1
|
Kaewkrasaesin C, Kositanurit W, Chotwanvirat P, Laichuthai N. Enhancing outcome prediction by applying the 2019 WHO DM classification to adults with hyperglycemic crises: A single-center cohort in Thailand. Diabetes Metab Syndr 2024; 18:103012. [PMID: 38643708 DOI: 10.1016/j.dsx.2024.103012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 04/10/2024] [Accepted: 04/13/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND AND AIMS Hyperglycemic crisis is a metabolic catastrophe which can occur in any type of diabetes. In 2019, the World Health Organization (WHO) revised the classification of diabetes mellitus (DM) and established two new hybrid forms, latent autoimmune diabetes in adults (LADA) and ketosis-prone type 2 diabetes (T2D). This study aimed to determine clinical outcomes after a hyperglycemic crisis event in people with diabetes classified subtypes by 2019 WHO DM classification. METHODS A five-year (2015-2019) retrospective study of adult patients admitted with hyperglycemic crises was conducted. Types of diabetes were recategorized based on the 2019 WHO DM classification. Clinical characteristics, in-admission treatment and complications, long-term follow-up outcomes, and mortality were collected, analyzed, and compared. RESULTS A total of 185 admissions occurred in 136 patients. The mean age was 50.6 ± 18.4 years (49.3 % men). The annual average incidence of hyperglycemic crises was 5.2 events/1000 persons. The proportion of type 1 diabetes, T2D, LADA, ketosis-prone T2D, and pancreatic DM were 15.4 %, 69.1 %, 2.2 %, 11 %, and 2.2 %, respectively. In-hospital mortality was 3.7 % while cumulative mortality totaled 19.1 %. During the 24-month follow-up, ketosis-prone T2D had the highest success of insulin discontinuation (HR 6.59; 95 % CI 6.69-319.4; p < 0.001), while T2D demonstrated the highest mortality compared to others (HR, 2.89; 95%CI 1.15-6.27; p = 0.02). CONCLUSION The reclassification of diabetes based on 2019 WHO DM classification helped elucidate differences in long-term outcomes and mortality among DM types. The new classification, which separates ketosis-prone T2D from standard T2D, should be encouraged in clinical practice for precise and individualized management.
Collapse
Affiliation(s)
- Chatchon Kaewkrasaesin
- Division of Medicine, Taksin Hospital, Medical Service Department, Bangkok Metropolitan Administration, Bangkok, 10600, Thailand; Diabetes and Metabolic Care Center, Taksin Hospital, Medical Service Department, Bangkok Metropolitan Administration, Bangkok, 10600, Thailand.
| | - Weerapat Kositanurit
- Department of Physiology, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Phawinpon Chotwanvirat
- Diabetes and Metabolic Care Center, Taksin Hospital, Medical Service Department, Bangkok Metropolitan Administration, Bangkok, 10600, Thailand
| | - Nitchakarn Laichuthai
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand; Excellent Center in Diabetes, Hormones and Metabolism, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330, Thailand
| |
Collapse
|
2
|
Kubota-Mishra E, Huang X, Minard CG, Astudillo M, Refaey A, Montes G, Sisley S, Ram N, Winter WE, Naylor RN, Balasubramanyam A, Redondo MJ, Tosur M. High Prevalence of A-β+ Ketosis-Prone Diabetes in Children with Type 2 Diabetes and Diabetic Ketoacidosis at Diagnosis: Evidence from the Rare and Atypical Diabetes Network (RADIANT). Pediatr Diabetes 2024; 2024:5907924. [PMID: 38765897 PMCID: PMC11100136 DOI: 10.1155/2024/5907924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background A-β+ ketosis-prone diabetes (KPD) in adults is characterized by presentation with diabetic ketoacidosis (DKA), negative islet autoantibodies, and preserved β-cell function in persons with a phenotype of obesity-associated type 2 diabetes (T2D). The prevalence of KPD has not been evaluated in children. We investigated children with DKA at "T2D" onset and determined the prevalence and characteristics of pediatric A-β+ KPD within this cohort. Methods We reviewed the records of 716 children with T2D at a large academic hospital and compared clinical characteristics of those with and without DKA at onset. In the latter group, we identified patients with A-β+ KPD using criteria of the Rare and Atypical Diabetes Network (RADIANT) and defined its prevalence and characteristics. Results Mean age at diagnosis was 13.7 ± 2.4 years: 63% female; 59% Hispanic, 29% African American, 9% non-Hispanic White, and 3% other. Fifty-six (7.8%) presented with DKA at diagnosis and lacked islet autoantibodies. Children presenting with DKA were older and had lower C-peptide and higher glucose concentrations than those without DKA. Twenty-five children with DKA (45%) met RADIANT A-β+ KPD criteria. They were predominantly male (64%), African American or Hispanic (96%), with substantial C-peptide (1.3 ± 0.7 ng/mL) at presentation with DKA and excellent long-term glycemic control (HbA1c 6.6% ± 1.9% at follow-up (median 1.3 years postdiagnosis)). Conclusions In children with a clinical phenotype of T2D and DKA at diagnosis, approximately half meet criteria for A-β+ KPD. They manifest the key characteristics of obesity, preserved β-cell function, male predominance, and potential to discontinue insulin therapy, similar to adults with A-β+ KPD.
Collapse
Affiliation(s)
- Elizabeth Kubota-Mishra
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Xiaofan Huang
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Marcela Astudillo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | | | - Graciela Montes
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sisley
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - William E. Winter
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Rochelle N. Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Departments of Pediatric and Medicine, University of Chicago, Chicago, IL, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Maria J. Redondo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Mustafa Tosur
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - RADIANT Study Group
- The RADIANT Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, USA
| |
Collapse
|
3
|
Raubenheimer PJ, Skelton J, Peya B, Dave JA, Levitt NS. Phenotype and predictors of insulin independence in adults presenting with diabetic ketoacidosis: a prospective cohort study. Diabetologia 2024; 67:494-505. [PMID: 38240751 PMCID: PMC10844464 DOI: 10.1007/s00125-023-06067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/06/2023] [Indexed: 02/06/2024]
Abstract
AIMS/HYPOTHESIS The aim of this work was to describe the phenotype of adults presenting with a first episode of diabetic ketoacidosis (DKA) in Cape Town, South Africa, and identify predictors of insulin independence at 12 and 60 months after presentation. METHODS A prospective, descriptive cohort study of all individuals, 18 years or older, presenting for the first time with DKA to four public-sector hospitals of the Groote Schuur Academic Health Complex was performed. Clinical, biochemical and laboratory data including GAD antibody and C-peptide status were collected at baseline. Insulin was systematically weaned and stopped in individuals who achieved normoglycaemia within the months after DKA. Individuals were followed for 12 months and then annually until 5 years after initial presentation with ketoacidosis. RESULTS Eighty-eight individuals newly diagnosed with diabetes when presenting with DKA were included and followed for 5 years. The mean ± SD age was 35±10 years and the median (IQR) BMI at diagnosis was 28.5 (23.3-33.4) kg/m2. Overall, 46% were insulin independent 12 months after diagnosis and 26% remained insulin independent 5 years after presentation. Forty-one participants (47%) tested negative for anti-GAD and anti-IA-2 antibodies and had C-peptide levels >0.3 nmol/l; in this group, 68% were insulin independent at 12 months and 37% at 5 years after diagnosis. The presence of acanthosis nigricans was strongly associated with insulin independence (OR 27.1 [95% CI 7.2, 102.2]; p<0.001); a positive antibody status was associated with a lower likelihood of insulin independence at 12 months (OR 0.10 [95% CI 0.03, 0.36]; p<0.001). On multivariable analysis only acanthosis (OR 11.5 [95% CI 2.5, 53.2]; p=0.004) was predictive of insulin independence 5 years after diagnosis. CONCLUSIONS/INTERPRETATION The predominant phenotype of adults presenting with a first episode of DKA in Cape Town, South Africa, was that of ketosis-prone type 2 diabetes. These individuals presented with obesity, acanthosis nigricans, negative antibodies and normal C-peptide and could potentially be weaned off insulin at follow-up. Classic type 1 diabetes (lower weight, antibody positivity, low or unrecordable C-peptide levels and long-term insulin dependence) was less common. The simple clinical sign of acanthosis nigricans is a strong predictor of insulin independence at 12 months and 5 years after initial presentation.
Collapse
Affiliation(s)
- Peter J Raubenheimer
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Joanna Skelton
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bukiwe Peya
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Naomi S Levitt
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| |
Collapse
|
4
|
Takizawa H, Ogawa O. A Case of Type 1 Diabetes Mellitus With Endogenous Insulin Secretory Depletion Confirmed in Two Weeks. Cureus 2024; 16:e55616. [PMID: 38586619 PMCID: PMC10995755 DOI: 10.7759/cureus.55616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/05/2024] [Indexed: 04/09/2024] Open
Abstract
Type 1 diabetes mellitus (T1DM) is manifested as a decrease in endogenous insulin secretion. With this report, we present a case of T1DM where a rapid decline in insulin secretion was observed in a short span of time. A 56-year-old female patient presented with cold-like symptoms with subsequent dry mouth and malaise to the hospital. Three weeks later, she was diagnosed with diabetic ketoacidosis based on the presence of hyperglycemia, metabolic acidosis, and positive ketone bodies. Her serum connecting peptide (CPR) levels substantially decreased (1.31 to 0.19 ng/mL after two weeks) and she was eventually diagnosed with T1DM. We hypothesized that a subtype T1DM with a longer beta cell loss rate than conventional fulminant type 1 diabetes was involved. This subtype showed characteristics of immune checkpoint inhibitor-associated fulminant type 1 diabetes and is suggested to exist among those diagnosed with conventional acute-onset type 1 diabetes. Finally, we recommend that diabetic ketoacidosis of unknown etiology should be investigated for the concurrent presence of T1DM.
Collapse
Affiliation(s)
- Hiroki Takizawa
- Department of Diabetes and Endocrinology, Kameda Medical Center, Kamogawa-City, JPN
- Department of Metabolism and Endocrinology, Juntendo University Graduate School, Tokyo, JPN
| | - Osamu Ogawa
- Department of Diabetes and Endocrinology, Kameda Medical Center, Kamogawa-City, JPN
- Information Management Headquarters, Kameda Medical Center, Kamogawa-City, JPN
| |
Collapse
|
5
|
ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Gaglia JL, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Selvin E, Stanton RC, Gabbay RA. 2. Diagnosis and Classification of Diabetes: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S20-S42. [PMID: 38078589 PMCID: PMC10725812 DOI: 10.2337/dc24-s002] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
6
|
Min R, Xu Y, Peng B. The clinical value of glycosylated hemoglobin level in newly diagnosed ketosis-prone type 2 diabetes. Front Endocrinol (Lausanne) 2023; 14:1244008. [PMID: 38027130 PMCID: PMC10667908 DOI: 10.3389/fendo.2023.1244008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/12/2023] [Indexed: 12/01/2023] Open
Abstract
Objective To evaluate the clinical value of glycosylated hemoglobin (HbA1c) in newly diagnosed ketosis-prone type 2 diabetes (KPD). Methods A total of 330 patients with newly diagnosed type 2 diabetes (T2DM) hospitalized in our department with an average age of 48.72 ± 13.07 years old were selected and divided into T2DM group (193 cases) and KPD group (137 cases) according to whether they were combined with ketosis. According to the quartile level of HbA1c, they were divided into group A (HbA1c < 8.90%, 84 cases), group B (8.90%≤HbA1c < 10.70%, 86 cases), group C (10.70%≤HbA1c ≤ 12.40%, 85 cases) and group D (HbA1c > 12.40%, 75 cases). The general clinical features, laboratory indicators and islet function of each group were compared. Spearman correlation analysis was used to explore the correlation between HbA1c and β- Hydroxybutyric acid (β- HB) and islet function. ROC curve was used to analyze the sensitivity and specificity of HbA1c in diagnosing KPD, and the optimal tangent point was obtained. Results HbA1c, β-HB, FFA, RBG, insulin dosage, GSP, OGTT (0, 0.5, 1, 2, 3h) in KPD group were significantly higher than those in T2DM group (P< 0.001). HDL-C, IRT (0, 0.5, 1, 2, 3h), HOMA-β, HOMA-IR, HOMA-IS, ΔC30/ΔG30, AUC insulin were significantly lower than those in T2DM group (P< 0.001). With the increase of HbA1c level, the incidence of ketosis, β-HB, FFA and insulin dosage increased, while IRT (0, 0.5, 1, 2, 3h), ΔC30/ΔG30, AUC insulin, HOMA-β and HOMA-IS decreased accordingly (P< 0.001). In all newly diagnosed T2DM patients, Spearman correlation analysis showed that HbA1c was positively correlated with β-HB (r=0.539, P < 0.001), and was negatively correlated with HOMA-β (r=-0.564, P < 0.001), HOMA-IS (r=-0.517, P < 0.01, P < 0.001), HOMA-IR (r=-0.177, P < 0.001), ΔC30/ΔG30 (r=-0.427, P < 0.01) and AUC insulin (r=-0.581, P < 0.001). In ROC curve analysis, the optimal threshold for the diagnosis of KPD was 10.15%, Youden index was 0.616, area under the curve (AUC) was 0.882, sensitivity = 92.70%, specificity = 70.50%. Conclusion In newly diagnosed T2DM patients, if HbA1c > 10.15%, it is more likely to develop KPD. Monitoring HbA1c level is conducive to timely detection of high-risk individuals with KPD and taking appropriate measures to prevent the occurrence and development of the disease.
Collapse
Affiliation(s)
- Rui Min
- Department of Geriatrics, Wuhan Fourth Hospital, Wuhan, Hubei, China
| | - Yancheng Xu
- Department of Endocrinology, Zhongnan Hospital, Wuhan University, Wuhan, Hubei, China
| | - Bocheng Peng
- Department of Pain, Wuhan Fourth Hospital, Wuhan, Hubei, China
| |
Collapse
|
7
|
Veneti S, Grammatikopoulou MG, Kintiraki E, Mintziori G, Goulis DG. Ketone Bodies in Diabetes Mellitus: Friend or Foe? Nutrients 2023; 15:4383. [PMID: 37892458 PMCID: PMC10609881 DOI: 10.3390/nu15204383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 10/29/2023] Open
Abstract
In glucose-deprived conditions, ketone bodies are produced by the liver mitochondria, through the catabolism of fatty acids, and are used peripherally, as an alternative energy source. Ketones are produced in the body under normal conditions, including during pregnancy and the neonatal period, when following a ketogenic diet (KD), fasting, or exercising. Additionally, ketone synthesis is also augmented under pathological conditions, including cases of diabetic ketoacidosis (DKA), alcoholism, and several metabolic disorders. Nonetheless, diet is the main regulator of total body ketone concentrations. The KDs are mimicking the fasting state, altering the default metabolism towards the use of ketones as the primary fuel source. Recently, KD has gained recognition as a medical nutrition therapy for a plethora of metabolic conditions, including obesity and diabetes mellitus (DM). The present review aims to discuss the role of ketones, KDs, ketonemia, and ketonuria in DM, presenting all the available new evidence in a comprehensive manner.
Collapse
Affiliation(s)
- Stavroula Veneti
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Maria G. Grammatikopoulou
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
- Unit of Immunonutrition and Clinical Nutrition, Department of Rheumatology and Clinical Immunology, Faculty of Medicine, School of Health Sciences, University of Thessaly, Biopolis, GR-41110 Larissa, Greece
| | - Evangelia Kintiraki
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Gesthimani Mintziori
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| | - Dimitrios G. Goulis
- Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, GR-54124 Thessaloniki, Greece; (S.V.); (E.K.)
| |
Collapse
|
8
|
Saadeh NA, Hammouri HM, Zahran DJ. Diabetic Ketoacidosis in Northern Jordan: Seasonal Morbidity and Characteristics of Patients. Diabetes Metab Syndr Obes 2023; 16:3057-3064. [PMID: 37810572 PMCID: PMC10559898 DOI: 10.2147/dmso.s413405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/10/2023] [Indexed: 10/10/2023] Open
Abstract
Purpose This study aimed to characterize adult patients admitted with diabetic ketoacidosis (DKA) in northern Jordan. Methods The study examined medical records of patients diagnosed with DKA from January 2015 to April 2018. Variables analyzed included diabetes type, precipitating illness, admission month, hospital length of stay, and biochemical markers. Results Out of 232 admissions with DKA, 70% were diagnosed with type 2 diabetes, and 56% were females. 12% of admissions had a new diagnosis of diabetes, of which 51% had type 2 diabetes. Sepsis (48%), Non-adherence (26%), and diabetic foot infections (18%) were the most encountered precipitating factors for DKA in T1DM. As for T2DM, sepsis (52%), acute coronary syndrome (12%), and pancreatitis (8%) were the most precipitating factors for DKA. High urea levels, high creatinine levels, low phosphorous levels, low hemoglobin levels, and high platelet counts were associated with a longer hospital stay for type 1 diabetes. For type 2 diabetes, low pH on admission, old age, and high Hb A1c within 6 months of admission were factors associated with a prolonged hospital stay. The study found a significant peak of admissions for DKA in both type 1 and type 2 patients in the winter and spring months (Pearson P-value= 0.0013). Conclusion The results of the present study highlight the seasonal variation in the frequency of DKA hospitalizations. It also highlights sepsis as the most frequent precipitating factor of DKA in both type 1 and type 2 DM patients.
Collapse
Affiliation(s)
- Nesreen A Saadeh
- Faculty of Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Hanan M Hammouri
- Department of Mathematics and Statistics, Jordan University of Science and Technology, Irbid, Jordan
| | - Deeb J Zahran
- St. James’s University Hospital, Infectious Diseases Department, Leeds, UK
| |
Collapse
|
9
|
Chen Y, Xie Y, Xia Y, Xie Z, Huang G, Fan L, Zhou Z, Li X. Prevalence, clinical characteristics and HLA genotypes of idiopathic type 1 diabetes: A cross-sectional study. Diabetes Metab Res Rev 2023; 39:e3676. [PMID: 37337767 DOI: 10.1002/dmrr.3676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 05/02/2023] [Accepted: 05/10/2023] [Indexed: 06/21/2023]
Abstract
AIMS Idiopathic type 1 diabetes (T1D) is a neglected subtype of T1D. Our aim was to investigate the frequency, clinical characteristics, and human leucocyte antigen (HLA) genotypes of idiopathic T1D. METHODS We enrolled 1205 newly diagnosed T1D patients in our analysis. To exclude monogenic diabetes in autoantibody-negative patients, we utilised a custom monogenic diabetes gene panel. Individuals negative for autoantibodies and subsequently excluded for monogenic diabetes were diagnosed with idiopathic T1D. We collected clinical characteristics, measured islet autoantibodies by radioligand assay and obtained HLA data. RESULTS After excluding 11 patients with monogenic diabetes, 284 cases were diagnosed with idiopathic T1D, accounting for 23.8% (284/1194) of all newly diagnosed T1D cases. When compared with autoimmune T1D, idiopathic T1D patients showed an older onset age, higher body mass index among adults, lower haemoglobin A1c, higher levels of fasting C-peptide and 2-h postprandial C-peptide, and were likely to have type 2 diabetes (T2D) family history and carry 0 susceptible HLA haplotype (all p < 0.01). A lower proportion of individuals carrying 2 susceptible HLA haplotypes in idiopathic T1D was observed in the adult-onset subgroup (15.7% vs. 38.0% in child-onset subgroup, p < 0.001) and in subgroup with preserved beta-cell function (11.0% vs. 30.1% in subgroup with poor beta-cell function, p < 0.001). Multivariable correlation analyses indicated that being overweight, having T2D family history and lacking susceptible HLA haplotypes were associated with negative autoantibodies. CONCLUSIONS Idiopathic T1D represents about 1/4 of newly diagnosed T1D, with adult-onset and preserved beta-cell function patients showing lower HLA susceptibility and more insulin resistance.
Collapse
Affiliation(s)
- Yan Chen
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yuting Xie
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Ying Xia
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhiguo Xie
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Gan Huang
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Li Fan
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Zhiguang Zhou
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Xia Li
- National Clinical Research Center for Metabolic Diseases, Key Laboratory of Diabetes Immunology (Central South University), Ministry of Education, and Department of Metabolism and Endocrinology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| |
Collapse
|
10
|
Abstract
Despite major advances over the past decade, prevention and treatment of type 1 diabetes mellitus (T1DM) remain suboptimal, with large and unexplained variations in individual responses to interventions. The current classification schema for diabetes mellitus does not capture the complexity of this disease or guide clinical management effectively. One of the approaches to achieve the goal of applying precision medicine in diabetes mellitus is to identify endotypes (that is, well-defined subtypes) of the disease each of which has a distinct aetiopathogenesis that might be amenable to specific interventions. Here, we describe epidemiological, clinical, genetic, immunological, histological and metabolic differences within T1DM that, together, suggest heterogeneity in its aetiology and pathogenesis. We then present the emerging endotypes and their impact on T1DM prediction, prevention and treatment.
Collapse
Affiliation(s)
- Maria J Redondo
- Paediatric Diabetes & Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Noel G Morgan
- Exeter Centre of Excellence for Diabetes Research (EXCEED), Department of Clinical and Biomedical and Science, University of Exeter Medical School, Exeter, UK
| |
Collapse
|
11
|
Balasubramanyam A, Redondo MJ, Craigen W, Dai H, Davis A, Desai D, Dussan M, Faruqi J, Gaba R, Gonzalez I, Jhangiani S, Kubota-Mishra E, Liu P, Murdock D, Posey J, Ram N, Sabo A, Sisley S, Tosur M, Venner E, Astudillo M, Cardenas A, Fang MA, Hattery E, Ideouzu A, Jimenez J, Kikani N, Montes G, O’Brien NG, Wong LJ, Goland R, Chung WK, Evans A, Gandica R, Leibel R, Mofford K, Pring J, Evans-Molina C, Anwar F, Monaco G, Neyman A, Saeed Z, Sims E, Spall M, Hernandez-Perez M, Mather K, Moors K, Udler MS, Florez JC, Calverley M, Chen V, Chu K, Cromer S, Deutsch A, Faciebene M, Greaux E, Koren D, Kreienkamp R, Larkin M, Marshall W, Ricevuto P, Sabean A, Thangthaeng N, Han C, Sherwood J, Billings LK, Banerji MA, Bally K, Brown N, Ji B, Soni L, Lee M, Abrams J, Thomas L, Abrams J, Skiwiersky S, Philipson LH, Greeley SAW, Bell G, Banogon S, Desai J, Ehrmann D, Letourneau-Freiberg LR, Naylor RN, Papciak E, Friedman Ross L, Sundaresan M, Bender C, Tian P, Rasouli N, Kashkouli MB, Baker C, Her A, King C, Pyreddy A, Singh V, Barklow J, Farhat N, Lorch R, Odean C, Schleis G, Underkofler C, Pollin TI, Bryan H, Maloney K, Miller R, Newton P, Nikita ME, Nwaba D, Silver K, Tiner J, Whitlatch H, Palmer K, Riley S, Streeten E, Oral EA, Broome D, Dill Gomes A, Foss de Freitas M, Gregg B, Grigoryan S, Imam S, Sonmez Ince M, Neidert A, Richison C, Akinci B, Hench R, Buse J, Armstrong C, Christensen C, Diner J, Fraser R, Fulghum K, Ghorbani T, Kass A, Klein K, Kirkman MS, Hirsch IB, Baran J, Dong X, Kahn SE, Khakpour D, Mandava P, Sameshima L, Kalerus T, Pihoker C, Loots B, Santarelli K, Pascual C, Niswender K, Edwards N, Gregory J, Powers A, Ramirez A, Scott J, Smith J, Urano F, Hughes J, Hurst S, McGill J, Stone S, May J, Krischer JP, Adusumalli R, Albritton B, Aquino A, Bransford P, Cadigan N, Gandolfo L, Garmeson J, Gomes J, Gowing R, Karges C, Kirk C, Muller S, Morissette J, Parikh HM, Perez-Laras F, Remedios CL, Ruiz P, Sulman N, Toth M, Wurmser L, Eberhard C, Fiske S, Hutchinson B, Nekkanti S, Wood R, Florez JC, Alkanaq A, Brandes M, Burtt N, Flannick J, Olorunfemi P, Udler MS, Caulkins L, Wasserfall C, Winter W, Pittman D, Akolkar B, Lee C, Carey DJ, Hood D, Marcovina SM, Newgard CB. The Rare and Atypical Diabetes Network (RADIANT) Study: Design and Early Results. Diabetes Care 2023; 46:1265-1270. [PMID: 37104866 PMCID: PMC10234756 DOI: 10.2337/dc22-2440] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE The Rare and Atypical Diabetes Network (RADIANT) will perform a study of individuals and, if deemed informative, a study of their family members with uncharacterized forms of diabetes. RESEARCH DESIGN AND METHODS The protocol includes genomic (whole-genome [WGS], RNA, and mitochondrial sequencing), phenotypic (vital signs, biometric measurements, questionnaires, and photography), metabolomics, and metabolic assessments. RESULTS Among 122 with WGS results of 878 enrolled individuals, a likely pathogenic variant in a known diabetes monogenic gene was found in 3 (2.5%), and six new monogenic variants have been identified in the SMAD5, PTPMT1, INS, NFKB1, IGF1R, and PAX6 genes. Frequent phenotypic clusters are lean type 2 diabetes, autoantibody-negative and insulin-deficient diabetes, lipodystrophic diabetes, and new forms of possible monogenic or oligogenic diabetes. CONCLUSIONS The analyses will lead to improved means of atypical diabetes identification. Genetic sequencing can identify new variants, and metabolomics and transcriptomics analysis can identify novel mechanisms and biomarkers for atypical disease.
Collapse
|
12
|
Deutsch AJ, Stalbow L, Majarian TD, Mercader JM, Manning AK, Florez JC, Loos RJ, Udler MS. Polygenic Scores Help Reduce Racial Disparities in Predictive Accuracy of Automated Type 1 Diabetes Classification Algorithms. Diabetes Care 2023; 46:794-800. [PMID: 36745605 PMCID: PMC10090893 DOI: 10.2337/dc22-1833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/10/2023] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Automated algorithms to identify individuals with type 1 diabetes using electronic health records are increasingly used in biomedical research. It is not known whether the accuracy of these algorithms differs by self-reported race. We investigated whether polygenic scores improve identification of individuals with type 1 diabetes. RESEARCH DESIGN AND METHODS We investigated two large hospital-based biobanks (Mass General Brigham [MGB] and BioMe) and identified individuals with type 1 diabetes using an established automated algorithm. We performed medical record reviews to validate the diagnosis of type 1 diabetes. We implemented two published polygenic scores for type 1 diabetes (developed in individuals of European or African ancestry). We assessed the classification algorithm before and after incorporating polygenic scores. RESULTS The automated algorithm was more likely to incorrectly assign a diagnosis of type 1 diabetes in self-reported non-White individuals than in self-reported White individuals (odds ratio 3.45; 95% CI 1.54-7.69; P = 0.0026). After incorporating polygenic scores into the MGB Biobank, the positive predictive value of the type 1 diabetes algorithm increased from 70 to 97% for self-reported White individuals (meaning that 97% of those predicted to have type 1 diabetes indeed had type 1 diabetes) and from 53 to 100% for self-reported non-White individuals. Similar results were found in BioMe. CONCLUSIONS Automated phenotyping algorithms may exacerbate health disparities because of an increased risk of misclassification of individuals from underrepresented populations. Polygenic scores may be used to improve the performance of phenotyping algorithms and potentially reduce this disparity.
Collapse
Affiliation(s)
- Aaron J. Deutsch
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Lauren Stalbow
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Timothy D. Majarian
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Josep M. Mercader
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Alisa K. Manning
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
- Clinical and Translational Epidemiology Unit, Mongan Institute, Massachusetts General Hospital, Boston, MA
| | - Jose C. Florez
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Ruth J.F. Loos
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Miriam S. Udler
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| |
Collapse
|
13
|
Parikh HM, Remedios CL, Hampe CS, Balasubramanyam A, Fisher-Hoch SP, Choi YJ, Patel S, McCormick JB, Redondo MJ, Krischer JP. Data Mining Framework for Discovering and Clustering Phenotypes of Atypical Diabetes. J Clin Endocrinol Metab 2023; 108:834-846. [PMID: 36314086 DOI: 10.1210/clinem/dgac632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/24/2022] [Indexed: 12/23/2022]
Abstract
CONTEXT Some individuals present with forms of diabetes that are "atypical" (AD), which do not conform to typical features of either type 1 diabetes (T1D) or type 2 diabetes (T2D). These forms of AD display a range of phenotypic characteristics that likely reflect different endotypes based on unique etiologies or pathogenic processes. OBJECTIVE To develop an analytical approach to identify and cluster phenotypes of AD. METHODS We developed Discover Atypical Diabetes (DiscoverAD), a data mining framework, to identify and cluster phenotypes of AD. DiscoverAD was trained against characteristics of manually classified patients with AD among 278 adults with diabetes within the Cameron County Hispanic Cohort (CCHC) (Study A). We then tested DiscoverAD in a separate population of 758 multiethnic children with T1D within the Texas Children's Hospital Registry for New-Onset Type 1 Diabetes (TCHRNO-1) (Study B). RESULTS We identified an AD frequency of 11.5% in the CCHC (Study A) and 5.3% in the pediatric TCHRNO-1 (Study B). Cluster analysis identified 4 distinct groups of AD in Study A: cluster 1, positive for the 65 kDa glutamate decarboxylase autoantibody (GAD65Ab), adult-onset, long disease duration, preserved beta-cell function, no insulin treatment; cluster 2, GAD65Ab negative, diagnosed at age ≤21 years; cluster 3, GAD65Ab negative, adult-onset, poor beta-cell function, lacking central obesity; cluster 4, diabetic ketoacidosis (DKA)-prone participants lacking a typical T1D phenotype. Applying DiscoverAD to the pediatric patients with T1D in Study B revealed 2 distinct groups of AD: cluster 1, autoantibody negative, poor beta-cell function, lower body mass index (BMI); cluster 2, autoantibody positive, higher BMI, higher incidence of DKA. CONCLUSION DiscoverAD can be adapted to different datasets to identify and define phenotypes of participants with AD based on available clinical variables.
Collapse
Affiliation(s)
- Hemang M Parikh
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Cassandra L Remedios
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Christiane S Hampe
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
| | - Susan P Fisher-Hoch
- The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, TX 78520, USA
| | - Ye Ji Choi
- The University of Texas Rio Grande Valley School of Medicine, Edinburg Campus, Edinburg, TX 78539, USA
| | - Sanjeet Patel
- The Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
| | - Joseph B McCormick
- The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, TX 78520, USA
| | - Maria J Redondo
- Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| |
Collapse
|
14
|
Kikani N, Balasubramanyam A. Remission in Ketosis-Prone Diabetes. Endocrinol Metab Clin North Am 2023; 52:165-174. [PMID: 36754492 DOI: 10.1016/j.ecl.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and biomarkers of autoimmune T1D. The A-β+ subgroup of KPD provides unique insight into the concept of "remission" since these patients have substantial preservation of beta-cell function permitting the discontinuation of insulin therapy, despite initial presentation with DKA. Measurements of C-peptide levels are essential to predict remission and guide potential insulin withdrawal. Further studies into predictors of remission and relapse can help us guide patients with A-β+ KPD toward remission and develop targeted treatments for this form of atypical diabetes.
Collapse
Affiliation(s)
- Nupur Kikani
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Unit 1461, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology, and Metabolism, Baylor College of Medicine, BCM 179A, One Baylor Plaza, Houston, TX 77030, USA.
| |
Collapse
|
15
|
Thewjitcharoen Y, Soontaree N, Waralee C, Siriwan B, Sirinate K, Ekgaluck W, Thep H. Prevalence and characteristics of misdiagnosed adult-onset type 1 diabetes mellitus in Thai people by random plasma C-peptide testing. Heliyon 2023; 9:e14262. [PMID: 36923852 PMCID: PMC10009731 DOI: 10.1016/j.heliyon.2023.e14262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 02/07/2023] [Accepted: 02/28/2023] [Indexed: 03/06/2023] Open
Abstract
Background It is critical to determine the exact type of diabetes because misclassification led to inappropriate treatments. The classification of DM can be aided by the measurement of pancreatic autoantibodies and plasma C-peptide levels. Previous studies suggested that random plasma C-peptide testing in those with clinically diagnosed adult T1DM of at least 3 years duration has led to reclassification in some cases. Aim This study aimed to assess the prevalence and characteristics of misdiagnosed adult-onset type 1 diabetes mellitus in Thai people by random plasma C-peptide testing. Methods A cross-sectional study of adult Thai patients diagnosed with clinically diagnosed T1DM and DM duration of at least 3 years at Theptarin Hospital, a diabetes center in Bangkok, Thailand was studied. Clinically misdiagnosis of T1DM was defined by preserved endogenous insulin secretion. Characteristics of the misdiagnosed patients were compared with definite T1DM patients. Results A total of 73 patients (females 52.1%, mean age 42.2 ± 12.5 years, duration of DM 20.3 ± 11.3 years) were studied. The prevalence of available anti-GAD and anti-IA2 were 53.3% and 20.8%, respectively. Preserved endogenous insulin secretion evaluated by random C-peptide or stimulated C-peptide was found in 8 patients (11.0%). The misdiagnosed patients had higher prevalence of hypertension and diabetic complications. Three patients were suspected to have monogenic diabetes and five patients were reclassified as possible T2DM. Conclusions Approximately one-tenth of adult T1DM patients were misdiagnosed. Random plasma C-peptide testing at least 3 years after a diagnosis of T1DM was superior to the measurement of pancreatic autoantibodies. Our present study highlights the need to increase accuracy in the diagnosis of T1DM patients by re-assessing endogenous insulin production with measurement of random plasma C-peptide levels.
Collapse
|
16
|
ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 2. Classification and Diagnosis of Diabetes: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S19-S40. [PMID: 36507649 PMCID: PMC9810477 DOI: 10.2337/dc23-s002] [Citation(s) in RCA: 609] [Impact Index Per Article: 609.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
17
|
Harrison LC. Type 1 Diabetes. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00071-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
|
18
|
Boike S, Mir M, Rauf I, Jama AB, Sunesara S, Mushtaq H, Khedr A, Nitesh J, Surani S, Khan SA. Ketosis-prone diabetes mellitus: A phenotype that hospitalists need to understand. World J Clin Cases 2022; 10:10867-10872. [PMID: 36338201 PMCID: PMC9631166 DOI: 10.12998/wjcc.v10.i30.10867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/23/2022] [Accepted: 09/09/2022] [Indexed: 02/05/2023] Open
Abstract
Diabetes has been classified mainly into types 1 and 2. Some type 2 diabetes patients, when developing ketosis, have been labeled as having atypical diabetes. Lately, syndromes of ketosis-prone diabetes, primarily in patients who we previously classified as type 2 diabetics, have emerged, and calls are being made to even reclassify diabetes. This mini-review will extensively deal with the historical, molecular, phenotypical, and clinical basis of why ketosis-prone diabetes is different than the traditional principles of type 1 and 2 diabetes and should be classified as such. Clinicians, especially those who are not diabetologists or endocrinologists, as well as hospitalists, intensivists, and primary care providers, will greatly benefit from this review.
Collapse
Affiliation(s)
- Sydney Boike
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Mikael Mir
- Medicine, University of Minnesota Medical School, Minneapolis, MN 55455, United States
| | - Ibtisam Rauf
- Medicine, St. George’s School of Medicine, Grenada FZ818, West Indies
| | - Abbas B Jama
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Shaleen Sunesara
- Medicine, University of Southern California, Los Angeles, CA 90007, United States
| | - Hisham Mushtaq
- Medicine, St. Vincent’s Medical Center, Bridgeport, CT 06606, United States
| | - Anwar Khedr
- Medicine, BronxCare Health System, Bronx, NY 10457, United States
| | - Jain Nitesh
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| | - Salim Surani
- Medicine, Texas A&M University, Bryan, TX 77843, United States
- Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
| | - Syed A Khan
- Critical Care Medicine, Mayo Clinic Health System, Mankato, MN 56001, United States
| |
Collapse
|
19
|
Makahleh L, Othman A, Vedantam V, Vedantam N. Ketosis-Prone Type 2 Diabetes Mellitus: An Unusual Presentation. Cureus 2022; 14:e30031. [DOI: 10.7759/cureus.30031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/06/2022] Open
|
20
|
Jaromy M, Miller JD. Potential Clinical Applications for Continuous Ketone Monitoring in the Hospitalized Patient with Diabetes. Curr Diab Rep 2022; 22:501-510. [PMID: 35984565 PMCID: PMC9388986 DOI: 10.1007/s11892-022-01489-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW In this review, the authors discuss potential clinical applications for continuous ketone monitoring (CKM) in a broad continuum of clinical settings from pre-hospital care and the emergency department to acute inpatient management and post-discharge follow-up. RECENT FINDINGS Though in its early stages, the concept of a novel continuous ketone sensing technology exerts great potential for use in the detection and hospital management of DKA, namely to overcome diagnostic barriers associated with ketoacidosis in patients with diabetes and obtain real-time BOHB levels, which may be useful in understanding both patients' response to treatment and DKA trajectory. Peri- and intra-operative use of CKM technology can potentially be applied in a number of urgent and elective surgical procedures frequently underwent by patients with diabetes and in the observation of patients during peri-operative fasting. In transitional care management, CKM technology could potentially facilitate patients' safe transition through levels of care, following hospital discharge from a DKA episode. This evaluation of the literature presents the potential advantages of adopting CKM and integrating this technology into the care algorithm of patients at risk for ketoacidosis.
Collapse
Affiliation(s)
- Michelle Jaromy
- New York Institute of Technology College of Osteopathic Medicine, 101 Northern Blvd, Glen Head, Oyster Bay, NY 11545 USA
| | - Joshua D. Miller
- Division of Endocrinology and Metabolism, Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd, Stony Brook, Brookhaven, NY 11794 USA
| |
Collapse
|
21
|
Yotsapon T, Surat K, Veekij V, Kewalin W, Soontaree N, Sirinate K, Thep H. Recurrent Hypertriglyceridemia-Induced Pancreatitis due to Multifactorial Chylomicronemia Syndrome in a Patient With Ketosis-Prone Diabetes Mellitus. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2022; 15:11795476221119445. [PMID: 36046370 PMCID: PMC9421055 DOI: 10.1177/11795476221119445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 07/26/2022] [Indexed: 11/25/2022]
Abstract
The triad of diabetic ketoacidosis (DKA), severe hypertriglyceridemia, and acute pancreatitis have been occasionally described in severely obese patients with type 2 diabetes mellitus (T2DM). Herein, we present a long-term clinical course of a Thai man with ketosis-prone diabetes mellitus (KPDM) complicated with recurrent pancreatitis due to multifactorial chylomicronemia syndrome. Genetic testing showed no mutation in lipoprotein lipase (LPL) and its co-factors. The patient was referred to multidisciplinary team for lifelong weight loss consultation, limiting intake of fat and simple carbohydrates, and adherence to lipid-lowering medications. Subsequent follow-up 1 year later showed no recurrent pancreatitis. In patients with multifactorial chylomicronemia syndrome, long-term management with dietary modifications together with pharmacotherapy remains the cornerstone of successful treatment.
Collapse
Affiliation(s)
| | - Komindr Surat
- Division of Clinical Nutrition, Theptarin Hospital, Bangkok, Thailand
| | | | | | | | | | | |
Collapse
|
22
|
Chandrashekhar Joshi S, Pozzilli P. COVID-19 induced Diabetes: A novel presentation. Diabetes Res Clin Pract 2022; 191:110034. [PMID: 35940303 PMCID: PMC9355745 DOI: 10.1016/j.diabres.2022.110034] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/03/2022] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The COVID-19 pandemic disproportionately affected patients who had comorbid diabetes mellitus. COVID-19 patients with diabetes experience significantly higher rates of complications and mortality. COVID-induced diabetes is a novel phenomenon observed in critically ill patients. The aims of this review were to explore the literature about COVID-induced diabetes and the pathophysiological mechanisms that could lead to this novel presentation. METHODS A literature search was performed using PUBMED, Google Scholar, MEDLINE and Embase for original studies (meta-analyses, cross-sectional studies, case series, case reports) about new-onset diabetes following COVID infection, and the proposed biochemical pathways behind this presentation. It was assumed that the authors of the studies used the current diagnostic criteria for diagnosis of type 1 and type 2 diabetes. RESULTS COVID-19 causes dysregulation of glucose homeostasis leading to new-onset diabetes and hyperglycaemia. This is also seen in patients with no previous risk factors for diabetes mellitus. The atypical glycaemic parameters and increased rates of DKA suggest that COVID-induced diabetes is a novel form of diabetes. A spectrum of COVID-induced diabetes has also been noted. COVID-induced diabetes is associated with remarkably higher mortality rates and worse outcomes compared to COVID-19 patients with pre-existing diabetes. The novel presentation of COVID-induced diabetes could be due to beta cell damage and insulin resistance caused by SARS-CoV-2. CONCLUSION COVID-induced diabetes is essential to detect early, owing to its implications on prognosis. Further studies must include follow-up of these patients to better understand the trajectory of COVID-induced diabetes and the best management plan. It is also important to assess the beta cell function and insulin resistance of COVID-induced diabetes patients over time to better understand the underlying biochemical mechanisms.
Collapse
Affiliation(s)
| | - Paolo Pozzilli
- The Blizard Institute, Centre of Immunobiology, Barts and the London School of Medicine and Dentistry, Queen Mary, University of London, UK; Unit of Endocrinology and Diabetes, Campus Bio-Medico University of Rome, Italy.
| |
Collapse
|
23
|
Ji B, Suresh S, Bally K, Naher K, Banerji MA. Ketosis-Prone Type 2 Diabetes (Flatbush Diabetes) in Remission: A Report of Two Cases. Cureus 2022; 14:e28514. [PMID: 36185931 PMCID: PMC9514152 DOI: 10.7759/cureus.28514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/21/2022] Open
Abstract
Diabetic ketoacidosis (DKA) is a triad of uncontrolled hyperglycemia, metabolic acidosis, and increased total body ketone concentration. It is a well-known manifestation of type 1 diabetes mellitus (T1DM). However, it can also be the first presentation of type 2 diabetes mellitus (T2DM). This subtype of diabetes shares the characteristics of both T1DM and T2DM and is called 'Flatbush diabetes,' also known as 'ketosis-prone T2DM.' This article highlights the importance of early identification of ketosis-prone T2DM (KPD). We describe two cases of African American men with no past medical histories who presented with unproved DKA as the first presentation of T2DM requiring initial intensive insulin therapy, which was gradually withdrawn with the addition of metformin. Both patients are currently insulin independent for more than 15 months. It is an essential clinical entity to recognize as insulin independence positively impacts the quality of life and decreases the economic burden on the health care system.
Collapse
|
24
|
Redondo MJ, Gignoux CR, Dabelea D, Hagopian WA, Onengut-Gumuscu S, Oram RA, Rich SS. Type 1 diabetes in diverse ancestries and the use of genetic risk scores. Lancet Diabetes Endocrinol 2022; 10:597-608. [PMID: 35724677 PMCID: PMC10024251 DOI: 10.1016/s2213-8587(22)00159-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 04/16/2022] [Accepted: 05/06/2022] [Indexed: 02/06/2023]
Abstract
Over 75 genetic loci within and outside of the HLA region influence type 1 diabetes risk. Genetic risk scores (GRS), which facilitate the integration of complex genetic information, have been developed in type 1 diabetes and incorporated into models and algorithms for classification, prognosis, and prediction of disease and response to preventive and therapeutic interventions. However, the development and validation of GRS across different ancestries is still emerging, as is knowledge on type 1 diabetes genetics in populations of diverse genetic ancestries. In this Review, we provide a summary of the current evidence on the evolutionary genetic variation in type 1 diabetes and the racial and ethnic differences in type 1 diabetes epidemiology, clinical characteristics, and preclinical course. We also discuss the influence of genetics on type 1 diabetes with differences across ancestries and the development and validation of GRS in various populations.
Collapse
Affiliation(s)
- Maria J Redondo
- Division of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA.
| | - Christopher R Gignoux
- Department of Medicine and Colorado Center for Personalized Medicine, Anschutz Medical Campus, University of Colorado, Aurora, CO, USA
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - William A Hagopian
- Division of Diabetes Programs, Pacific Northwest Research Institute, Seattle, WA, USA
| | - Suna Onengut-Gumuscu
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, University of Exeter, Exeter, UK; The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Stephen S Rich
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
25
|
Sørgjerd EP, Mjelle R, Beisvåg V, Flatberg A, Grill V, Åsvold BO. Small RNAs are differentially expressed in autoimmune and non-autoimmune diabetes and controls. Eur J Endocrinol 2022; 187:231-240. [PMID: 35616612 PMCID: PMC9254298 DOI: 10.1530/eje-22-0083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Accepted: 05/26/2022] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Diabetes is a heterogeneous disease and a precise diagnosis of diabetes subgroups is necessary to initiate proper early treatment and clinical management of the disease. Circulating small RNAs (sRNAs) are potentially diagnostic biomarkers in diseases, including diabetes. Here we aimed to examine whether profiles of circulating sRNAs differed between patients with autoimmune and non-autoimmune diabetes and non-diabetic controls. DESIGN This cross-sectional case-control study included participants from the third survey of the HUNT study. METHODS We performed sRNA sequencing in serum from adult-onset type 1 diabetes (n = 51), type 2 diabetes (n = 50) and latent autoimmune diabetes in adult (LADA, n = 51), as well as non-diabetic HUNT3 participants as control group (n = 51). Differential expression analysis of the sRNAs was performed in R using limma-voom. RESULTS We identified differences in sRNA expression between autoimmune (type 1 diabetes and LADA) and non-autoimmune diabetes (type 2 diabetes) and between patients with diabetes and non-diabetic controls. Focusing on miRNA, we identified 10 differentially expressed mature miRNAs and 30 differentially expressed miRNA variants (isomiRs). We also identified significant changes within other sRNA classes, including a pronounced downregulation of a tRNA fragment in patients with diabetes compared to non-diabetic controls. We created cross-validated sRNA signatures based on the significant sRNAs that distinguished patients with diabetes from non-diabetic controls, and autoimmune from non-autoimmune diabetes, with high specificity and sensitivity. sRNA profiles did not distinguish between type 1 diabetes and LADA. CONCLUSIONS Circulating sRNAs are differentially expressed between patients with diabetes and non-diabetic controls and between autoimmune and non-autoimmune diabetes.
Collapse
Affiliation(s)
- Elin Pettersen Sørgjerd
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Correspondence should be addressed to E P Sørgjerd;
| | - Robin Mjelle
- Bioinformatics Core Facility – BioCore, Norwegian University of Science and Technology NTNU, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Vidar Beisvåg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Central Administration, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Arnar Flatberg
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
- Central Administration, St. Olav’s Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Valdemar Grill
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Bjørn O Åsvold
- HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Levanger, Norway
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| |
Collapse
|
26
|
Gaba R, Balasubramanyam A. Covid-19: A new cause of "provoked" A-β+ Ketosis-Prone Diabetes. J Diabetes Complications 2022; 36:108147. [PMID: 35153127 PMCID: PMC8820105 DOI: 10.1016/j.jdiacomp.2022.108147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 01/08/2023]
Affiliation(s)
- Ruchi Gaba
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, United States of America.
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, United States of America.
| |
Collapse
|
27
|
Gupta RD, Atri A, Mondal S, Bhattacharjee A, Garai R, Hazra AK, Choudhury B, Dutta DS, Lodh M, Ganguly A. Characterizing progressive beta-cell recovery after new-onset DKA in COVID-19 provoked A-β+ KPD (ketosis-prone diabetes): A prospective study from Eastern India. J Diabetes Complications 2022; 36:108100. [PMID: 34916147 PMCID: PMC8656268 DOI: 10.1016/j.jdiacomp.2021.108100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recent literature suggests a bi-directional relationship between COVID-19 infection and diabetes mellitus, with an increasing number of previously normoglycemic adults with COVID-19 being admitted with new-onset diabetic ketoacidosis (DKA). However, the possibility of COVID-19 being a potential trigger for A-β + ketosis-prone diabetes (KPD) in these patients needs elucidation. Our study aimed at analyzing such a cohort of patients and determining their natural course of β-cell recovery on serial follow-up. METHODS After initial screening, n = 42 previously non-diabetic patients with new-onset DKA and RT-PCR positive COVID-19, were included in our ten-month follow-up study. Of these, n = 22 were negative (suspected A-β + KPD) and n = 20 were positive (Type 1A DM) for autoantibodies (GAD/IA-2/ZnT8). Subsequently, n = 19 suspected KPD and n = 18 Type 1A DM patients were followed-up over ten months with serial assessments of clinical, biochemical and β-cell secretion. Amongst the former, n = 15 (79%) patients achieved insulin independence, while n = 4 (21%) continued to require insulin at ten-months follow-up. RESULTS On comparison, the suspected KPD patients showed significantly greater BMI, age, Hba1c, IL-6 and worse DKA parameters at presentation. Serial C-peptide estimations demonstrated significant β-cell recovery in KPD group, with complete recovery seen in the 15 patients who became insulin independent on follow-up. Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were associated with poorer recovery of β-cell secretion at ten-month follow-up amongst the KPD patients, CONCLUSIONS: This is the first prospective study to demonstrate progressive recovery of β-cell secretion in new-onset A-β + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM. Given their significant potential for β-cell recovery, meticulous follow-up involving C-peptide estimations can help guide treatment and avoid injudicious use of insulin.
Collapse
Affiliation(s)
- Riddhi Das Gupta
- Department of Endocrinology and Metabolism, HealthWorld Hospitals, Durgapur, India.
| | - Avica Atri
- Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunetra Mondal
- Department of Endocrinology and Metabolism, HealthWorld Hospitals, Durgapur, India
| | | | - Ramprasad Garai
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Arindam Kumar Hazra
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Brojen Choudhury
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Dhriti Sundar Dutta
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Moushumi Lodh
- Department of Biochemistry, HealthWorld Hospitals, Durgapur, India
| | | |
Collapse
|
28
|
Zucchini S. Editorial: Clinical aspects of different forms of diabetes in children and adolescents. Front Endocrinol (Lausanne) 2022; 13:1110373. [PMID: 36601014 PMCID: PMC9806333 DOI: 10.3389/fendo.2022.1110373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022] Open
|
29
|
Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
Collapse
|
30
|
Redondo MJ, Balasubramanyam A. Toward an Improved Classification of Type 2 Diabetes: Lessons From Research into the Heterogeneity of a Complex Disease. J Clin Endocrinol Metab 2021; 106:e4822-e4833. [PMID: 34291809 PMCID: PMC8787852 DOI: 10.1210/clinem/dgab545] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Accumulating evidence indicates that type 2 diabetes (T2D) is phenotypically heterogeneous. Defining and classifying variant forms of T2D are priorities to better understand its pathophysiology and usher clinical practice into an era of "precision diabetes." EVIDENCE ACQUISITION AND METHODS We reviewed literature related to heterogeneity of T2D over the past 5 decades and identified a range of phenotypic variants of T2D. Their descriptions expose inadequacies in current classification systems. We attempt to link phenotypically diverse forms to pathophysiology, explore investigative methods that have characterized "atypical" forms of T2D on an etiological basis, and review conceptual frameworks for an improved taxonomy. Finally, we propose future directions to achieve the goal of an etiological classification of T2D. EVIDENCE SYNTHESIS Differences among ethnic and racial groups were early observations of phenotypic heterogeneity. Investigations that uncover complex interactions of pathophysiologic pathways leading to T2D are supported by epidemiological and clinical differences between the sexes and between adult and youth-onset T2D. Approaches to an etiological classification are illustrated by investigations of atypical forms of T2D, such as monogenic diabetes and syndromes of ketosis-prone diabetes. Conceptual frameworks that accommodate heterogeneity in T2D include an overlap between known diabetes types, a "palette" model integrated with a "threshold hypothesis," and a spectrum model of atypical diabetes. CONCLUSION The heterogeneity of T2D demands an improved, etiological classification scheme. Excellent phenotypic descriptions of emerging syndromes in different populations, continued clinical and molecular investigations of atypical forms of diabetes, and useful conceptual models can be utilized to achieve this important goal.
Collapse
Affiliation(s)
- Maria J Redondo
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
| |
Collapse
|
31
|
Yang D, Patel S, Szlachcic WJ, Chmielowiec J, Scaduto D, Putluri N, Sreekumar A, Suliburk J, Metzker M, Balasubramanyam A, Borowiak M. Pancreatic Differentiation of Stem Cells Reveals Pathogenesis of a Syndrome of Ketosis-Prone Diabetes. Diabetes 2021; 70:2419-2429. [PMID: 34344789 PMCID: PMC8576504 DOI: 10.2337/db20-1293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 07/28/2021] [Indexed: 11/29/2022]
Abstract
Genetic analysis of an adult patient with an unusual course of ketosis-prone diabetes (KPD) and lacking islet autoantibodies demonstrated a nucleotide variant in the 5'-untranslated region (UTR) of PDX1, a β-cell development gene. When differentiated to the pancreatic lineage, his induced pluripotent stem cells stalled at the definitive endoderm (DE) stage. Metabolomics analysis of the cells revealed that this was associated with leucine hypersensitivity during transition from the DE to the pancreatic progenitor (PP) stage, and RNA sequencing showed that defects in leucine-sensitive mTOR pathways contribute to the differentiation deficiency. CRISPR/Cas9 manipulation of the PDX1 variant demonstrated that it is necessary and sufficient to confer leucine sensitivity and the differentiation block, likely due to disruption of binding of the transcriptional regulator NFY to the PDX1 5'-UTR, leading to decreased PDX1 expression at the early PP stage. Thus, the combination of an underlying defect in leucine catabolism characteristic of KPD with a functionally relevant heterozygous variant in a critical β-cell gene that confers increased leucine sensitivity and inhibits endocrine cell differentiation resulted in the phenotype of late-onset β-cell failure in this patient. We define the molecular pathogenesis of a diabetes syndrome and demonstrate the power of multiomics analysis of patient-specific stem cells for clinical discovery.
Collapse
Affiliation(s)
- Diane Yang
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX
- McNair Medical Institute, Baylor College of Medicine, Houston, TX
| | - Sanjeet Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | | | - Jolanta Chmielowiec
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX
| | | | - Nagireddy Putluri
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX
| | - Arun Sreekumar
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX
| | - James Suliburk
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | | | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Malgorzata Borowiak
- Center for Cell and Gene Therapy, Baylor College of Medicine, Texas Children's Hospital and Houston Methodist Hospital, Houston, TX
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX
- McNair Medical Institute, Baylor College of Medicine, Houston, TX
- Adam Mickiewicz University, Poznan, Poland
| |
Collapse
|
32
|
Tanabe H, Masuzaki H, Shimabukuro M. Novel strategies for glycaemic control and preventing diabetic complications applying the clustering-based classification of adult-onset diabetes mellitus: A perspective. Diabetes Res Clin Pract 2021; 180:109067. [PMID: 34563587 DOI: 10.1016/j.diabres.2021.109067] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 09/13/2021] [Accepted: 09/20/2021] [Indexed: 12/17/2022]
Abstract
Diabetes mellitus results from an interplay between insulin resistance and β-cell dysfunction. Since their relative contributions to its pathogenesis are difficult to quantify, therapeutic strategies for glycaemic control are determined primarily based on two limited metrics: plasma glucose and haemoglobin A1c. Recent attempts have been made to subclassify diabetes mellitus to better predict its associated pathology and plan appropriate therapeutic strategies. These classifications are based on data-driven cluster analysis using autoimmunity, age, obesity (metabolically unhealthy and healthy phenotypes), insulin secretory capacity and resistance, and ethnicity. This review addresses potential therapeutic strategies for the cluster-based classifications of adult-onset diabetes mellitus to achieve better glycaemic control and prevent or at least delay the concomitant complications.
Collapse
Affiliation(s)
- Hayato Tanabe
- Department of Diabetes, Endocrinology and Metabolism, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Hiroaki Masuzaki
- Division of Endocrinology, Diabetes and Metabolism, Hematology, Rheumatology (Second Department of Internal Medicine), University of the Ryukyus, Okinawa 903-0215, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology and Metabolism, School of Medicine, Fukushima Medical University, Fukushima 960-1295, Japan.
| |
Collapse
|
33
|
Jahoor F, Hsu JW, Mehta PB, Keene KR, Gaba R, Mulukutla SN, Caducoy E, Peacock WF, Patel SG, Bennet R, Lernmark A, Balasubramanyam A. Metabolomics Profiling of Patients With A-β+ Ketosis-Prone Diabetes During Diabetic Ketoacidosis. Diabetes 2021; 70:1898-1909. [PMID: 34021044 PMCID: PMC8385613 DOI: 10.2337/db21-0066] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/18/2021] [Indexed: 12/28/2022]
Abstract
When stable and near-normoglycemic, patients with "A-β+" ketosis-prone diabetes (KPD) manifest accelerated leucine catabolism and blunted ketone oxidation, which may underlie their proclivity to develop diabetic ketoacidosis (DKA). To understand metabolic derangements in A-β+ KPD patients during DKA, we compared serum metabolomics profiles of adults during acute hyperglycemic crises, without (n = 21) or with (n = 74) DKA, and healthy control subjects (n = 17). Based on 65 kDa GAD islet autoantibody status, C-peptide, and clinical features, 53 DKA patients were categorized as having KPD and 21 type 1 diabetes (T1D); 21 nonketotic patients were categorized as having type 2 diabetes (T2D). Patients with KPD and patients with T1D had higher counterregulatory hormones and lower insulin-to-glucagon ratio than patients with T2D and control subjects. Compared with patients withT2D and control subjects, patients with KPD and patients with T1D had lower free carnitine and higher long-chain acylcarnitines and acetylcarnitine (C2) but lower palmitoylcarnitine (C16)-to-C2 ratio; a positive relationship between C16 and C2 but negative relationship between carnitine and β-hydroxybutyrate (BOHB); higher branched-chain amino acids (BCAAs) and their ketoacids but lower ketoisocaproate (KIC)-to-Leu, ketomethylvalerate (KMV)-to-Ile, ketoisovalerate (KIV)-to-Val, isovalerylcarnitine-to-KIC+KMV, propionylcarnitine-to-KIV+KMV, KIC+KMV-to-C2, and KIC-to-BOHB ratios; and lower glutamate and 3-methylhistidine. These data suggest that during DKA, patients with KPD resemble patients with T1D in having impaired BCAA catabolism and accelerated fatty acid flux to ketones-a reversal of their distinctive BCAA metabolic defect when stable. The natural history of A-β+ KPD is marked by chronic but varying dysregulation of BCAA metabolism.
Collapse
Affiliation(s)
- Farook Jahoor
- Children's Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, and Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jean W Hsu
- Children's Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, and Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Paras B Mehta
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Kelly R Keene
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
- Ben Taub General Hospital, Harris Health System, Houston, TX
| | - Ruchi Gaba
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
- Ben Taub General Hospital, Harris Health System, Houston, TX
| | | | - Eunice Caducoy
- Children's Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, and Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
- Ben Taub General Hospital, Harris Health System, Houston, TX
| | - Sanjeet G Patel
- Division of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rasmus Bennet
- Unit for Diabetes and Celiac Disease, Lund University, Malmo, Sweden
| | - Ake Lernmark
- Unit for Diabetes and Celiac Disease, Lund University, Malmo, Sweden
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
- Ben Taub General Hospital, Harris Health System, Houston, TX
| |
Collapse
|
34
|
Zhang JY, Shang T, Koliwad SK, Klonoff DC. Continuous Ketone Monitoring: A New Paradigm for Physiologic Monitoring. J Diabetes Sci Technol 2021; 15:775-780. [PMID: 33834884 PMCID: PMC8258504 DOI: 10.1177/19322968211009860] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this issue of JDST, Alva and colleagues present for the first time, development of a continuous ketone monitor (CKM) tested both in vitro and in humans. Their sensor measured betahydroxybutyrate (BHB) in interstitial fluid (ISF). The sensor was based on wired enzyme electrochemistry technology using BHB dehydrogenase. The sensor required only a single retrospective calibration without a need for further adjustments over 14 days. The device produced a linear response over the 0-8 mM range with good accuracy. This novel CKM could provide a new dimension of useful automatically collected information for managing diabetes. Passively collected ISF ketone information would be useful for predicting and managing ketoacidosis in patients with type 1 diabetes, as well as other states of abnormal ketonemia. Although additional studies of this CKM will be required to assess performance in intended patient populations and prospective factory calibration will be required to support real time measurements, this novel monitor has the potential to greatly improve outcomes for people with diabetes. In the future, a CKM might be integrated with a continuous glucose monitor in the same sensor platform.
Collapse
Affiliation(s)
| | - Trisha Shang
- Diabetes Technology Society, Burlingame, CA, USA
| | - Suneil K. Koliwad
- Division of Endocrinology and Metabolism, University of California San Francisco, San Francisco, CA, USA
| | - David C. Klonoff
- Mills-Peninsula Medical Center, San Mateo, CA, USA
- David C. Klonoff, MD, FACP, FRCP (Edin), Fellow AIMBE, Diabetes Research Institute, Mills-Peninsula Medical Center 100 South San Mateo Drive, Room 5147, San Mateo, CA 94401, USA.
| |
Collapse
|
35
|
Foteinopoulou E, Clarke CAL, Pattenden RJ, Ritchie SA, McMurray EM, Reynolds RM, Arunagirinathan G, Gibb FW, McKnight JA, Strachan MWJ. Impact of routine clinic measurement of serum C-peptide in people with a clinician-diagnosis of type 1 diabetes. Diabet Med 2021; 38:e14449. [PMID: 33131101 DOI: 10.1111/dme.14449] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/15/2020] [Accepted: 10/29/2020] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine the impact of the routine use of serum C-peptide in an out-patient clinic setting on individuals with a clinician-diagnosis of type 1 diabetes. METHODS In this single-centre study, individuals with type 1 diabetes of at least 3 years duration were offered random serum C-peptide testing at routine clinic review. A C-peptide ≥200 pmol/L prompted further evaluation of the individual using a diagnostic algorithm that included measurement of islet cell antibodies and genetic testing. Where appropriate, a trial of anti-diabetic co-therapies was considered. RESULTS Serum C-peptide testing was performed in 859 individuals (90% of the eligible cohort), of whom 114 (13.2%) had C-peptide ≥200 pmol/L. The cause of diabetes was reclassified in 58 individuals (6.8% of the tested cohort). The majority of reclassifications were to type 2 diabetes (44 individuals; 5.1%), with a smaller proportion of monogenic diabetes (14 individuals; 1.6%). Overall, 13 individuals (1.5%) successfully discontinued insulin, while a further 16 individuals (1.9%) had improved glycaemic control following the addition of co-therapies. The estimated total cost of the testing programme was £23,262 (~€26,053), that is, £27 (~€30) per individual tested. In current terms, the cost of prior insulin therapy in the individuals with monogenic diabetes who successfully stopped insulin was approximately £57,000 (~€64,000). CONCLUSIONS/INTERPRETATION Serum C-peptide testing can easily be incorporated into an out-patient clinic setting and could be a cost-effective intervention. C-peptide testing should be strongly considered in individuals with a clinician-diagnosis of type 1 diabetes of at least 3 years duration.
Collapse
Affiliation(s)
- Evgenia Foteinopoulou
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| | - Catriona A L Clarke
- Department of Clinical Biochemistry, Western General Hospital, Edinburgh, UK
| | - Rebecca J Pattenden
- Department of Clinical Biochemistry, Western General Hospital, Edinburgh, UK
| | - Stuart A Ritchie
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| | - Emily M McMurray
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| | - Rebecca M Reynolds
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| | | | - Fraser W Gibb
- Edinburgh Centre for Endocrinology & Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John A McKnight
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| | - Mark W J Strachan
- Edinburgh Centre for Endocrinology & Diabetes, Western General Hospital, Edinburgh, UK
| |
Collapse
|
36
|
Pan J, Yang X, Zhu W. Domino effect of pituitary growth hormone tumor complicated by diabetic ketoacidosis and pituitary apoplexy: a case report. BMC Endocr Disord 2021; 21:109. [PMID: 34039339 PMCID: PMC8157700 DOI: 10.1186/s12902-021-00768-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/16/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Patients with growth hormone (GH)-secreting adenoma usually develop glucose intolerance. GH increases metabolic rate and, when secreted aberrantly, may result in metabolic syndrome. Herein, we examine the associations of pituitary tumor-induced secretion of hormone with insulin resistance and metabolic syndrome, and determine the relation of pituitary tumor apoplexy-induced diabetic ketoacidosis (DKA) and acute pancreatitis. CASE PRESENTATION A 44-year-old male with a history of hypertension presented to the emergency department of our hospital on February 14, 2019 with symptoms of headache, dizziness, and vomiting. Computed tomography of the head revealed pituitary tumor with bleeding. An ultrasound scan of the abdomen revealed fatty liver and acute pancreatitis. Further examination revealed the presence of DKA, hypertriglyceridemia, cortical hypofunction crisis and acute kidney injury. Surgical endoscopic resection of the pituitary tumor resection via the transsphenoidal approach was performed. The patient's postoperative recovery was remarkable. CONCLUSIONS Long-term growth hormone abnormality may trigger insulin resistance, leading to metabolic syndrome and impaired glucose and lipid metabolism. The pituitary adenoma apoplexy may also directly induce DKA, creating a domino effect, which further deteriorate the aberrant metabolism of glucose and lipids.
Collapse
Affiliation(s)
- JinYu Pan
- Graduate Department, BengBu Medical College, 233030, Bengbu, Anhui, China
| | - XiangHong Yang
- Department of Intensive Care Uint, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 310014, Hangzhou, Zhejiang, China
| | - Wei Zhu
- Department of Emergency Medicine, Zhejiang Provincial People's Hospital (People's Hospital of Hangzhou Medical College), 158 Shangtang Road, 310014, Hangzhou, Zhejiang, People's Republic of China.
| |
Collapse
|
37
|
Patel SK, Ma CS, Fourlanos S, Greenfield JR. Autoantibody-Negative Type 1 Diabetes: A Neglected Subtype. Trends Endocrinol Metab 2021; 32:295-305. [PMID: 33712367 DOI: 10.1016/j.tem.2021.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/03/2021] [Accepted: 02/05/2021] [Indexed: 12/16/2022]
Abstract
Up to 15% of individuals with a clinical phenotype of type 1 diabetes (T1D) do not have evidence of seropositivity for pancreatic islet autoantibodies. On this basis, they are classified as nonimmune or idiopathic, and remain an understudied population, as they are excluded from T1D immunomodulatory trials. Our limited understanding of the disease aetiopathogenesis in autoantibody-negative T1D hinders our ability to improve diagnostic pathways and discover novel therapeutic agents; particularly as we progress towards an era of precision medicine. This review summarises the current understanding and challenges in studying autoantibody-negative T1D. We review the literature regarding T1D classification, and the role of autoimmunity and defects in the immunogenic pathway that may distinguish autoantibody-positive and -negative T1D.
Collapse
Affiliation(s)
- Shivani K Patel
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, NSW, Australia; Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia
| | - Cindy S Ma
- St. Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia; Human Immune Disorders, Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Spiros Fourlanos
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jerry R Greenfield
- Diabetes and Metabolism, Garvan Institute of Medical Research, Sydney, NSW, Australia; Department of Diabetes and Endocrinology, St. Vincent's Hospital, Sydney, NSW, Australia; St. Vincent's Clinical School, Faculty of Medicine, UNSW Sydney, Sydney, NSW, Australia.
| |
Collapse
|
38
|
Waddankeri SS, Swaraj Waddankeri M, Gurushantappa Mangshetty B. Clinical and Biochemical Characteristics and Treatment Outcomes of Ketosis-Prone Diabetes: The Remission Prone Diabetes. Int J Endocrinol Metab 2021; 19:e106799. [PMID: 34149844 PMCID: PMC8198612 DOI: 10.5812/ijem.106799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the severe acute complications of diabetes. It has long been considered a key clinical characteristic of type 1 diabetes mellitus (T1DM) with severe and irreversible deficient insulin levels. Ketosis-prone diabetes (KPD) has pathophysiology close to T2DM but shows signs and symptoms associated with T1DM. In general, patients with ketosis-prone diabetes display elevated glucose and ketone levels; also, a higher hemoglobin A1C than conventional T2DM. OBJECTIVES The current research aimed to elucidate the clinical presentation and outline a management plan for KPD in the Indian population. METHODS The present case series is a descriptive, prospective, and observational case series on six unprovoked cases of KPD. They were managed using the standard protocol of DKA management. RESULTS The recruited cases followed a set pattern of very high insulin requirement at diagnosis. On follow-up, the insulin requirement progressively declined, and all of the cases were able to stop insulin therapy after a mean period of four weeks. None of the cases presented any organ damage at diagnosis. There was no recurrence of DKA during the two-year follow-up. All of the cases had normal liver and renal functions. Autoantibodies were negative in all of the cases. CONCLUSIONS Ketosis-prone diabetes is the most under-recognized and under-diagnosed among all types of diabetes. Its recognition is of utmost importance as the approach of its treatment varies widely from that of the conventional type of diabetes. Proper follow-up, especially in unprovoked cases of DKA with obese phenotype, could help elucidate this rare entity of KPD where insulin can be stopped and maintain normoglycemia for a substantial period without insulin.
Collapse
Affiliation(s)
- Swaraj Shrikant Waddankeri
- Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India
- Corresponding Author: Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India.
| | | | | |
Collapse
|
39
|
de Lima Ramaldes LA, Dos Santos SS, de Sa JR, Dualib PM, Dib SA. The first series of cases of ketosis-prone type 2 diabetes (flatbush diabetes) in Brazilian adults. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 65:231-236. [PMID: 33905625 PMCID: PMC10065323 DOI: 10.20945/2359-3997000000329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ketosis-prone type 2 diabetes (KPD) is an emerging form of diabetes mellitus characterized by unprovoked ketoacidosis, absence of autoimmunity and beta-cell dysfunction. The KPD may improve after initial glycemic compensation and evolve to exogenous insulin independence, most cases were observed in populations with African or Hispanic backgrounds. We reviewed the literature on KPD and, to date, only one case of KPD has been described in Brazil's multi-ethnic population. A group of adult Brazilian KPD patients without autoimmunity and insulinopenia was identified for this study. We report a retrospective study of four KPD cases (3 males) evaluated in southeast Brazil, the patients were overweight or obese, age between the third and fifth decades of life, had a family history of type 2 diabetes, hyperglycemia (809.5 ± 344.2 mg/dL), acidosis (pH 7.21 ± 0.07; normal range (nr): 7.35-7.45 and bicarbonate 9.1 ± 6.2; nr: 22-26 mEq/mL), ketonuria (142.5 ± 114.4 mg/dL; nr: absence), absence of glutamic acid decarboxylase antibodies (GAD-65), and beta-cell function reserve (C-peptide 1.19 ± 0.53 ng/mL - nr: 1.1-4.4 ng/mL) on diagnosis. After glycemic compensation, there was increase of C-peptide (2.21 ± 0.41) indicating the recovery of beta-cell function and the time to insulin independence was 7.7 ± 3.5 months. They evolved after the period of glucotoxicity with insulin withdrawal and could be treated with oral antidiabetic therapy. This is the first case series of KPD described in Brazil being characterized by ketoacidosis at diagnosis, absence of autoimmunity, recovery of beta-cell function and insulin independence.
Collapse
Affiliation(s)
- Luana Aparecida de Lima Ramaldes
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil,
| | - Sarah Simaan Dos Santos
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - João Roberto de Sa
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Patrícia Médici Dualib
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| | - Sérgio Atala Dib
- Departamento de Medicina, Disciplina de Endocrinologia, Centro de Diabetes, Universidade Federal de São Paulo, São Paulo, SP, Brasil
| |
Collapse
|
40
|
Wallia A, Prince G, Touma E, El Muayed M, Seley JJ. Caring for Hospitalized Patients with Diabetes Mellitus, Hyperglycemia, and COVID-19: Bridging the Remaining Knowledge Gaps. Curr Diab Rep 2020; 20:77. [PMID: 33244614 PMCID: PMC7690847 DOI: 10.1007/s11892-020-01366-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW This review discusses the interplay between coronavirus disease 2019 (COVID-19, caused by SARS-CoV-2 infection), diabetes mellitus, and hyperglycemia in the hospital setting. There are data emerging about diabetes and hyperglycemia, their prevalence, and potential risks in the setting of SARS-CoV-2 infection and COVID-19. RECENT FINDINGS It is known that viral infections exert effects on beta cell function and insulin resistance. Therefore, much can be learned about SARS-CoV-2/COVID-19 from examining these known relationships. Such pathophysiological underpinnings may unlock greater understanding as we navigate atypical cases of hyperglycemia, severe insulin resistance, and diabetic ketoacidosis amidst COVID-19. Glycemic outcomes likely have beneficial effects on morbidity and mortality, but this needs to be studied. Changes in diabetes-related protocols and new technology can be deployed in the inpatient setting to potentially improve healthcare worker and patient safety; however, one must weigh the risks and benefits of implementation during a pandemic. Ultimately, knowledge and research must be shared at record speed to combat this global crisis.
Collapse
Affiliation(s)
- Amisha Wallia
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
- Institute of Public Health, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Grace Prince
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Emilie Touma
- Institute of Public Health, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Malek El Muayed
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Jane Jeffrie Seley
- Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine, New York, NY, USA
| |
Collapse
|
41
|
Abstract
An etiologically based classification of diabetes is needed to account for the heterogeneity of type 1 and type 2 diabetes (T1D and T2D) and emerging forms of diabetes worldwide. It may be productive for both classification and clinical discovery to consider variant forms of diabetes as a spectrum. Maturity onset diabetes of youth and neonatal diabetes serve as models for etiologically defined, rare forms of diabetes in the spectrum. Ketosis-prone diabetes is a model for more complex forms, amenable to phenotypic dissection. Bioinformatic approaches such as clustering analyses of large datasets and multi-omics investigations of rare and atypical phenotypes are promising avenues to explore and define new subgroups of diabetes.
Collapse
Affiliation(s)
- Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA;
| |
Collapse
|
42
|
Redondo MJ, Hagopian WA, Oram R, Steck AK, Vehik K, Weedon M, Balasubramanyam A, Dabelea D. The clinical consequences of heterogeneity within and between different diabetes types. Diabetologia 2020; 63:2040-2048. [PMID: 32894314 PMCID: PMC8498993 DOI: 10.1007/s00125-020-05211-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022]
Abstract
Advances in molecular methods and the ability to share large population-based datasets are uncovering heterogeneity within diabetes types, and some commonalities between types. Within type 1 diabetes, endotypes have been discovered based on demographic (e.g. age at diagnosis, race/ethnicity), genetic, immunological, histopathological, metabolic and/or clinical course characteristics, with implications for disease prediction, prevention, diagnosis and treatment. In type 2 diabetes, the relative contributions of insulin resistance and beta cell dysfunction are heterogeneous and relate to demographics, genetics and clinical characteristics, with substantial interaction from environmental exposures. Investigators have proposed approaches that vary from simple to complex in combining these data to identify type 2 diabetes clusters relevant to prognosis and treatment. Advances in pharmacogenetics and pharmacodynamics are also improving treatment. Monogenic diabetes is a prime example of how understanding heterogeneity within diabetes types can lead to precision medicine, since phenotype and treatment are affected by which gene is mutated. Heterogeneity also blurs the classic distinctions between diabetes types, and has led to the definition of additional categories, such as latent autoimmune diabetes in adults, type 1.5 diabetes and ketosis-prone diabetes. Furthermore, monogenic diabetes shares many features with type 1 and type 2 diabetes, which make diagnosis difficult. These challenges to the current classification framework in adult and paediatric diabetes require new approaches. The 'palette model' and the 'threshold hypothesis' can be combined to help explain the heterogeneity within and between diabetes types. Leveraging such approaches for therapeutic benefit will be an important next step for precision medicine in diabetes. Graphical abstract.
Collapse
MESH Headings
- Age of Onset
- Autoimmunity/genetics
- Autoimmunity/immunology
- Diabetes Mellitus/genetics
- Diabetes Mellitus/immunology
- Diabetes Mellitus/metabolism
- Diabetes Mellitus/therapy
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/immunology
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/genetics
- Diabetes Mellitus, Type 2/immunology
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/therapy
- Gene-Environment Interaction
- Genetic Predisposition to Disease
- Health Services Accessibility
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/genetics
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/metabolism
- Infant, Newborn, Diseases/therapy
- Inflammation/genetics
- Inflammation/immunology
- Insulin Resistance
- Latent Autoimmune Diabetes in Adults/genetics
- Latent Autoimmune Diabetes in Adults/immunology
- Latent Autoimmune Diabetes in Adults/metabolism
- Latent Autoimmune Diabetes in Adults/therapy
Collapse
Affiliation(s)
- Maria J Redondo
- Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, MWT 10th floor, Houston, TX, 77030, USA.
| | | | - Richard Oram
- University of Exeter Medical School, Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kendra Vehik
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | | | | | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| |
Collapse
|
43
|
Sjöholm Å. Atypical diabetes: a diagnostic challenge. BMJ Open Diabetes Res Care 2020; 8:8/1/e001470. [PMID: 32771985 PMCID: PMC7418657 DOI: 10.1136/bmjdrc-2020-001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/17/2020] [Accepted: 06/27/2020] [Indexed: 02/03/2023] Open
Abstract
In medical school, we learned how to classify diabetes according to different clinical characteristics. However, at the dawn of the precision medicine era, it is clear that today's clinical reality does not always align well with textbook teachings. The terms juvenile versus elderly-onset diabetes, as well as insulin-dependent versus non-insulin-dependent diabetes, have become obsolete. Contrary to what is often taught severe ketoacidosis may occur in type 2 diabetes. Patients may also suffer from two or more forms of diabetes simultaneously or consecutively. Five authentic cases of diabetes with uncommon characteristics that pose diagnostic challenges are presented here.
Collapse
Affiliation(s)
- Åke Sjöholm
- Department of Internal Medicine, Region Gävleborg, Gavle, Sweden
| |
Collapse
|
44
|
Zhu B, Lin Z, Chen X, Gusdon AM, Shen W, Chen J, Zheng L, Sun H, Li Y, Zhu C, Li J, Qu S. Circulating osteocalcin: A potential predictor of ketosis in type 2 diabetes. Diabetes Metab Res Rev 2020; 36:e3265. [PMID: 31850672 DOI: 10.1002/dmrr.3265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 07/05/2019] [Accepted: 12/11/2019] [Indexed: 12/28/2022]
Abstract
AIMS Osteocalcin contributes to the regulation of endocrine system. However, the association between osteocalcin and ketosis has not been evaluated. We thus aimed to explore the relationship between total osteocalcin and risk of ketosis in type 2 diabetes (T2DM). MATERIALS AND METHODS We identified 6157 diabetes patients from Shanghai Tenth People's Hospital between 1 January 2011 and 1 March 2017. Six hundred eight subjects were enrolled in the retrospective cross-sectional study: 304 T2DM patients with ketosis whose age, gender, and body mass index were matched with 304 T2DM patients without ketosis. A further retrospective nested case-control study was conducted in 252 T2DM patients without ketosis for a mean duration of 21.58 ± 12.43 months to investigate the occurrence of ketosis. RESULTS Osteocalcin levels were negatively correlated with blood ketones (adjusted r = -0.263) and urine ketones (adjusted r = -0.183). The inverse dose-dependent relationship of osteocalcin and risk of ketosis was present across osteocalcin level quintiles (top quintile as the reference, adjusted odds ratio [95% CI] = 2.56 [0.80-8.17], 3.71 [0.90-15.29], 10.77 [2.63-44.15], 23.81 [4.32-131.17] per osteocalcin quintile, respectively). Ketosis occurred in 17 of the 252 T2DM patients during follow-up. The Cox regression analysis indicated that osteocalcin was an independent protective factor against development of ketosis (adjusted hazard ratio [95% CI]: 0.668 [0.460-0.971]). CONCLUSIONS Total osteocalcin can be used as a predictor of ketosis in T2DM.
Collapse
Affiliation(s)
- Bing Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Ziwei Lin
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Xianying Chen
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
| | - Aaron M Gusdon
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Wenjun Shen
- Division of Endocrinology,Gerontology and Metabolism, Stanford University, Stanford, CA, USA
- Veterans Affairs Palo AltoHealth Care System, Palo Alto, CA, USA
| | - Jia Chen
- Department of Endocrinology, Beijing Jishuitan Hospital, 4th Medical College of Peking University, Beijing, China
| | - Liang Zheng
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Hang Sun
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Yan Li
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Cuiling Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Jue Li
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
- Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
| |
Collapse
|
45
|
Abstract
Diabetic ketoacidosis (DKA) has largely been considered unique to type 1 diabetes because of the absolute lack of insulin production secondary to beta-cell dysfunction. However, a relatively new diabetes subtype known as ketosis-prone type 2 diabetes mellitus (DM) may also elicit diabetic ketoacidosis. Ketosis-prone type 2 DM shares a similar pathophysiology as type 2 DM, but presents initially with signs and symptoms consistent with type 1 DM. Patients with ketosis-prone type 2 DM often present with elevated glucose levels of 500-700 mg/dl, elevated ketone levels, and elevations in hemoglobin A1C. Unlike DKA seen in type 1 DM, they do not exhibit autoantibodies to beta cells. The similarity with type 1 DM exists in their impaired insulin secretion, which, when combined with extreme insulin resistance, will lead to ketoacidosis. Despite the initial clinical presentation that resembles type 1 DM, patients may not require lifelong insulin and achieve appropriate glycemic control with oral agents. Nurse practitioners must recognize the clinical picture of ketosis-prone type 2 DM and use a multifaceted approach, encouraging dietary changes, increased physical activity, and medication adherence to build the self-management skills of the patient and ultimately decrease the long-term disease burden.
Collapse
|
46
|
An Unexpected Case of Diabetic Ketoacidosis on the Psychiatry Ward: Olanzapine-Associated Adult Ketosis-Prone Type 2 Diabetes Mellitus. Can J Diabetes 2020; 44:216-218. [DOI: 10.1016/j.jcjd.2019.07.148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 06/21/2019] [Accepted: 07/18/2019] [Indexed: 11/20/2022]
|
47
|
Hartig SM, Cox AR. Paracrine signaling in islet function and survival. J Mol Med (Berl) 2020; 98:451-467. [PMID: 32067063 DOI: 10.1007/s00109-020-01887-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 02/05/2020] [Accepted: 02/11/2020] [Indexed: 02/06/2023]
Abstract
The pancreatic islet is a dense cellular network comprised of several cell types with endocrine function vital in the control of glucose homeostasis, metabolism, and feeding behavior. Within the islet, endocrine hormones also form an intricate paracrine network with supportive cells (endothelial, neuronal, immune) and secondary signaling molecules regulating cellular function and survival. Modulation of these signals has potential consequences for diabetes development, progression, and therapeutic intervention. Beta cell loss, reduced endogenous insulin secretion, and dysregulated glucagon secretion are hallmark features of both type 1 and 2 diabetes that not only impact systemic regulation of glucose, but also contribute to the function and survival of cells within the islet. Advancing research and technology have revealed new islet biology (cellular identity and transcriptomes) and identified previously unrecognized paracrine signals and mechanisms (somatostatin and ghrelin paracrine actions), while shifting prior views of intraislet communication. This review will summarize the paracrine signals regulating islet endocrine function and survival, the disruption and dysfunction that occur in diabetes, and potential therapeutic targets to preserve beta cell mass and function.
Collapse
Affiliation(s)
- Sean M Hartig
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA
- Department of Molecular and Cellular Biology, Baylor College of Medicine, Houston, TX, 77030, USA
| | - Aaron R Cox
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX, 77030, USA.
| |
Collapse
|
48
|
Sahoo SK, Zaidi G, Vipin VP, Chapla A, Thomas N, Yu L, Asthana P, Bhatia E. Heterogeneity in the aetiology of diabetes mellitus in young adults: A prospective study from north India. Indian J Med Res 2020; 149:479-488. [PMID: 31411171 PMCID: PMC6676834 DOI: 10.4103/ijmr.ijmr_1004_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background & objectives: In contrast to Caucasians of European origin, the aetiology of diabetes mellitus (DM) in young adults in other ethnic groups, including Indians is likely to be heterogeneous and difficult to determine. This study was undertaken to determine the aetiology of diabetes in young Indian adults using a protocol-based set of simple clinical and investigation tools. Methods: In this prospective study, 105 Indian young adults with diabetes (age at onset 18-35 yr; duration <2 yr) were studied for a period of 1-3 years. Pancreatic imaging, fasting C-peptide, islet antibodies (against glutamic acid decarboxylase, tyrosine phosphatase and zinc transporter-8) and mitochondrial A3243G mutational analysis were performed in all patients. Four patients were screened for maturity-onset diabetes of the young (MODY) using next-generation sequencing. Results: Type 1 and type 2 diabetes mellitus (T1DM and T2DM) were equally frequent (40% each), followed by fibrocalculous pancreatic diabetes (FCPD, 15%). Less common aetiologies included MODY (2%), mitochondrial diabetes (1%) and Flatbush diabetes (2%). There was considerable phenotypic overlap between the main aetiological subtypes. Elevated islet antibodies were noted in 62 per cent of T1DM patients [positive predictive value (PPV) 84%; negative predictive value (NPV) 78%] while low plasma C-peptide (<250 pmol/l) was present in 56 per cent of T1DM patients [PPV 96% (after excluding FCPD), NPV 72%]. Using these tests and observing the clinical course over one year, a final diagnosis was made in 103 (99%) patients, while the diagnosis at recruitment changed in 23 per cent of patients. Interpretation & conclusions: The aetiology of diabetes in young adults was heterogeneous, with T1DM and T2DM being equally common. FCPD was also frequent, warranting its screening in Indian patients. Testing for islet antibodies and C-peptide in this age group had good PPV for diagnosis of T1DM.
Collapse
Affiliation(s)
- Saroj Kumar Sahoo
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Ghazala Zaidi
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Valam Puthussery Vipin
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Aaron Chapla
- Department of Endocrinology, Christian Medical College, Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Christian Medical College, Vellore, India
| | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Pranjul Asthana
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Eesh Bhatia
- Department of Endocrinology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| |
Collapse
|
49
|
Shidler KL, Letourneau LR, Novak LM. Uncommon Presentations of Diabetes: Zebras in the Herd. Clin Diabetes 2020; 38:78-92. [PMID: 31975755 PMCID: PMC6969666 DOI: 10.2337/cd19-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The majority of patients with diabetes are diagnosed as having either type 1 or type 2 diabetes. However, when encountered in clinical practice, some patients may not match the classic diagnostic criteria or expected clinical presentation for either type of the disease. Latent autoimmune, ketosis-prone, and monogenic diabetes are nonclassical forms of diabetes that are often misdiagnosed as either type 1 or type 2 diabetes. Recognizing the distinguishing clinical characteristics and understanding the diagnostic criteria for each will lead to appropriate treatment, facilitate personalized medicine, and improve patient outcomes.
Collapse
Affiliation(s)
- Karen L. Shidler
- North Central Indiana Area Health Education Center, Rochester, IN
| | | | - Lucia M. Novak
- Riverside Diabetes Center, Riverside Medical Associates, Riverdale, MD
| |
Collapse
|
50
|
Hwang WB, Kim JH, Cho SM. Two cases of ketosis-prone diabetes mellitus in Korean adolescents. Ann Pediatr Endocrinol Metab 2019; 24:257-261. [PMID: 31905447 PMCID: PMC6944861 DOI: 10.6065/apem.2019.24.4.257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 04/22/2019] [Indexed: 11/23/2022] Open
Abstract
In recent years, reports of diabetes mellitus (DM) cases that do not fit the traditional classification system have increased in prevalence. While insulin deficiency appears as type 1 DM (T1DM), the new type also has the clinical features of type 2 DM (T2DM); as such, this new type of DM is called ketosis-prone diabetes (KPD) and is correlated with findings of severe hyperglycemia and ketoacidosis. To provide a clear, clinical classification of DM, new classification systems are being studied. Among these, the Aβ system demonstrates the highest sensitivity and specificity in predicting clinical features and prognosis. We report 2 cases of KPD in Korean pediatric patients. The first patient was referred while in a state of diabetic ketoacidosis (DKA) and was considered to have T1DM. However, their blood glucose was well-controlled even with small doses of insulin, and the treatment was able to be changed to metformin therapy. The second patient seemed to be a typical case of T2DM because of his obesity and strong family history. However, blood glucose was not well-controlled with a regular diet, and ketosis occurred. After performing a glucagon stimulation test, both patients showed different clinical features that were finally diagnosed as type A-β+ KPD. The rapid and accurate diagnosis of KPD can reduce the duration of inappropriate insulin use and improve patients' quality of life. Further, the treatment of KPD children should be individualized according to each patient's lifestyle to preventing recurrent DKA.
Collapse
Affiliation(s)
- Won Bin Hwang
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Ji Hyun Kim
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea,Address for correspondence: Ji Hyun Kim, MD, PhD Department of Pediatrics, Dongguk University Ilsan Hospital, 27 Dongguk-ro, Ilsandong-gu, Goyang 10326, Korea Tel: +82-31-961-7190 Fax: +82-31-961-7188 E-mail:
| | - Sung Min Cho
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| |
Collapse
|