth-limiting effect on P. aeruginosa by PMNs was also observed in vitro, where this limitation was alleviated in the presence of the alternative electron acceptor nitrate. The finding that P. aeruginosa growth patterns correlate with the number of surrounding PMNs points to a bacteriostatic effect by PMNs via their strong O2 consumption, which slows the growth of P. aeruginosa in infected CF lungs. In support of this, the growth of P. aeruginosa was significantly higher in the respiratory airways than in the conducting airways of mice. These results indicate a complex host-pathogen interaction in chronic P. aeruginosa infection of the CF lung whereby PMNs slow the growth of the bacteria and render them less susceptible to antibiotic treatment while enabling them to persist by anaerobic respiration.
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106
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Abstract
Improved life expectancy in cystic fibrosis (CF) has led to an expanding population of adults with CF, now representing almost 50 % of the total CF population. This creates new challenges from long-term complications such as diabetes mellitus (DM), a condition that is present in 40 %-50 % of adults with CF. Cystic fibrosis-related diabetes (CFRD) results from a primary defect of insulin deficiency and although sharing features with type 1 (DM1) and type 2 diabetes (DM2), it is a clinically distinct condition. Progression to diabetes is associated with poorer CF clinical outcomes and increased mortality. CFRD is not associated with an increased risk of cardiovascular disease and the prevalence of microvascular complications is lower than DM1 or DM2. Rather, the primary goal of insulin therapy is the preservation of lung function and optimization of nutritional status. There is increasing evidence that appropriate screening and early intervention with insulin can reverse weight loss and improve pulmonary function. This approach may include targeting postprandial hyperglycemia not detected by standard diagnostic tests such as the oral glucose tolerance test. Further clinical research is required to guide when and how much to intervene in patients who are already dealing with the burden of one chronic illness.
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Affiliation(s)
- Donal O'Shea
- Department of Endocrinology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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107
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Early assessment of glucose abnormalities during continuous glucose monitoring associated with lung function impairment in cystic fibrosis patients. J Cyst Fibros 2014; 13:478-84. [DOI: 10.1016/j.jcf.2013.11.005] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Revised: 10/13/2013] [Accepted: 11/18/2013] [Indexed: 01/07/2023]
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108
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Scheuing N, Berger G, Bergis D, Gohlke B, Konrad K, Laubner K, Lilienthal E, Moser C, Schütz-Fuhrmann I, Thon A, Holl RW. Adherence to clinical care guidelines for cystic fibrosis-related diabetes in 659 German/Austrian patients. J Cyst Fibros 2014; 13:730-6. [PMID: 24917115 DOI: 10.1016/j.jcf.2014.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 04/10/2014] [Accepted: 05/09/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND In Germany/Austria, data on medical care for cystic fibrosis-related diabetes (CFRD) is limited. METHODS Anonymized data from 659 CFRD patients were analyzed and compared to the latest ADA/CFF guidelines. RESULTS Specialized diabetes clinics were attended less frequently than recommended (3.1 vs. 4.0 times yearly). 7.9% of patients had a complete profile of examinations: diabetes education (44.9%), HbA1c (88.8%), blood pressure (79.5%), BMI (86.5%), lipid status (37.5%), retinopathy (29.9%), microalbuminuria (33.2%), and self-monitoring of blood glucose (71.6%). HbA1c and blood pressure were measured less frequently than recommended (2.3 and 2.0 vs. 4.0 times yearly). Overall, guidelines were followed more frequently in children than adults. Contrary to recommendations, not all patients were treated with insulin (77.2 vs. 100.0%). Insulin therapy was initiated earlier in children than adults, but there was still a substantial delay (0.9 vs. 2.7years after diagnosis, p<0.001). CONCLUSION In CFRD patients studied, adherence to care guidelines was suboptimal.
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Affiliation(s)
- Nicole Scheuing
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Albert-Einstein-Allee 41, D-89081 Ulm, Germany.
| | - Gabriele Berger
- Department of Pediatrics and Adolescent Medicine, Medical University Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria
| | - Dominik Bergis
- Department of Internal Medicine I, Division of Endocrinology & Metabolism, Goethe University Hospital, Theodor-Stern-Kai 7, D-60590 Frankfurt am Main, Germany
| | - Bettina Gohlke
- Pediatric Endocrinology Division, Children's Hospital, University of Bonn, Adenauerallee 119, D-53113 Bonn, Germany
| | - Katja Konrad
- Department of Pediatrics II, University Children's Hospital Essen, Hufelandstraße 55, D-45147 Essen, Germany
| | - Katharina Laubner
- Department of Internal Medicine II, Division of Endocrinology and Diabetology, University Hospital of Freiburg, Hugstetter Straße 49, D-79106 Freiburg, Germany
| | - Eggert Lilienthal
- Department of Pediatrics, University of Bochum, Alexandrinenstraße 5, D-44791 Bochum, Germany
| | - Christine Moser
- Department of Pediatrics I, Medical University of Innsbruck, Christoph Probst Platz 1, A-6020 Innsbruck, Austria
| | - Ingrid Schütz-Fuhrmann
- 3rd Medical Department, Hospital Hietzing, Wolkersbergenstraße 1, A-1130 Vienna, Austria
| | - Angelika Thon
- Department of Pediatrics, Hannover Medical School, Carl-Neuberg-Straße 1, D-30625 Hannover, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Albert-Einstein-Allee 41, D-89081 Ulm, Germany
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109
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Middleton PG, Wagenaar M, Matson AG, Craig ME, Holmes-Walker DJ, Katz T, Hameed S. Australian standards of care for cystic fibrosis-related diabetes. Respirology 2013; 19:185-192. [DOI: 10.1111/resp.12227] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/08/2013] [Accepted: 11/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Maria E. Craig
- Sydney Children's Hospital Network (Westmead); Sydney New South Wales Australia
| | | | - Tamarah Katz
- Sydney Children's Hospital Network; Sydney New South Wales Australia
| | - Shihab Hameed
- Sydney Children's Hospital Network; Sydney New South Wales Australia
- School of Women's and Children's Health; Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
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110
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Scheuing N, Holl RW, Dockter G, Fink K, Junge S, Naehrlich L, Smaczny C, Staab D, Thalhammer G, van Koningsbruggen-Rietschel S, Ballmann M. Diabetes in cystic fibrosis: multicenter screening results based on current guidelines. PLoS One 2013; 8:e81545. [PMID: 24324701 PMCID: PMC3855692 DOI: 10.1371/journal.pone.0081545] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/24/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Published estimates on age-dependent frequency of diabetes in cystic fibrosis (CF) vary widely, and are based mostly on older data. However, CF treatment and prevention of comorbidities changed over recent years. In many studies, definition of cystic fibrosis-related diabetes (CFRD) is not in line with current guideline recommendations. Therefore, we evaluated age-dependent occurrence of glucose abnormalities and associated risk factors in CF patients who participated in a multicenter screening program using oral glucose tolerance tests (OGTT). METHODS Between 2001 and 2010, 43 specialized CF centers from Germany and Austria serially performed 5,179 standardized OGTTs in 1,658 clinically stable, non-pregnant CF patients with no prior steroid medication or lung transplantation. Age-dependent occurrence of impaired fasting glucose (IFG), impaired glucose tolerance (IGT), IFG+IGT, one (DGT) or two consecutive (CFRD) diabetic OGTTs was analyzed, using Kaplan Meier curves. Cox proportional-hazards models were created to elucidate the influence of sex or underweight. RESULTS At baseline/last OGTT, median age was 15.9 years/18.2 years and 30.6%/31.8% of patients were underweight. 25% of patients showed IFG at age 14.3 years; IGT at age 16.3 years; IFG+IGT combined at age 17.7 years. DGT was observed in 25% of patients at age 22.6 years; CFRD at age 34.5 years. Females had a 3.54 [95% CI 1.23-10.18] times higher risk for CFRD; risk for DGT was 2.21 [1.22-3.98] times higher. Underweight was a risk factor for IGT (HR [95% CI]: 1.38 [1.11-1.71]) and IFG+IGT (1.43 [1.11-1.83]), and in males also for DGT (1.49 [1.09-2.04]). CONCLUSIONS/SIGNIFICANCE If confirmation of diabetes by a second test is required, as recommended in current guidelines, age at CFRD diagnosis was higher compared to most previous studies. However, known risk factors for glucose abnormalities in CF were confirmed. Confirmation of diabetic OGT by a repeat test is important for a consistent diagnosis of CFRD.
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Affiliation(s)
- Nicole Scheuing
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Engineering, University of Ulm, Ulm, Germany
| | - Reinhard W. Holl
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Engineering, University of Ulm, Ulm, Germany
| | - Gerd Dockter
- Cystic Fibrosis Centre, Saarland University Hospital for Pediatric and Adolescent Medicine, Homburg/Saar, Germany
| | - Katharina Fink
- Institute of Epidemiology and Medical Biometry, Central Institute for Biomedical Engineering, University of Ulm, Ulm, Germany
| | - Sibylle Junge
- Clinic for Pediatric Pneumology and Neonatology, Hannover Medical School, Hannover, Germany
| | - Lutz Naehrlich
- Department of Pediatrics, Justus-Liebig University Giessen, Giessen, Germany
| | - Christina Smaczny
- Medical Clinic I, Pneumology and Allergology, Johann Wolfgang Goethe University, Frankfurt/Main, Germany
| | - Doris Staab
- Division of Pulmonology and Immunology, Department of Pediatrics, Charité Berlin, Berlin, Germany
| | - Gabriela Thalhammer
- Department for Pediatric Pulmonology and Allergology, Medical University of Graz, Graz, Austria
| | | | - Manfred Ballmann
- Department of Pediatric Pulmonology, St. Josef Hospital Pediatric Clinic, Ruhr University Bochum, Bochum, Germany
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111
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Monge ME, Pérez JJ, Dwivedi P, Zhou M, McCarty NA, Stecenko AA, Fernández FM. Ion mobility and liquid chromatography/mass spectrometry strategies for exhaled breath condensate glucose quantitation in cystic fibrosis studies. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2013; 27:2263-2271. [PMID: 24019192 DOI: 10.1002/rcm.6683] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 06/02/2023]
Abstract
RATIONALE Cystic fibrosis related diabetes (CFRD) is an important complication of cystic fibrosis (CF) because it causes acceleration in the decline in lung function. Monitoring concentrations of key metabolites such as glucose in airway lining fluid is necessary for improving our understanding of the biochemical mechanisms linking diabetes and CF. Targeted-metabolomic strategies for glucose quantitation in exhaled breath condensate (EBC) from healthy individuals are presented. METHODS Three different electrospray ionization mass spectrometry (ESI-MS)-based methods were developed for EBC sample interrogation and glucose quantitation without derivatization. Two methods utilized ultra-high-performance liquid chromatography (UHPLC) coupled to either time-of-flight (TOF) MS or triple quadrupole (QqQ) tandem MS (MS/MS). A third approach involved direct-infusion traveling wave ion mobility spectrometry (TWIMS) with TOF-MS detection. UHPLC/QqQ-MS/MS was used for urea quantitation as the EBC dilution marker. Matrix effects were mitigated using isotopically labeled glucose and urea as internal standards. RESULTS All the developed methods allowed glucose and urea quantitation in EBC with high accuracy and precision. The UHPLC/TOF-MS and UHPLC/QqQ-MS/MS methods provided similar analytical figures of merit. UHPLC/QqQ-MS/MS provided the highest sensitivity and the lowest limit of detection (LOD) of 1.5 nM in EBC for both glucose and urea. The TWIMS-TOF-MS-based method provided the highest sample throughput capability; however, the glucose LOD was ~3-fold higher than with the two chromatographic methods. CONCLUSIONS Mass spectrometric methods for the quantitative analysis of trace EBC glucose levels are reported and compared for the first time. The analytical figures of merit demonstrate the applicability of these methods to metabolite analysis of airway samples for CF and CFRD research.
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Affiliation(s)
- María Eugenia Monge
- School of Chemistry and Biochemistry, Georgia Institute of Technology, Atlanta, GA, 30332, USA
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112
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Garnett JP, Gray MA, Tarran R, Brodlie M, Ward C, Baker EH, Baines DL. Elevated paracellular glucose flux across cystic fibrosis airway epithelial monolayers is an important factor for Pseudomonas aeruginosa growth. PLoS One 2013; 8:e76283. [PMID: 24124542 PMCID: PMC3790714 DOI: 10.1371/journal.pone.0076283] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2013] [Accepted: 08/22/2013] [Indexed: 01/17/2023] Open
Abstract
People with cystic fibrosis (CF) who develop related diabetes (CFRD) have accelerated pulmonary decline, increased infection with antibiotic-resistant Pseudomonas aeruginosa and increased pulmonary exacerbations. We have previously shown that glucose concentrations are elevated in airway surface liquid (ASL) of people with CF, particularly in those with CFRD. We therefore explored the hypotheses that glucose homeostasis is altered in CF airway epithelia and that elevation of glucose flux into ASL drives increased bacterial growth, with an effect over and above other cystic fibrosis transmembrane conductance regulator (CFTR)-related ASL abnormalities. The aim of this study was to compare the mechanisms governing airway glucose homeostasis in CF and non-CF primary human bronchial epithelial (HBE) monolayers, under normal conditions and in the presence of Ps. aeruginosa filtrate. HBE-bacterial co-cultures were performed in the presence of 5 mM or 15 mM basolateral glucose to investigate how changes in blood glucose, such as those seen in CFRD, affects luminal Ps. aeruginosa growth. Calu-3 cell monolayers were used to evaluate the potential importance of glucose on Ps. aeruginosa growth, in comparison to other hallmarks of the CF ASL, namely mucus hyperviscosity and impaired CFTR-dependent fluid secretions. We show that elevation of basolateral glucose promotes the apical growth of Ps. aeruginosa on CF airway epithelial monolayers more than non-CF monolayers. Ps. aeruginosa secretions elicited more glucose flux across CF airway epithelial monolayers compared to non-CF monolayers which we propose increases glucose availability in ASL for bacterial growth. In addition, elevating basolateral glucose increased Ps. aeruginosa growth over and above any CFTR-dependent effects and the presence or absence of mucus in Calu-3 airway epithelia-bacteria co-cultures. Together these studies highlight the importance of glucose as an additional factor in promoting Ps. aeruginosa growth and respiratory infection in CF disease.
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Affiliation(s)
- James P. Garnett
- Division of Biomedical Sciences, St George's University of London, London, United Kingdom
| | - Michael A. Gray
- Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Robert Tarran
- Cystic Fibrosis/Pulmonary Research and Treatment Centre, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Malcolm Brodlie
- Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Christopher Ward
- Institute of Cellular Medicine, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Emma H. Baker
- Division of Biomedical Sciences, St George's University of London, London, United Kingdom
| | - Deborah L. Baines
- Division of Biomedical Sciences, St George's University of London, London, United Kingdom
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113
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Hunt WR, Zughaier SM, Guentert DE, Shenep MA, Koval M, McCarty NA, Hansen JM. Hyperglycemia impedes lung bacterial clearance in a murine model of cystic fibrosis-related diabetes. Am J Physiol Lung Cell Mol Physiol 2013; 306:L43-9. [PMID: 24097557 DOI: 10.1152/ajplung.00224.2013] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Cystic fibrosis-related diabetes (CFRD) is the most common comorbidity associated with cystic fibrosis (CF), impacting more than half of patients over age 30. CFRD is clinically significant, portending accelerated decline in lung function, more frequent pulmonary exacerbations, and increased mortality. Despite the profound morbidity associated with CFRD, little is known about the underlying CFRD-related pulmonary pathology. Our aim was to develop a murine model of CFRD to explore the hypothesis that elevated glucose in CFRD is associated with reduced lung bacterial clearance. A diabetic phenotype was induced in gut-corrected CF transmembrane conductance regulator (CFTR) knockout mice (CFKO) and their CFTR-expressing wild-type littermates (WT) utilizing streptozotocin. Mice were subsequently challenged with an intratracheal inoculation of Pseudomonas aeruginosa (PAO1) (75 μl of 1-5 × 10(6) cfu/ml) for 18 h. Bronchoalveolar lavage fluid was collected for glucose concentration and cell counts. A portion of the lung was homogenized and cultured as a measure of the remaining viable PAO1 inoculum. Diabetic mice had increased airway glucose compared with nondiabetic mice. The ability to clear bacteria from the lung was significantly reduced in diabetic WT mice and control CFKO mice. Critically, bacterial clearance by diabetic CFKO mice was significantly more diminished compared with nondiabetic CFKO mice, despite an even more robust recruitment of neutrophils to the airways. This finding that CFRD mice boast an exaggerated, but less effective, inflammatory cell response to intratracheal PAO1 challenge presents a novel and useful murine model to help identify therapeutic strategies that promote bacterial clearance in CFRD.
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114
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Kraft R, Herndon DN, Mlcak RP, Finnerty CC, Cox RA, Williams FN, Jeschke MG. Bacterial respiratory tract infections are promoted by systemic hyperglycemia after severe burn injury in pediatric patients. Burns 2013; 40:428-35. [PMID: 24074819 DOI: 10.1016/j.burns.2013.07.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Revised: 07/10/2013] [Accepted: 07/11/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND Burns are associated with hyperglycemia leading to increased incidence of infections with pneumonia being one of the most prominent and adverse complications. Recently, various studies in critically ill patients indicated that increased pulmonary glucose levels with airway/blood glucose threshold over 150 mg/dl lead to an overwhelming growth of bacteria in the broncho-pulmonary system, subsequently resulting in an increased risk of pulmonary infections. The aim of the present study was to determine whether a similar cutoff value exists for severely burned pediatric patients. METHODS One-hundred six severely burned pediatric patients were enrolled in the study. Patients were divided in two groups: high (H) defined as daily average glucose levels >75% of LOS >150 mg/dl), and low (L) with daily average glucose levels >75% of the LOS <150 mg/dl). Incidences of pneumonia, atelectasis, and acute respiratory distress syndrome (ARDS) were assessed. Incidence of infections, sepsis, and respiratory parameters were recorded. Blood was analyzed for glucose and insulin levels. Statistical analysis was performed using Student's t-test and chi-square test. Significance was set at p<0.05. RESULTS Patient groups were similar in demographics and injury characteristics. Pneumonia in patients on the mechanical ventilation (L: 21%, H: 32%) and off mechanical ventilation (L: 5%, H: 15%), as well as ARDS were significantly higher in the high group (L: 3%, H: 19%), p<0.05, while atelectasis was not different. Patients in the high group required significantly longer ventilation compared to low patients (p<0.05). Furthermore, incidence of infection and sepsis were significantly higher in the high group, p<0.05. CONCLUSION Our results indicate that systemic glucose levels over 150 mg/dl are associated with a higher incidence of pneumonia confirming the previous studies in critically ill patients.
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Affiliation(s)
- Robert Kraft
- Department of Trauma, Klinikum Memmingen, Germany
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, TX, United States; Department of Surgery, United States
| | - Ronald P Mlcak
- Shriners Hospitals for Children, Galveston, TX, United States
| | - Celeste C Finnerty
- Shriners Hospitals for Children, Galveston, TX, United States; Department of Surgery, United States; Sealy Center for Molecular Medicine, and the Institute for Translational Science, University Texas Medical Branch, Galveston, TX, United States
| | - Robert A Cox
- Shriners Hospitals for Children, Galveston, TX, United States
| | | | - Marc G Jeschke
- Department of Surgery, Division of Plastic Surgery, Department of Immunology, Ross Tilley Burn Centre - Sunnybrook Health Sciences Centre, Sunnybrook Research Institute, Toronto, ON, Canada.
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Garnett JP, Baker EH, Naik S, Lindsay JA, Knight GM, Gill S, Tregoning JS, Baines DL. Metformin reduces airway glucose permeability and hyperglycaemia-induced Staphylococcus aureus load independently of effects on blood glucose. Thorax 2013; 68:835-45. [PMID: 23709760 PMCID: PMC3756442 DOI: 10.1136/thoraxjnl-2012-203178] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Diabetes is a risk factor for respiratory infection, and hyperglycaemia is associated with increased glucose in airway surface liquid and risk of Staphylococcus aureus infection. OBJECTIVES To investigate whether elevation of basolateral/blood glucose concentration promotes airway Staphylococcus aureus growth and whether pretreatment with the antidiabetic drug metformin affects this relationship. METHODS Human airway epithelial cells grown at air-liquid interface (±18 h pre-treatment, 30 μM-1 mM metformin) were inoculated with 5×10(5) colony-forming units (CFU)/cm(2) S aureus 8325-4 or JE2 or Pseudomonas aeruginosa PA01 on the apical surface and incubated for 7 h. Wild-type C57BL/6 or db/db (leptin receptor-deficient) mice, 6-10 weeks old, were treated with intraperitoneal phosphate-buffered saline or 40 mg/kg metformin for 2 days before intranasal inoculation with 1×10(7) CFU S aureus. Mice were culled 24 h after infection and bronchoalveolar lavage fluid collected. RESULTS Apical S aureus growth increased with basolateral glucose concentration in an in vitro airway epithelia-bacteria co-culture model. S aureus reduced transepithelial electrical resistance (RT) and increased paracellular glucose flux. Metformin inhibited the glucose-induced growth of S aureus, increased RT and decreased glucose flux. Diabetic (db/db) mice infected with S aureus exhibited a higher bacterial load in their airways than control mice after 2 days and metformin treatment reversed this effect. Metformin did not decrease blood glucose but reduced paracellular flux across ex vivo murine tracheas. CONCLUSIONS Hyperglycaemia promotes respiratory S aureus infection, and metformin modifies glucose flux across the airway epithelium to limit hyperglycaemia-induced bacterial growth. Metformin might, therefore, be of additional benefit in the prevention and treatment of respiratory infection.
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Affiliation(s)
- James P Garnett
- Division of Biomedical Sciences, Centre for Cell Physiology and Pharmacology, St George's, University of London, London, UK
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116
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Progression of structural lung disease on CT scans in children with cystic fibrosis related diabetes. J Cyst Fibros 2013; 12:216-21. [DOI: 10.1016/j.jcf.2012.09.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2012] [Revised: 09/06/2012] [Accepted: 09/21/2012] [Indexed: 11/23/2022]
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Bremer AA. The use of insulin in cystic fibrosis-related diabetes: a philosophical difference from the use of insulin in type 1 and type 2 diabetes. Pediatr Pulmonol 2012; 47:1039-41. [PMID: 22911489 DOI: 10.1002/ppul.22662] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2012] [Accepted: 07/30/2012] [Indexed: 11/07/2022]
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Abstract
Lung epithelial cells interconnected by tight junctions provide a barrier to the free diffusion of solutes into airspaces. Transmembrane tight junction proteins known as claudins are essential for epithelial barrier function. Claudins are regulated through interactions with each other that are coordinated with other transmembrane tight junction proteins and cytosolic scaffold proteins. Of the 14 claudins expressed by the alveolar epithelium, claudin-3, claudin-4, and claudin-18 are the most prominent; each confers unique properties to alveolar barrier function. In particular, a protective role for claudin-4 in preventing lung injury has emerged. By contrast, lung diseases that affect claudin expression and impair barrier function, including alcoholic lung syndrome and sepsis, prime the lung for pulmonary edema. Thus, approaches to restore and/or augment lung claudin expression provide potential targets for promoting healthy barrier function.
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Affiliation(s)
- Michael Koval
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Emory University, Atlanta, Georgia 30322, USA.
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Rasouli N, Seggelke S, Gibbs J, Hawkins RM, Casciano ML, Cohlmia E, Taylor-Cousar J, Wang C, Pereira R, Hsia E, Draznin B. Cystic fibrosis-related diabetes in adults: inpatient management of 121 patients during 410 admissions. J Diabetes Sci Technol 2012; 6:1038-44. [PMID: 23063029 PMCID: PMC3570837 DOI: 10.1177/193229681200600507] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND With improved longevity, cystic fibrosis (CF)-related diabetes (CFRD) has emerged as the most common nonpulmonary complication of CF. Patients with CFRD are frequently admitted to the hospital with infections and deterioration of pulmonary function, during which time glycemic control might have an impact on pulmonary function, recovery from infection, and survival. METHODS AND RESULTS In an attempt to share our insight into inpatient management of CFRD, this article summarizes the experience of our inpatient glucose management team with hospital management of 121 adult CFRD patients who were hospitalized on 410 occasions at the University of Colorado Hospital between January 2009 and September 2011. This is a retrospective chart review descriptive study of inpatient management of CFRD in our center. Our cohort includes CFRD patients treated with basal and mealtime insulin through multiple daily injections or continuous subcutaneous insulin infusion (CSII), as well as patients receiving steroids or enteral nutrition, which adds complexity to the management of CFRD during hospitalization. CONCLUSIONS Multiple hospitalizations and intensive inpatient management of CF are integral elements of treatment. Inpatient therapy for CFRD requires a customized approach that is uniquely different from that of type 1 or type 2 diabetes. Our experience highlights clinical circumstances such as irregular food intake, high dose steroid therapy, and supplemental tube feeding. For many patients, it is possible to continue CSII therapy during hospitalization through a combination of mutual trust between the patient and hospital staff and oversight provided by the glucose management team.
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Affiliation(s)
- Neda Rasouli
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Stacey Seggelke
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Joanna Gibbs
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - R. Matthew Hawkins
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | | | - Elizabeth Cohlmia
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Jennifer Taylor-Cousar
- Pulmonary Division, Department of Medicine and Pediatrics, National Jewish Health, Denver, Colorado
- Pulmonary Division, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Cecilia Wang
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
- Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado
| | - Rocio Pereira
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Elisa Hsia
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
| | - Boris Draznin
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado
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Noronha RMD, Calliari LEP, Damaceno N, Muramatu LH, Monte O. Update on diagnosis and monitoring of cystic fibrosis-related diabetes mellitus (CFRD). ACTA ACUST UNITED AC 2012; 55:613-21. [PMID: 22218444 DOI: 10.1590/s0004-27302011000800016] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2011] [Accepted: 10/21/2011] [Indexed: 11/22/2022]
Abstract
Cystic fibrosis (CF) is the most common recessive autosomal disease among Caucasian. Children with CF have benefitted from advances in medical and nutritional treatments, and this can be gleaned from the improvement in the survival of these patients. The increase in the survival rate brought with it the appearance of co-morbidities related to CF. Nowadays cystic fibrosis-related diabetes (CFRD) is considered the most common complication associated with CF. It can appear as early as infancy or adolescence, and its prevalence can be as high as 50% in adult patients. Because of its high prevalence, difficulties in early detection and the risks involved, in recent years several studies and consensuses have focused on this condition, adding information about the epidemiology, pathophysiology, prognosis and treatment of CFRD. The main aspects of these new concepts, as well as the current recommendations for its diagnosis and follow-up, will be presented in this study.
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Affiliation(s)
- Renata Maria de Noronha
- Pediatric Endocrinology Unit, Pediatric Department, Santa Casa de São Paulo Hospital, Brazil.
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Low glycaemic index dietary interventions in youth with cystic fibrosis: a systematic review and discussion of the clinical implications. Nutrients 2012; 4:286-96. [PMID: 22606371 PMCID: PMC3347009 DOI: 10.3390/nu4040286] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2012] [Revised: 04/11/2012] [Accepted: 04/17/2012] [Indexed: 11/24/2022] Open
Abstract
A systematic review was conducted to assess what is known about the effect of low glycaemic index (GI) diets on glycaemic control, weight and quality of life in youth with cystic fibrosis (CF). Eligibility criteria were systematic reviews, randomised and non-randomised trials of low GI dietary interventions in CF. Outcomes examined were glycaemic control, quality of life, anthropometry and respiratory function. Reference lists were manually searched and experts in the field were consulted. Four studies met the eligibility criteria; two were excluded because they did not include data on any of the outcomes. The remaining two were studies that examined GI secondary to any other intervention: one used GI as a factor in enteral feeds and the other incorporated low GI dietary education into its treatment methodology. There is insufficient evidence to recommend use of low GI diets in CF. Since there is evidence to support use of low GI diets in type 1, type 2 and gestational diabetes, low GI diets should be tested as an intervention for CF. The potential risks and benefits of a low GI diet in CF are discussed.
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Minicucci L, Haupt M, Casciaro R, De Alessandri A, Bagnasco F, Lucidi V, Notarnicola S, Lorini R, Bertasi S, Raia V, Cialdella P, Haupt R. Slow-release insulin in cystic fibrosis patients with glucose intolerance: a randomized clinical trial. Pediatr Diabetes 2012; 13:197-202. [PMID: 22060105 DOI: 10.1111/j.1399-5448.2011.00810.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Early stages of glucose metabolism impairment are a period at risk in the long-term prognosis of cystic fibrosis (CF). Slow-release synthetic insulin glargine can be a therapeutic tool in this metabolic condition. METHODS In this phase 3 multicenter, controlled, two-arm, randomized clinical study, glargine was administered up to a dosage of 0.15 U/kg/die for a period of 18 months. Primary endpoint was the improvement of nutritional status [body mass index (BMI) Z score], while glucose tolerance [hemoglobin A1c (HbA1C) and respiratory function (FEV1 predicted] improvement were the secondary endpoints. RESULTS Thirty-four subjects (18 in the glargine arm and 16 in the control arm) were evaluated. Adherence to insulin treatment was excellent. No significant adverse events were reported. There were no significant differences in BMI, HbA1C and FEV1 values between the two groups nor within groups, except for HbA1C improvement in the glargine arm at month +18 (p = 0.04). CONCLUSIONS Glargine treatment was well accepted and tolerated. No real efficacy in improving clinical and glycometabolic conditions was demonstrated. Further studies are necessary to test glargine at higher dosage and for a longer follow-up period.
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Affiliation(s)
- Laura Minicucci
- Pediatric Department, CF Center, G. Gaslini Children Hospital, 16147 Genova, Italy.
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Pezzulo AA, Asif MH, Willander M, Zabner J. In Situ Quantification of Glucose Concentration in Airway Surface Liquid With Functionalized ZnO Nanorod-Coated Microelectrodes. JOURNAL OF ANALYTICAL & BIOANALYTICAL TECHNIQUES 2011; S7:002. [PMID: 23227447 PMCID: PMC3514975 DOI: 10.4172/2155-9872.s7-002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The surface of the airways that conduct gases into and out of the lungs has components that protect the host from inhaled and aspirated pathogens. The thin (4-7 µm height) layer of airway surface liquid (ASL) that lines the airways has physicochemical properties that are important for normal function of these antimicrobial components. Among these properties, low glucose concentration is required for normal antimicrobial activity. Current methods for assessing the ASL have important flaws (temporal resolution, dilution factors, collection volume), which have been a recurring obstacle for understanding diseases in which ASL composition is abnormal. To circumvent these problems, microelectrodes coated with ZnO nanorods and immobilized glucose oxidase was used to determine glucose concentration in ASL of well-differentiated cultures of human airway epithelia. The sensor responded to glucose linearly over a concentration range of 0.128 to 8 mM and the effects of electroactive interferents were minimal. The measured concentration of glucose in ASL was consistent with values previously reported. This method confirms the presence of a transepithelial glucose concentration gradient in human airway epithelia and is an important step towards characterizing the physicochemical properties of ASL and understanding diseases caused by changes in ASL composition.
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Affiliation(s)
- Alejandro A. Pezzulo
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Muhammad H. Asif
- Departments of Science and Technology, Campus Norrköping, Linköping University, Norrköping, Sweden
| | - Magnus Willander
- Departments of Science and Technology, Campus Norrköping, Linköping University, Norrköping, Sweden
| | - Joseph Zabner
- Department of Internal Medicine, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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Hameed S, Jaffé A, Verge CF. Cystic fibrosis related diabetes (CFRD)--the end stage of progressive insulin deficiency. Pediatr Pulmonol 2011; 46:747-60. [PMID: 21626717 DOI: 10.1002/ppul.21495] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Revised: 04/07/2011] [Accepted: 04/09/2011] [Indexed: 01/30/2023]
Abstract
In cystic fibrosis, gradual pancreatic destruction causes progressive insulin deficiency, culminating in cystic fibrosis related diabetes (CFRD). As a consequence of insulin deficiency, elevated glucose levels can be detected (well before the diagnosis of CFRD), by continuous ambulatory subcutaneous interstitial fluid glucose monitoring or 30-min sampled oral glucose tolerance test (OGTT). Current diagnostic criteria for CFRD (based on 0 and 120-min OGTT blood glucose levels) were originally designed to forecast microvascular disease in type 2 diabetes, rather than CF-specific outcomes such as declining weight or lung function. In CF, decline in either weight or lung function predicts early mortality. Both may precede the diagnosis of CFRD by several years. Insulin, a potent anabolic hormone, is recommended treatment for CFRD, but use in earlier stages of insulin deficiency is not established. Conventional dosing (with four or more insulin injections per day) is burdensome and carries substantial risk of hypoglycemia. However, recent uncontrolled trials suggest that once-daily injection of intermediate or long-acting insulin improves weight and lung function, with minimal hypoglycemia risk, in CFRD and also in early insulin deficiency. It is plausible that insulin may be of greater benefit to respiratory function when given prior to the diagnosis of CFRD, after which structural lung disease may be irreversible. It is also plausible that early insulin treatment may prolong the lifespan of the remaining insulin-secreting β-cells. Randomized controlled trials are now needed to determine whether or not current clinical practice should be altered toward the earlier commencement of insulin in CF.
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Affiliation(s)
- Shihab Hameed
- Department of Endocrinology, Sydney Children's Hospital, Randwick, NSW, Australia.
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Adler AI, Shine B, Haworth C, Leelarathna L, Bilton D. Hyperglycemia and death in cystic fibrosis-related diabetes. Diabetes Care 2011; 34:1577-8. [PMID: 21593303 PMCID: PMC3120212 DOI: 10.2337/dc10-2289] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes is common in cystic fibrosis and increases the risk of death, yet the role of hyperglycemia remains unproven. An association between glycemia and mortality would provide compelling evidence to support glucose lowering in cystic fibrosis-related diabetes (CFRD). RESEARCH DESIGN AND METHODS Using the U.K. Cystic Fibrosis Registry, we analyzed longitudinal data from 2006 to 2009 in 520 individuals with diabetes. We tested the association between HbA1c and mortality. RESULTS During a median follow-up of 2 years, 36 patients died. The median value of HbA1c was higher in those who died (7.3%) than in those who did not (6.7%). An HbA1c value of ≥6.5% was associated with a threefold increased risk of death (hazard ratio 3.2 [95% CI 1.4-7.3]; P=0.005) independent of potential confounders. CONCLUSIONS Hyperglycemia trebles the risk of death in patients with CFRD. These findings provide epidemiologic support for continued efforts to improve glycemic control.
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Affiliation(s)
- Amanda I Adler
- Wolfson Diabetes and Endocrine Clinic, Addenbrooke’s Hospital, Cambridge, UK.
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Abstract
PURPOSE OF REVIEW The aim is to provide a detailed review of recent publications on cystic fibrosis-related diabetes (CFRD) with a particular focus on the interplay between cystic fibrosis (CF) lung disease and diabetes. RECENT FINDINGS CFRD is a form of diabetes that is distinct from type 1 or type 2 diabetes. CFRD remains very common and increases in prevalence with increasing age so that one in two middle-aged CF persons have CFRD. People with CFRD have lower lung function, worse nutrition, more frequent hospitalization, and worse mortality than CF people without diabetes. The excess mortality previously noted in women with CFRD compared with CF women without diabetes or CF men is much less apparent. CFRD is due to insulin deficiency and peripheral insulin resistance is much less a factor. Genetic susceptibility and oxidant stress are key risk factors for developing CFRD. The lung is the prime end organ target in CFRD and mortality is due to respiratory failure, not vascular complications. Insulin is the mainstay of therapy and early recognition and institution of therapy appear to improve health outcomes. SUMMARY CFRD remains one of the most important co-morbidities in CF. Early recognition of the disease and therapeutic intervention may diminish the negative impact that diabetes has on lung health in CF. Although a clearer understanding of the role of oxidant stress and genetics in the pathogenesis of CFRD is being elucidated, much needs to be learned before more targeted, specific therapies can be developed for this distinct form of diabetes.
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Pezzulo AA, Gutiérrez J, Duschner KS, McConnell KS, Taft PJ, Ernst SE, Yahr TL, Rahmouni K, Klesney-Tait J, Stoltz DA, Zabner J. Glucose depletion in the airway surface liquid is essential for sterility of the airways. PLoS One 2011; 6:e16166. [PMID: 21311590 PMCID: PMC3029092 DOI: 10.1371/journal.pone.0016166] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2010] [Accepted: 12/08/2010] [Indexed: 11/19/2022] Open
Abstract
Diabetes mellitus predisposes the host to bacterial infections. Moreover, hyperglycemia has been shown to be an independent risk factor for respiratory infections. The luminal surface of airway epithelia is covered by a thin layer of airway surface liquid (ASL) and is normally sterile despite constant exposure to bacteria. The balance between bacterial growth and killing in the airway determines the outcome of exposure to inhaled or aspirated bacteria: infection or sterility. We hypothesized that restriction of carbon sources--including glucose--in the ASL is required for sterility of the lungs. We found that airway epithelia deplete glucose from the ASL via a novel mechanism involving polarized expression of GLUT-1 and GLUT-10, intracellular glucose phosphorylation, and low relative paracellular glucose permeability in well-differentiated cultures of human airway epithelia and in segments of airway epithelia excised from human tracheas. Moreover, we found that increased glucose concentration in the ASL augments growth of P. aeruginosa in vitro and in the lungs of hyperglycemic ob/ob and db/db mice in vivo. In contrast, hyperglycemia had no effect on intrapulmonary bacterial growth of a P. aeruginosa mutant that is unable to utilize glucose as a carbon source. Our data suggest that depletion of glucose in the airway epithelial surface is a novel mechanism for innate immunity. This mechanism is important for sterility of the airways and has implications in hyperglycemia and conditions that result in disruption of the epithelial barrier in the lung.
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Affiliation(s)
- Alejandro A. Pezzulo
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Jeydith Gutiérrez
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Kelly S. Duschner
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Kelly S. McConnell
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Peter J. Taft
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Sarah E. Ernst
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Timothy L. Yahr
- Department of Microbiology, University of Iowa, Iowa City, Iowa, United States of America
| | - Kamal Rahmouni
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Julia Klesney-Tait
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - David A. Stoltz
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
| | - Joseph Zabner
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa, United States of America
- * E-mail:
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Moran A, Becker D, Casella SJ, Gottlieb PA, Kirkman MS, Marshall BC, Slovis B. Epidemiology, pathophysiology, and prognostic implications of cystic fibrosis-related diabetes: a technical review. Diabetes Care 2010; 33:2677-83. [PMID: 21115770 PMCID: PMC2992212 DOI: 10.2337/dc10-1279] [Citation(s) in RCA: 169] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Antoinette Moran
- University of Minnesota Medical School, Minneapolis, Minnesota, USA.
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Sc NNM, Shoseyov D, Kerem E, Zangen DH. Patients with cystic fibrosis and normoglycemia exhibit diabetic glucose tolerance during pulmonary exacerbation. J Cyst Fibros 2010; 9:199-204. [DOI: 10.1016/j.jcf.2010.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Revised: 01/19/2010] [Accepted: 02/01/2010] [Indexed: 11/28/2022]
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Abstract
Diabetes is a frequent complication seen in cystic fibrosis patients as they reach adulthood. Cystic fibrosis related diabetes (CFRD) is distinguished as a separate entity with features that include progressive loss of islet beta cell mass and insulin deficiency, as well as insulin resistance. Abnormalities in glucose tolerance may be detectable for many years prior to the development of overt diabetes. Therefore oral glucose tolerance testing is the preferred screening method for the identification of those patients at the highest risk for progression to diabetes. Progression to diabetes has been linked to poor outcomes in CF including loss of pulmonary function and increased mortality among females. Given the role that insulin deficiency plays in CFRD, insulin replacement therapy remains the only recommended intervention. In the absence of definitive supportive data, the use of oral antidiabetic agents is not considered standard therapy and needs further study. As with other forms of diabetes, CFRD patients also experience microvascular complications and should be periodically evaluated for manifestations.
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Affiliation(s)
- Jacquelyn Zirbes
- Centre for Excellence in Pulmonary Biology, Stanford Cystic Fibrosis Centre, Stanford University Medical School, Palo Alto, CA, USA
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House HH, Middleton PG. Impact of different chloride and glucose solutions on nasal potential difference. Pediatr Pulmonol 2009; 44:645-8. [PMID: 19514053 DOI: 10.1002/ppul.21032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION The nasal potential difference (nasal PD) technique can provide useful diagnostic information and can be used to assess the physiological effect of new treatments for cystic fibrosis (CF). In preparation for multi center trials of new CF treatments, many groups worldwide have sought to standardize the protocol, but subtle differences in solution composition remain. This article has compared the effect of different chloride and glucose concentrations on the PD. METHODS Following pre-treatment with amiloride to block sodium absorption, the effect of 0 mM versus 6 mM chloride was compared in six non-CF and six CF subjects. In a separate series of experiments, the effect of glucose on baseline PD was examined in the range of 0-20 mM. RESULTS Following amiloride pre-treatment, the change from 6 to 0 mM chloride increased the PD by approximately 2 mV in the non-CF subjects; the reverse protocol decreased PD by a similar amount. As expected, little change in PD occurred in the CF subjects. Changing the glucose concentration between 0, 10, and 20 mM had little effect on nasal PD in non-CF and CF subjects. CONCLUSION The use of 0 mM chloride gives responses in the non-CF subjects, which are approximately 2 mV greater than protocols which use low (6 mM) chloride. Different glucose concentrations appear to exert little effect on baseline PD, suggesting that electrogenic glucose transport plays a limited role in airway transport at rest.
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Affiliation(s)
- Hugh H House
- Cystic Fibrosis Unit, Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, University of Sydney at Westmead, Westmead, NSW 2145, Australia
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Mohan K, Israel KL, Miller H, Grainger R, Ledson MJ, Walshaw MJ. Long-Term Effect of Insulin Treatment in Cystic Fibrosis-Related Diabetes. Respiration 2008; 76:181-6. [DOI: 10.1159/000110206] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2007] [Accepted: 08/10/2007] [Indexed: 11/19/2022] Open
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Baker EH, Clark N, Brennan AL, Fisher DA, Gyi KM, Hodson ME, Philips BJ, Baines DL, Wood DM. Hyperglycemia and cystic fibrosis alter respiratory fluid glucose concentrations estimated by breath condensate analysis. J Appl Physiol (1985) 2007; 102:1969-75. [PMID: 17303703 DOI: 10.1152/japplphysiol.01425.2006] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In animals, glucose concentrations are 3–20 times lower in lung lining fluid than in plasma. In humans, glucose concentrations are normally low (<1 mmol/l) in nasal and bronchial fluid, but they are elevated by inflammation or hyperglycemia. Furthermore, elevated bronchial glucose is associated with increased respiratory infection in intensive care patients. Our aims were to estimate normal glucose concentrations in fluid from distal human lung sampled noninvasively and to determine effects of hyperglycemia and lung disease on lung glucose concentrations. Respiratory fluid was sampled as exhaled breath condensate, and glucose was measured by chromatography with pulsed amperometric detection. Dilution corrections, based on conductivity, were applied to estimate respiratory fluid glucose concentrations (breath glucose). We found that breath glucose in healthy volunteers was 0.40 mmol/l (SD 0.24), reproducible, and unaffected by changes in salivary glucose. Breath-to-blood glucose ratio (BBGR) was 0.08 (SD 0.05). Breath glucose increased during experimental hyperglycemia ( P < 0.05) and was elevated in diabetic patients without lung disease [1.20 mmol/l (SD 0.69)] in proportion to hyperglycemia [BBGR 0.09 (SD 0.06)]. Breath glucose was elevated more than expected for blood glucose in cystic fibrosis patients [breath 2.04 mmol/l (SD 1.14), BBGR 0.29 (SD 0.17)] and in cystic fibrosis-related diabetes [breath 4.00 mmol/l (SD 2.07), BBGR 0.54 (0.28); P < 0.0001]. These data indicate that 1) this method makes a biologically plausible estimate of respiratory fluid glucose concentration, 2) respiratory fluid glucose concentrations are elevated by hyperglycemia and lung disease, and 3) effects of hyperglycemia and lung disease can be distinguished using the BBGR. This method will support future in vivo investigation of the cause and effect of elevated respiratory fluid glucose in human lung disease.
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Affiliation(s)
- Emma H Baker
- Cardiac and Vascular Sciences (Respiratory), St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK.
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Costa M, Potvin S, Hammana I, Malet A, Berthiaume Y, Jeanneret A, Lavoie A, Lévesque R, Perrier J, Poisson D, Karelis AD, Chiasson JL, Rabasa-Lhoret R. Increased glucose excursion in cystic fibrosis and its association with a worse clinical status. J Cyst Fibros 2007; 6:376-83. [PMID: 17409029 DOI: 10.1016/j.jcf.2007.02.005] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2006] [Revised: 02/18/2007] [Accepted: 02/19/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND Abnormal glucose tolerance is a frequent co-morbidity in cystic fibrosis patients (CF), and is associated with a worse prognosis. The objectives are to investigate (a) the relative contribution of insulinopenia and insulin resistance (IR) for glucose tolerance and (b) the association between various glucose parameters and CF clinical status. METHODS Oral glucose tolerance tests were performed in 114 consecutive CF patients not known to be diabetic as well as 14 controls similar for age and BMI. RESULTS Abnormal glucose tolerance was found in 40% of patients with CF: 28% had impaired glucose tolerance (IGT) and 12% had new cystic fibrosis related diabetes (CFRD). Compared to control subjects, all CF patients were characterized by an increased glucose excursion (AUC). While reduced early insulin release characterised CF, IGT and CFRD patients also present IR thus both mechanisms significantly contribute to glucose tolerance abnormalities. Increased glucose AUC and reduced early insulin release but not glucose tolerance categories were associated with a reduced pulmonary function (FEV(1)). CONCLUSION In CF, early insulin secretion defect but also IR contribute to glucose intolerance. Early in the course of the disease, increased glucose AUC and reduced early insulin secretion are more closely associated with a worse clinical status than conventional glucose tolerance categories.
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Affiliation(s)
- Myriam Costa
- Diabetes Research group, CHUM Research Center Hôtel-Dieu, Montreal QC, Canada H2W 1T7
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McNamara PJ, Proctor RA. Bacterial interactions and the microevolution of cytochrome bd: implications for pathogenesis. J Bacteriol 2006; 188:7997-8. [PMID: 17108290 PMCID: PMC1698182 DOI: 10.1128/jb.01364-06] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Peter J McNamara
- Department Medical Microbiology and Immunology, University of Wisconsin Medical School, Madison, WI 53706, USA.
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