Endocrine pancreatic insufficiency in chronic pancreatitis

Structural Basis of the Pancreatitis-Associated Autoproteolytic Failsafe Mechanism in Human Anionic Trypsin

Objective

Methods

Results

Conclusion

Diabetes Status After Lateral Pancreaticojejunostomy and Frey’s Procedure in Chronic Calcific Pancreatitis: An Observational Study

Introduction

Diabetes secondary to pancreatic diseases is commonly referred to as pancreatogenic diabetes or type 3c diabetes mellitus. This study was conducted to determine the status of diabetes mellitus after Frey’s procedure and lateral pancreaticojejunostomy (LPJ) in diabetic and nondiabetic patients with chronic calcific pancreatitis (CCP) and to discuss the clinicopathological course as well as diabetes in CCP.

Materials and methods

This study was designed as a retrospective observational study consisting of 27 patients with CCP who were surgically treated either with the pancreatic head coring Frey’s procedure or with LPJ. Surgeries were performed in a tertiary care hospital of Eastern India by a team of surgeons following the same surgical principle. The diagnosis of CCP was made by clinical and radiological evaluations. Visual Analog Scale (VAS) scoring was used perioperatively to assess pain. Postoperatively, all the patients were monitored clinically; pain scoring and relevant investigations were done depending upon subjective and objective indications. Special attention was paid to diabetic patients through frequent follow-ups and tight glycemic control. All 27 patients were followed up with at least two outpatient follow-ups.

Results

The trends in fasting blood sugar values in the LPJ group showed a small spike in the early postoperative period (two weeks) with a p-value of >0.05, and later on, it improved over 18 months of follow-up, reaching below the preoperative values (mean 109.38). On the contrary, the fasting blood glucose levels in Frey’s procedure revealed a significant spike in the early postoperative period (two weeks) with a mean sugar value of 148 mg/dl and a p-value of 0.01. The levels stayed well above the preoperative values over 18 months of follow-up. The trends in HbA1c showed marginal improvement in the LPJ group in a six-month follow-up period (p-value 0.008) from the preoperative levels. In Frey’s procedure group, postoperative HbA1c levels at three months revealed an increase, which can be attributed to the minor but significant loss of pancreatic tissue from the head, which continued to be on the higher side at the six-month follow-up. Trends in mean insulin dosage showed a significant spike in the early postoperative period (two weeks) both in the LPJ (p-value 0.01) and Frey’s procedure group (0.01); however, in the LPJ group, the insulin dose showed a reduction over the 18-month follow-up, reaching below the mean preoperative insulin dose. While in the Frey’s procedure group, the postoperative insulin dose remained higher throughout the 18-month follow-up period (p-value <0.05).

Conclusions

LPJ has got a little effect on the diabetic status of nondiabetic patients. Frey’s procedure leads to marginal deterioration of the diabetic status and increases in insulin dosage in both diabetic and nondiabetic patients.

Outcomes of Islet Autotransplantation in Chronic Pancreatitis Patients with Complete Acinar Atrophy

Total pancreatectomy with islet autotransplantation (TPIAT) is a promising treatment for refractory chronic pancreatitis (CP). Pathological features of CP include progressive fibrosis in pancreas parenchyma, atrophy, and/or ductal occlusion. Complete acinar atrophy (CAA) caused by chronic fibrosis and necroinflammation results in exocrine sufficiency and may influence islet isolation characteristics during TPIAT. In this analysis of patients who underwent TPIAT at our center, we compared transplant outcomes among those with CAA (n = 5) vs non-acinar atrophy (NAA; matching controls, n = 36). Data were analyzed using one-way analysis of variance with Bonferroni post hoc test or Student's t test. Pancreas digestion was longer in CAA than in NAA cases (18.6 vs 14.6 min) despite a lower pancreas weight (55.2 vs 91.2 g). Obtained tissue volume was 1.0 ml in the CAA group and 12.1 ml in the NAA group. Both groups had similar islet viability (96%) and islet dose (CAA, 3,391 IEQ/kg; NAA, 4141.1 IEQ/kg). During islet infusion, serum cytokine (IL-6, IL-8, and MCP-1) levels and plasma hsa-miR-375 levels were lower in the CAA group than in the NAA group, but not significantly. Serum tumor necrosis factor α levels at 3 h after infusion were significantly higher in CAA group than in NAA group. After TPIAT, the metabolic outcomes of the CAA group were comparable with that of the NAA group. Narcotics usage decreased significantly over 24 months in both groups, with the CAA group reporting being pain free at 12 months. Complete atrophy of acinar cells of pancreas did not significantly impact islet yield or endocrine function after TPIAT.

Insulin-like growth factor 1 and insulin-like growth factor binding protein 2 serum levels as potential biomarkers in differential diagnosis between chronic pancreatitis and pancreatic adenocarcinoma in reference to pancreatic diabetes

INTRODUCTION

Insulin-like growth factor 1 (IGF-1) has been connected with development of pancreatic ductal adenocarcinoma (PDAC).

AIM

To evaluate the serum concentration levels of IGF-1 and insulin-like growth factor binding protein 2 (IGFBP-2) in patients with chronic pancreatitis (CP) and PDAC. Their values in diabetes mellitus (DM) were also assessed.

MATERIAL AND METHODS

The study included 83 patients with CP, 92 patients with PDAC, and 20 subjects as a control group. The concentrations of IGF-1 and IGFBP-2 were estimated with ELISA (Corgenix UK Ltd, R&D Systems).

RESULTS

The IGF-1 was higher in CP compared with PDAC (81.11 ±57.18 ng/ml vs. 53.18 ±36.05 ng/ml, p < 0.001), and both CP and PDAC were different from controls (81.11 ±57.18 ng/ml vs. 70.66 ±16.57 ng/ml, p < 0.001 and 53.18 ±36.05 ng/ml vs. 70.66 ±16.57 ng/ml, p < 0.001). CP without cysts have lower IGF-1 compared to those with CP and cysts (60.35 ±34.68 ng/ml vs. 93.55 ±64.78 ng/ml, p < 0.05). IGF-1 in CP without DM was higher compared to IGF-1 in PDAC without DM (91.13 ±65.48 ng/ml vs. 54.75 ±40.41 ng/ml, p < 0.001). In CP and DM the IGF-1 was elevated in comparison to PDAC and DM (62.20 ±32.38 ng/ml vs. 48.45 ±24.88 ng/ml, p < 0.05). IGFBP-2 was higher in CP compared to PDAC (512.42 ±299.77 ng/ml vs 301.59 ±190.36 ng/ml, p < 0.001). In CP and PDAC the IGFBP-2 level was elevated compared to the control group (512.42 ±299.77 ng/ml vs. 51.92 ±29.40 ng/ml, p < 0.001 and 301.59 ±190.36 ng/ml vs. 51.92 ±29.40 ng/ml, p < 0.001). IGFBP-2 in CP without DM was higher compared to PDAC without DM (559.39 ±281.43 vs. 296.53 ±196.93, p < 0.001).

CONCLUSIONS

IGF-1 and IGFBP-2 may be biomarkers of CP and PDAC. IGF-1 may be an indicator that signals whether pancreatic diabetes is from CP or PDAC.

Risk Factors Associated With Progression Toward Endocrine Insufficiency in Chronic Pancreatitis

OBJECTIVE

Little data exist describing the change over time in islet function and glycemic control in patients with chronic pancreatitis (CP).

METHODS

In 325 CP patients who underwent 2 mixed meal tolerance tests and/or glycated hemoglobin (HbA1c) levels, we estimated the rate of change in metabolic measures per 6 months and assessed the association between potential risk factors for diabetes and rate of change using multivariate regression models.

RESULTS

Per 6-month time, HbA1c increased by 0.062% with a standard error of 0.029% (P = 0.037) and the ratio (area under the curve (AUC) C-peptide to AUC glucose from mixed meal tolerance testing) decreased by 0.0028 with a standard error of 0.0011 (P = 0.014). We observed more rapid decline in smokers (AUC C-peptide, P = 0.043) and patients with surgical drainage (AUC glucose, P = 0.001; ratio, P = 0.03) or with calcific pancreatitis (HbA1c, P = 0.003). In multivariate models, AUC C-peptide and ratio declined at a greater rate in smokers and HbA1c in those with pancreatic calcifications (both P < 0.05).

CONCLUSIONS

We observed a measurable decline in β-cell function and glycemic control in patients with CP. Patients with a history of tobacco smoking, surgical drainage, or pancreatic calcification may be at highest risk.

Clube Português do Pâncreas Recommendations for Chronic Pancreatitis: Etiology, Natural History, and Diagnosis (Part I)

Chronic pancreatitis (CP) is a heterogeneous disease, with different causes and often a long delay between onset and full classic presentation. Clinical presentation depends on the stage of the disease. In earlier stages, recurrent episodes of acute pancreatitis are the major signs dominating clinical presentation. As the inflammatory process goes on, less acute episodes occur, and pain adopts different aspects or may even disappear. After 10-15 years from onset, functional insufficiency occurs. Then, a classic presentation with pain and pancreatic exocrine and endocrine insufficiency appears. Diagnosis remains challenging in the early stages of the disease, as its initial presentation is usually ill-defined and overlaps with other digestive disorders. Computed tomography and magnetic resonance cholangiopancreatography should be the first choice in patients with suspected CP. If the results are normal or equivocal but still there is a high suspicion of CP, the next option should be endoscopic ultrasound. Endoscopic retrograde cholangiopancreatography is mainly a therapeutic technique, and for the diagnostic purpose should only be used when all other imaging modalities and pancreatic function tests have been exhausted. Indirect tests are used to quantify the degree of insufficiency in already-established late CP. Recommendations on CP were developed by Clube Português do Pâncreas (CPP), based on literature review to answer predefined topics, subsequently discussed and approved by all members of CPP. Recommendations are separated in two parts: "chronic pancreatitis etiology, natural history, and diagnosis," and "chronic pancreatitis medical, endoscopic, and surgical treatment." This abstract pertains to part I.

Impact of hyperglycemia on autoimmune pancreatitis and regulatory T-cells

AIM

To evaluate the influence of hyperglycemia on the progression of autoimmune pancreatitis.

METHODS

We induced hyperglycemia by repetitive intraperitoneal (ip) injection of 50 mg/kg streptozotocin in MRL/MpJ mice, which develop autoimmune pancreatitis due to a genetic predisposition. We compared the extent of inflammation (histological score, CD3+ lymphocytes, CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells) in the pancreas of hyperglycemic and normoglycemic mice. We also analyzed the number of leukocytes, lymphocytes, granulocytes and monocytes in the blood. In addition, we determined the percentage of CD3+ lymphocytes, CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells, Foxp3+ CD25+ T-helper and Foxp3- T-helper cells in the spleen by flow cytometry.

RESULTS

Treatment with streptozotocin caused a strong induction of hyperglycemia and a reduction in body weight (P < 0.001). Severe hyperglycemia did not, however, lead to an aggravation, but rather to a slight attenuation of autoimmune pancreatitis. In the pancreas, both the histological score of the pancreas as well as the number of CD3+ lymphocytes (P < 0.053) were decreased by hyperglycemia. No major changes in the percentage of CD8+ T-cells, CD4+ T-cells, Foxp3+ T-helper cells were observed between hyperglycemic and normoglycemic mice. Hyperglycemia increased the numbers of leukocytes (P < 0.001), lymphocytes (P = 0.016), granulocytes and monocytes (P = 0.001) in the blood. Hyperglycemia also moderately reduced the percentage of CD3+ lymphocytes (P = 0.057), significantly increased the percentage of Foxp3+ T-helper cells (P = 0.018) and Foxp3+ CD25+ T-helper cells (P = 0.021) and reduced the percentage of Foxp3- T-helper cells (P = 0.034) in the spleen.

CONCLUSION

Hyperglycemia does not aggravate but moderately attenuates autoimmune pancreatitis, possibly by increasing the percentage of regulatory T-cells in the spleen.

Chronic pancreatitis: Multicentre prospective data collection and analysis by the Hungarian Pancreatic Study Group

Introduction

Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life.

Aims and methods

Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions.

Results

Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004).

Conclusions

According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.

Comorbid risks of deep vein thrombosis and pulmonary thromboembolism in patients with chronic pancreatitis: a nationwide cohort study

ESSENTIALS: Risks of deep vein thrombosis (DVT) and pulmonary embolism (PE) in chronic pancreatitis (CP) are unclear. We conducted a nationwide cohort study to evaluate the risks of DVT and PE in CP patients. 17 778 patients with CP and 71 106 without CP were followed for 86 740 and 429 116 person-years, respectively. Patients with CP had a 2.95-fold increased rate of DVT and a 4.51-fold increased rate of PE.

BACKGROUND

Studies on the association between chronic pancreatitis (CP) and cardiovascular diseases are scarce. We conducted a nationwide cohort study to evaluate the risks of deep vein thrombosis (DVT) and pulmonary embolism (PE) in CP patients.

METHODS

Using the data from the Taiwan National Health Insurance Research Database, we randomly selected a non-CP cohort from insurants without a history of CP, and frequency-matched them at a ratio of 4 : 1 according to age, sex and index year with each patient newly diagnosed with CP between 2000 and 2010. The follow-up period ranged from the index date of new CP diagnosis to the diagnosis of DVT or PE, censoring, or the end of 2011. We used univariable and multivariable Cox proportional hazard regression models to determine the risks of DVT and PE.

RESULTS

In total, 17 778 patients in the CP cohort (82.6% men; mean age of 48.6 years) and 71 106 persons in the non-CP cohort were observed for 86 740 and 429 116 person-years, respectively. The CP cohort showed a 2.95-fold greater adjusted hazard ratio (aHR) for DVT (95% confidence interval [CI] 2.06-4.22) and a 4.51-fold greater aHR for PE (95% CI 2.86-7.11) than the non-CP cohort. Substantial risks of DVT and PE were evident in patients with CP aged < 55 years. The CP cohort with comorbidities showed increased risks of DVT and PE as compared with the non-CP cohort with no comorbidities.

CONCLUSIONS

The risks of DVT and PE are significantly higher in CP patients than in the general population.

Rosiglitazone inhibits hepatic insulin resistance induced by chronic pancreatitis and IKK-β/NF-κB expression in liver

OBJECTIVES

This study aimed to investigate the influence of rosiglitazone on hepatic insulin resistance and the expressions of IκB kinase-β (IKK-β)/nuclear factor-κB (NF-κB) in chronic pancreatitis (CP).

METHODS

After CP was induced in rats, rosiglitazone and GW9662 were administered at the doses of 4 and 2 mg/kg per day for 4 weeks, respectively. Then, glucose and insulin tolerance tests were performed. Hepatocytes were isolated for the glucose release experiments. Determination of the IKK-β, NF-κB, and Ser307p-insulin receptor substrates-1 (Ser307p-IRS-1) expression in the liver was performed.

RESULTS

The increased plasma glucose, reduced insulin sensitivity, and the capacity of insulin to suppress glucose release in hepatocytes were observed in CP rats. The IKK-β, NF-κB, and Ser307p-IRS-1 expressions were significantly higher in the liver of CP rats than in sham-operated rats (P < 0.05). Rosiglitazone treatment significantly improved hepatic insulin sensitivity and inhibited the IKK-β, NF-κB, and Ser307p-IRS-1 expressions in the liver (P < 0.05). Counteraction with peroxisome proliferator-activated receptor-γ by GW9662 attenuated the aforementioned effects of rosiglitazone.

CONCLUSIONS

Rosiglitazone attenuates hepatic insulin resistance induced by CP. The inhibition of hepatic IKK-β and NF-κB expressions via peroxisome proliferator-activated receptor-γ may be involved in the therapeutic effect of rosiglitazone.

Characterization of two deletions of the CTRC locus

Novel variants associated with chronic pancreatitis are being increasingly reported. However, most studies have so far only analyzed point mutations and small insertions or deletions. Here we report the characterization of two distinct deletions of the CTRC locus. Variants in four chronic pancreatitis genes, PRSS1, SPINK1, CTRC and CFTR, were systematically analyzed in the studied cases. Copy number change of the CTRC gene was analyzed by quantitative fluorescent multiplex PCR (QFM-PCR). Walking QFM-PCR followed by long-range PCR and direct sequencing were employed to identify the deletion breakpoints at the nucleotide level. A heterozygous CTRC-deleting complex rearrangement, which was co-inherited with different trans variants in SPINK1, CFTR or PRSS1, is associated with variable phenotypes (chronic pancreatitis; pancreatic cancer and chronic pancreatitis; and type 1 diabetes). Moreover, a different homozygous deletion of the CTRC locus was found in an unrelated patient with asymptomatic chronic pancreatitis. Our findings revealed a hitherto unrecognized level of complexity of genotype-phenotype correlation in chronic pancreatitis. The CTRC-deleting complex rearrangement probably resulted from LINE-1-mediated Alu insertion, which represents a novel mutational mechanism causing chronic pancreatitis.

Patient satisfaction and cost-effectiveness following total pancreatectomy with islet cell transplantation for chronic pancreatitis

OBJECTIVES

Chronic pancreatitis (CP) results in an extremely poor quality of life and substantially increases health care utilization. Few data exist regarding the cost-effectiveness of surgical treatment for CP.

METHODS

This article examined the cost-effectiveness of total pancreatectomy (TP) with islet cell autotransplantation (IAT) for CP.

RESULTS

Sixty patients undergoing TP + IAT and 37 patients undergoing TP were identified. Surgery resulted in significant reduction in opiate use, frequency of hospital admissions, and length of stay as well as visual analog scale scores for pain. Total pancreatectomy + IAT resulted in longer survival than TP alone (16.6 vs 12.9 years); 21.6% of patients with TP + IAT were insulin-independent, and those requiring insulin have reduced daily requirements compared with those having TP alone (22 vs 35 IU). The cost of TP + IAT with attendant admission and analgesia costs over the 16-year survival period was £110,445 compared with £101,608 estimated 16-year costs if no TP + IAT was undertaken.

CONCLUSIONS

Total pancreatectomy + IAT is effective in improving pain and reducing analgesia. Islet cell transplantation offers the chance of insulin independence and results in lower insulin requirements, as well as conferring a survival advantage when compared with TP alone. Total pancreatectomy + IAT is cost-neutral when compared with nonsurgical or segmental surgical therapy.

Oxidative stress and antioxidant capacity in patients with chronic pancreatitis with and without diabetes mellitus

AIM

To determine oxidant stress and antioxidant capacity in chronic pancreatitis (CP) patients with and without diabetes mellitus.

METHODS

This study is a secondary data analysis of our earlier study on 127 (male = 86) patients with CP, grouped as those with diabetes (case; n = 23) and those without diabetes (control). Markers of antioxidant status included vitamins A and E, total antioxidant capacity (TAC; measured as ferric-reducing ability of plasma [FRAP]), and total glutathione (T-GSH). Markers for oxidative stress included lipid peroxidation, measured as thiobarbituric acid reactive substances (TBARS) and serum superoxide dismutase (s-SOD).

RESULTS

Patients with diabetes were older (mean [SD] age 36.4 [9.7] vs. 29.3 [10.0] years; p = 0.032), had longer duration of CP [4 (0.3-21) vs. 3 (0.3-24) years; p = 0.07), and had a lower TAC (269.8 [92.4] vs. 355.5 [128.6] μmoles Fe(+2) liberated; p = 0.003) compared to those without diabetes. In multiple logistic regression analysis taking all exploratory variables, FRAP (<270 μmoles Fe(+2) liberated) was associated with diabetes independent of duration of CP, age of patients, and TBARS levels. However, oxidative stress levels were not different between diabetic and nondiabetic patients.

CONCLUSIONS

Diabetes was found to be associated with longer duration of CP and with low antioxidant capacity. Further studies will be needed to evaluate a causal association.

Diabetes aggravates acute pancreatitis and inhibits pancreas regeneration in mice

AIMS/HYPOTHESIS

It is well established that acute pancreatitis often causes diabetes and that a high blood glucose level associated with pancreatitis is a marker of poor prognosis. The aim of this study was to evaluate if diabetes merely reflects the severity of pancreatitis or whether it can also aggravate the progression of this disease in a vicious circle.

METHODS

Reversible acute oedematous pancreatitis was induced in untreated and streptozotocin-treated diabetic mice by injection of cerulein. Progression of pancreatitis was studied by immunohistochemistry, ELISA and various other enzyme assays. The production of regenerating islet-derived 3β (REG3β) was determined by western blot and immunohistochemistry.

RESULTS

While cerulein treatment in non-diabetic mice resulted in acute pancreatitis followed by regeneration of the pancreas within 7 days, diabetes aggravated pancreatitis, inhibited the regeneration of the exocrine tissue and led to strong atrophy of the pancreas. The aggravation of pancreatitis by diabetes was characterised by decreased production of the anti-inflammatory protein REG3β, increased inflammation, augmented oedema formation and increased cell death during the acute phase of pancreatitis (p < 0.05). During the regenerative phase, diabetes augmented inflammation, increased cell death, reduced acinar cell expansion and increased the expansion of duct as well as interstitial cells, resulting in the formation of tubular complexes (p < 0.05). Administration of insulin reversed the observed phenotype in diabetic mice.

CONCLUSIONS/INTERPRETATION

Diabetes aggravates acute pancreatitis and suppresses regeneration of the exocrine tissue. Thus, diabetes is not just a concomitant phenomenon of pancreatitis, but can have a fundamental influence on the progression of acute pancreatitis.

Expression and regulation of chemokines in murine and human type 1 diabetes

More than one-half of the ~50 human chemokines have been associated with or implicated in the pathogenesis of type 1 diabetes, yet their actual expression patterns in the islet environment of type 1 diabetic patients remain, at present, poorly defined. Here, we have integrated a human islet culture system, murine models of virus-induced and spontaneous type 1 diabetes, and the histopathological examination of pancreata from diabetic organ donors with the goal of providing a foundation for the informed selection of potential therapeutic targets within the chemokine/receptor family. Chemokine (C-C motif) ligand (CCL) 5 (CCL5), CCL8, CCL22, chemokine (C-X-C motif) ligand (CXCL) 9 (CXCL9), CXCL10, and chemokine (C-X3-C motif) ligand (CX3CL) 1 (CX3CL1) were the major chemokines transcribed (in an inducible nitric oxide synthase-dependent but not nuclear factor-κB-dependent fashion) and translated by human islet cells in response to in vitro inflammatory stimuli. CXCL10 was identified as the dominant chemokine expressed in vivo in the islet environment of prediabetic animals and type 1 diabetic patients, whereas CCL5, CCL8, CXCL9, and CX3CL1 proteins were present at lower levels in the islets of both species. Of importance, additional expression of the same chemokines in human acinar tissues emphasizes an underappreciated involvement of the exocrine pancreas in the natural course of type 1 diabetes that will require consideration for additional type 1 diabetes pathogenesis and immune intervention studies.

Improved glycemic control in pancreatic diabetes through intensive conservative insulin therapy

OBJECTIVE

The aim of this study was to evaluate the effectivity and safety of insulin therapy in patients with DM secondary to underlying chronic pancreatitis with initially inappropriate glycemic control.

METHODS

Pancreatic DM patients treated with oral antidiabetics (OAD) or pre-mixed insulin (PMI) with HbA1c ≥7.0% were recruited. Intensive conservative insulin treatment (ICT) (Group A, n = 16) or PMI (Group B, n = 8) was introduced instead of OAD, or the initial PMI therapy was switched to ICT (Group C, n = 10). The changes in HbA1c, fasting plasma glucose, body weight and hypoglycemic events from baseline to 2 years were followed.

RESULTS

The patients in Group A and B had been treated with oral antidiabetics for 55 ± 68 months before switching to insulin therapy. The level of HbA1c had worsened from 8.3 ± 1.5% to 9.8 ± 1.7% during this period. The ICT had reduced HbA1c significantly from 9.7 ± 1.8% to 7.6 ± 1.4% after 12 weeks, in Group A, and five patients had HbA1c<7.0%. The introduction of PMI in Group B reduced HbA1c from 10.0 ± 1.4% to 9.0 ± 0.6% by 12 weeks. None of the patients had HbA1c<7.0%. By 12 weeks, the introduction of ICT in Group C had reduced the level of HbA1c from 8.8 ± 1.7% to 7.7 ± 1.2%. Two patients reached HbA1c<7.0%. There were two severe hypoglycemic episodes during the 2 years, one-one case in Group A and B.

CONCLUSIONS

Oral medication becomes insufficient early in pancreatic DM. Long-term improvement of glycemic control can be achieved through intensified insulin therapy and in selected cases through PMI with a low risk of hypoglycemia.

Interferon γ and glycemic status in diabetes associated with chronic pancreatitis

BACKGROUND/AIMS

Although the role of cytokines in the etiopathology of chronic pancreatitis (CP) is well recognized, information on pancreatic tissue cytokines in CP with/without associated diabetes is unavailable. The aim of the present study was to identify the differences in pancreatic cytokines and observe their correlations with the glycemic status in CP.

METHODS

Pancreata were obtained from CP patients (n = 44), with/without associated diabetes and non-diabetic control subjects (n= 20). Patients with CP were classified into two groups after ascertaining their diabetic status. Pancreatic cytokines (IL 1β, IL 6, IL 8, IL 10, IL 12P70, TNF α, IFN γ) were analyzed by flow cytometer. The influence of individual and cocktail of cytokines on glucose stimulated insulin release (GSIR) was examined by challenging the islets from control subjects.

RESULTS

The pancreatic IFN γ levels in diabetic and non diabetic CP patients were significantly higher in comparison to controls. The glucose stimulated insulin release (GSIR) in response to high glucose concentration in control islets, islets from non-diabetic and diabetic CP patients was 8.2, 5.67 and 3.15 μU × 10(-3)/min/islet equivalent respectively. IFN γ resulted in 82.35% decrease in GSIR from the control islet cells at a concentration of >20 pg/ml which was reversed by epigallocatechin-3-gallate (EGCG).

CONCLUSION

These results suggest that IFN γ among other cytokines, play a major role in β-cell dysfunction associated with CP.

Characteristics of pancreatic diabetes in patients with autoimmune pancreatitis

OBJECTIVE

Although patients with autoimmune pancreatitis (AIP) tend to have concurrent diverse disorders, very few studies have focused on diabetes mellitus (DM) coexisting with AIP.

METHODS

In total 102 AIP patients with DM were divided into three groups. Those with DM before the onset of AIP were labeled group A (n=35), those who developed DM and AIP simultaneously were labeled group B (n=58) and those who developed DM after steroid therapy for AIP were labeled group C (n=9). The characteristics of DM among the three groups were evaluated.

RESULTS

No significant differences were noted in the age of DM onset among the three groups. However, the mean duration of DM was significantly longer in group A (8.7 years) than in groups B and C. AIP developed 6.8 years after DM onset in group A, whereas it developed 1.8 years after steroid therapy in group C. Group A had the highest rate (25.7%) of family members with a history of AIP. Levels of serum albumin, total cholesterol and triglyceride were significantly lower in group A. No correlations were found between glycated hemoglobin and benzoyl-tyrosyl para-aminobenzoic acid. Hypoglycemia was observed in 20% of patients under insulin therapy. Most of them were habitual drinkers and received no pancreatic enzymes. Group A showed a high prevalence of retinopathy, nephropathy and macrovascular disorders than group B.

CONCLUSION

Aspects of AIP-associated pancreatic diabetes were clarified. AIP-associated DM must be controlled by a full assessment of the pancreatic endocrine and exocrine function.

Epidemiological study of pancreatic diabetes in Japan in 2005: a nationwide study

OBJECTIVES

There have been few epidemiological studies on pancreatic diabetes. In this study, we determined the incidence and pathology of pancreatic diabetes in Japan.

METHODS

We examined the epidemiology of pancreatic diabetes in Japan in 2005 by using a nationwide stratified random-sampling method. Especially, we focused on newly developed diabetes in association with the occurrence of pancreatic disease (true pancreatic diabetes).

RESULTS

A total of 19,500 individuals received treatment for true pancreatic diabetes, accounting for 0.8% of patients with diabetes. Prevalence was estimated to be 15.2 per 100,000 with an annual onset incidence of 1.1 per 100,000. With regard to the complications in true pancreatic diabetes, the incidence of retinopathy was lower than that in types 1 and 2 diabetes. Among true pancreatic diabetes with chronic pancreatitis, alcoholic pancreatitis was found in the largest sector. Furthermore, as many as 53.7% were continuous drinkers, and 66.7% received insulin therapy. The frequency of hypoglycemia was high in regular drinkers treated with insulin. Hypoglycemia was a major cause of death in patients who were on insulin and continuous drinkers.

CONCLUSION

We clarified the epidemiology of pancreatic diabetes in Japan. Patients with chronic pancreatitis-associated pancreatic diabetes should receive lifestyle guidance focused on drinking cessation.

Interactions between the endocrine and exocrine pancreas and their clinical relevance

In consequence of the close anatomical and functional links between the exocrine and endocrine pancreas, any disease affecting one of these parts will inevitably affect the other. Pancreatic conditions which might cause diabetes mellitus include acute and chronic pancreatitis, pancreatic surgery, cystic fibrosis and pancreatic cancer. The development of diabetes greatly influences the prognosis and quality of life of patients with exocrine pancreatic diseases. It may cause life-threatening complications, such as hypoglycemia, due to the lack of glucagon and the impaired absorption of nutrients, or the micro- and macrovascular complications may impair the organ functions. Diabetes mellitus is an independent risk factor of mortality in those with exocrine pancreatic diseases. The treatment of pancreatic diabetes, a distinct metabolic and clinical form of diabetes, requires special knowledge. Diet and pancreatic enzyme replacement therapy may be sufficient in the early stages. Oral antidiabetic drugs are not recommended. If the diet proves inadequate to reach the glycemic goals, insulin treatment with multiple injections is required. Impairments of the exocrine pancreatic function and morphology in diabetic patients are frequent and well known. Atrophy of the exocrine tissue may be caused by the lack of trophic insulin, whereas pancreatic fibrosis can result from activation of stellate cells by hyperglycemia, or from microangiopathy and neuropathy. The regulation of the exocrine pancreatic function is also damaged because of the impaired effect of islet hormones. In the event of a proven impairment of the pancreatic exocrine function in diabetes mellitus, pancreatic enzyme replacement therapy is indicated. This may improve the nutritional condition of the patient and decrease the metabolic instability.

The current managements of pancreatic diabetes in Japan

Pancreatic diabetes is secondary diabetes followed by progressions of pancreatic exocrine diseases, such as chronic pancreatitis, pancreatic neoplasm and post-pancreatectomy. Because of destruction and reduction of the pancreatic endocrine and exocrine functional compartments, patients with pancreatic diabetes frequently show malnutrition from maldigestion and malabsorption by insufficiencies in pancreatic digestive enzymes, and show unstable glycemic control and prolonged hypoglycemia by insufficiencies in synthesis and secretion of insulin and glucagon. Epidemiological studies have suggested that the incidence and development of pancreatic diabetes in patients with chronic pancreatitis (CP) depends on several risk factors, such as alcohol intake, the presence of pancreatic calcification and the long-term duration of CP. The clinical management of pancreatic diabetes is divided into two parts: one is the supplementation of pancreatic digestive enzymes and the other is the achievement of appropriate glycemic control. The appropriate and sufficient pancreatic exocrine replacement therapy is important for the maintenance of better nutrient conditions for patients with pancreatic diabetes. Furthermore, the intensive insulin therapy combined with short- or ultra-short-acting insulin and long-acting insulin glargine can be achieved for stable glycemic control and reduction of severe frequent hypoglycemia in patients with pancreatic diabetes. These current advanced management techniques against insufficiencies of pancreatic exocrine endocrine functions are beneficial for improving and maintaining the quality of life in patients with pancreatic diabetes.

Critical roles for macrophages in islet angiogenesis and maintenance during pancreatic degeneration

OBJECTIVE

Chronic pancreatitis, characterized by pancreatic exocrine tissue destruction with initial maintenance of islets, eventually leads to insulin-dependent diabetes in most patients. Mice deficient for the transcription factors E2F1 and E2F2 suffer from a chronic pancreatitis-like syndrome and become diabetic. Surprisingly, onset of diabetes can be prevented through bone marrow transplantation. The goal of the described studies was to determine the hematopoietic cell type responsible for maintaining islets and the associated mechanism of this protection.

RESEARCH DESIGN AND METHODS

Mouse models of acute and chronic pancreatitis, together with mice genetically deficient for macrophage production, were used to determine roles for macrophages in islet angiogenesis and maintenance.

RESULTS

We demonstrate that macrophages are essential for preventing endocrine cell loss and diabetes. Macrophages expressing matrix metalloproteinase-9 migrate to the deteriorating pancreas. E2f1/E2f2 mutant mice transplanted with wild-type, but not macrophage-deficient colony stimulating factor 1 receptor mutant (Csf1r(-/-)), bone marrow exhibit increased angiogenesis and proliferation within islets, coinciding with increased islet mass. A similar macrophage dependency for islet and islet vasculature maintenance is observed during caerulein-induced pancreatitis.

CONCLUSIONS

These findings demonstrate that macrophages promote islet angiogenesis and protect against islet loss during exocrine degeneration, could explain why most patients with chronic pancreatitis develop diabetes, and suggest an avenue for preventing pancreatitis-associated diabetes.

Hydrogen sulfide, nitric oxide and a molecular mass 66 u substance in the exhaled breath of chronic pancreatitis patients

BACKGROUND/AIMS

Human exhaled breath contains many molecules either present as gases or occurring in a soluble form in the vapor of the breath. This study was designed to evaluate the substances present in the exhaled breath of chronic pancreatitis (CP) patients.

SUBJECTS

Thirty-one consecutive CP patients (11 with exocrine insufficiency) and 31 healthy subjects (HS) were studied.

METHODS

Ninety-eight different substances were analyzed using a mass spectrometer on a breath sample from all subjects and on each respective ambient air sample.

RESULTS

H(2)S, NO and a substance having a molecular mass of 66 u (M66) were those which had significantly higher concentrations in CP patients than in HS after adjustment for the ambient air; the estimated increases attributable to the disease were 14% (p = 0.040) for H(2)S, 84% (p = 0.006) for M66 and 50% (p = 0.033) for NO, but the three volatile compounds showed poor diagnostic accuracy in differentiating CP patients from HS (AUC-ROC: 0.664, 0.715, and 0.602 for H(2)S, M66, and NO, respectively). Finally, no significant differences of H(2)S, M66, and NO were found between patients with and without alcoholic pancreatitis as well as between patients with and without pancreatic insufficiency.

CONCLUSIONS

Exhaled breath analysis can rapidly and easily assess the presence of volatile compounds (H(2)S, NO and a substance having a molecular mass of 66 u) which may have properties capable of explaining, at least in part, the pathogenesis of CP.

Pancreatic diabetes in a follow-up survey of chronic pancreatitis in Japan

BACKGROUND

We aimed to determine the cumulative rate of diabetes mellitus (DM) and the risk factors for DM in patients with chronic pancreatitis (CP) in Japan.

METHODS

We conducted a follow-up survey of CP in 2002 in patients registered as having CP in 1994, and confirmed 656 patients to be checked in regard to the survey items concerning diabetes. We analyzed the cumulative rate of DM and the risk factors for DM over an 8-year follow up period.

RESULTS

In 1994, 35.1% of 656 CP patients had DM, and the incidence of diabetes had increased to 50.4% in 2002. Of 418 patients without diabetes in 1994, 28.9% (121/418) were newly diagnosed with DM in 2002. Alcoholic CP was the most common type of CP in patients with newly developed diabetes, accounting for 67.8%. The incidence of DM was highest in those with alcoholic CP (34.3%) followed by idiopathic CP (23.0%). The risk of diabetes increased 1.32-fold after the onset of pancreatic calcification. Of 121 patients with newly diagnosed DM in 2002, 37 (30.6%) had pancreatic stones in 1994 and 49 (40.5%) had a stone in 2002. The highest incidence of newly diagnosed DM was observed in patients with continuous alcoholic intake (40.9%). Patients treated with camostat mesilate developed DM less frequently than those without camostat mesilate.

CONCLUSIONS

The present study showed that the incidence of DM in patients with CP increased with time. Of 418 CP patients without DM in 1994, 28.9% developed DM over a period of 8 years. Continuous alcoholic intake aggravated CP and increased the risk of DM in those with CP.

Chronic pancreatitis

PURPOSE OF REVIEW

As in our previous reviews, we endeavor to review important new observations in chronic pancreatitis made in the past year. Topics recently reviewed were truncated to accommodate a surge in publications on clinical aspects of chronic pancreatitis, which contained new observations or insights into new or old concepts.

RECENT FINDINGS

Cystic fibrosis carriers have been found to be at increased risk of pancreatitis. Autoimmune pancreatitis may belong to a multiorgan immunoglobulin G4-related autoimmune disease, and the natural history of chronic pancreatitis differs among the etiologies. Diffusion-weighted magnetic resonance imaging improves upon previous methodologies for diagnosing reduced pancreatic exocrine secretion, and fecal elastase-1 has been found to be a poor test for diagnosing pancreatic malabsorption. Visceral hyperalgesia or heightened central pain perception may contribute to pain in chronic pancreatitis. Instruments are evolving to assess quality of life in chronic pancreatitis, and fibrolytic agents have been found to have therapeutic promise.

SUMMARY

Researchers this past year have further characterized genetic, molecular and clinical aspects of chronic pancreatitis. Advancing the understanding of fibrogenesis, mechanisms of exocrine insufficiency, calcification, and pain and continuing development/modification of diagnostic tests should lead to improved prevention, detection and treatment of the condition. More accurate quantification of outcomes is critical for translating potential therapies from bench to bedside.

Impact of smoking on patients with idiopathic chronic pancreatitis

OBJECTIVES

Chronic pancreatitis is usually caused by heavy alcohol intake and, in many studies, also smoking. Because heavy drinkers usually smoke, making it difficult to separate the effects of these 2 factors, we thought to study the impact of smoking on the progression of nonalcoholic idiopathic chronic pancreatitis (ICP) METHODS: We used data from 83 patients with ICP in Switzerland and from 83 patients in Italy. We studied the impact of smoking on progression of disease as measured by the appearance of calcification and diabetes using Cox regression models.

RESULTS

In both centers, the prevalence of smoking was significantly higher in patients with ICP than in the background population. In Italian patients, smoking increased the risk of pancreatic calcifications (hazard ratio = 2.09; 95% confidence interval, 1.07-4.10). Smoking also shortened the time to appearance of calcification. Heavy smoking (>20 cigarettes per day) was associated with the appearance of diabetes (hazard ratio = 3.94; 95% confidence interval, 1.14-13.6). For those patients who never reported consuming alcohol, smoking remains a significant risk factor.

CONCLUSIONS

In nonalcoholic ICP, smoking is associated with disease progression as measured by the appearance of pancreatic calcification and, to a lower extent, of diabetes. These findings were chiefly observed in patients who were older than 35 years at the time of onset of disease.