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Stone SI, Balasubramanyam A, Posey JE. Atypical Diabetes: What Have We Learned and What Does the Future Hold? Diabetes Care 2024; 47:770-781. [PMID: 38329838 PMCID: PMC11043229 DOI: 10.2337/dci23-0038] [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: 08/02/2023] [Accepted: 11/21/2023] [Indexed: 02/10/2024]
Abstract
As our understanding of the pathophysiology of diabetes evolves, we increasingly recognize that many patients may have a form of diabetes that does not neatly fit with a diagnosis of either type 1 or type 2 diabetes. The discovery and description of these forms of "atypical diabetes" have led to major contributions to our collective understanding of the basic biology that drives insulin secretion, insulin resistance, and islet autoimmunity. These discoveries now pave the way to a better classification of diabetes based on distinct endotypes. In this review, we highlight the key biological and clinical insights that can be gained from studying known forms of atypical diabetes. Additionally, we provide a framework for identification of patients with atypical diabetes based on their clinical, metabolic, and molecular features. Helpful clinical and genetic resources for evaluating patients suspected of having atypical diabetes are provided. Therefore, appreciating the various endotypes associated with atypical diabetes will enhance diagnostic accuracy and facilitate targeted treatment decisions.
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Affiliation(s)
- Stephen I. Stone
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Jennifer E. Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
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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.
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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
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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.
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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
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Cosson E, Thioye EMM, Tatulashvili S, Vicaut E, Larger E, Sal M, Pinto S, Fabre E, Lalatonne Y, Sutton A, Nachtergaele C, Portal JJ, Zerguine M, Carbillon L, Bihan H. The Prognosis of Glutamic Acid Decarboxylase Antibodies in Women With Hyperglycemia in Pregnancy. J Clin Endocrinol Metab 2024; 109:e1117-e1124. [PMID: 37888829 DOI: 10.1210/clinem/dgad617] [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: 05/25/2023] [Indexed: 10/28/2023]
Abstract
CONTEXT We recently reported that the presence of glutamic acid decarboxylase antibodies (GADA) was not associated with large-for-gestational-age infants in women with hyperglycemia in pregnancy (HIP). OBJECTIVE We explored the association between the presence of GADA and other HIP-related adverse pregnancy outcomes. METHODS This observational prospective study, conducted at a university hospital in a suburb of Paris, France, included 1182 consecutive women with HIP measured for GADA at HIP care initiation between 2012 and 2017. Post hoc analyses for outcomes included gestational weight gain, insulin therapy, cesarean delivery, hypertensive disorders, small-for-gestational-age infant, prematurity, and neonatal hypoglycemia. RESULTS Of the 1182 women studied, 87 (7.4%) had positive (≥ 1 IU/mL) GADA. Although socioeconomic, clinical, and biological characteristics were similar across women in the positive and negative GADA groups, higher fasting plasma glucose values during early HIP screening were observed in the former (5.5 ± 1.5 vs 5.2 ± 0.7 mmol/L respectively, P < .001). At HIP care initiation, fructosamine levels were higher in women with positive GADA (208 ± 23 vs 200 ± 18 µmol/L; P < .05). In the homeostatic model assessment, insulin resistance (HOMA-IR) and beta secretion (HOMA-B) rates were similar in both groups. Gestational weight gain and the rates of all adverse outcomes were similar in both groups except for cesarean delivery (18.4 and 27.3% for positive and negative GADA, respectively; adjusted odds ratio 0.49 [95% CI, 0.26-0.92], P = .026). CONCLUSION Universal measurement of GADA in women with HIP highlighted that 7.4% had positive GADA. No association was observed between GADA and HIP-related adverse pregnancy outcomes, except a lower risk of cesarean delivery.
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Affiliation(s)
- Emmanuel Cosson
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
- Equipe de Recherche en Epidémiologie Nutritionnelle (EREN), Université Sorbonne Paris Nord and Université Paris Cité, INSERM, INRAE, CNAM, Center of Research in Epidemiology and StatisticS (CRESS), 93000 Bobigny, France
| | - Elhadji Mamadou Moussa Thioye
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
| | - Sopio Tatulashvili
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
- Equipe de Recherche en Epidémiologie Nutritionnelle (EREN), Université Sorbonne Paris Nord and Université Paris Cité, INSERM, INRAE, CNAM, Center of Research in Epidemiology and StatisticS (CRESS), 93000 Bobigny, France
| | - Eric Vicaut
- AP-HP, Unité de Recherche Clinique St-Louis-Lariboisière, Université Denis Diderot, 75010 Paris, France
| | - Etienne Larger
- Institut Cochin, CNRS, Inserm, Université de Paris, 75014 Paris, France
- Service de Diabétologie et Immunologie Clinique, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Hôpitaux Universitaires de Paris Centre-Université Paris Cité, 75014 Paris, France
| | - Meriem Sal
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
| | - Sara Pinto
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
| | - Emmanuelle Fabre
- AP-HP, Avicenne and Jean Verdier Hospitals, Paris 13 University, Sorbonne Paris Cité, Biochemistry Department, 93000 Bobigny, France
- Signalisation, microenvironnement et hémopathies lymphoïdes, Inserm, UMR-978, Université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Yoann Lalatonne
- APHP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Nuclear Medicine, 93000 Bobigny, France
- Laboratory for Vascular Translational Science, Inserm, UMR-1148, Université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Angela Sutton
- AP-HP, Avicenne and Jean Verdier Hospitals, Paris 13 University, Sorbonne Paris Cité, Biochemistry Department, 93000 Bobigny, France
- Laboratory for Vascular Translational Science, Inserm, UMR-1148, Université Sorbonne Paris Nord, 93000 Bobigny, France
| | - Charlotte Nachtergaele
- AP-HP, Unité de Recherche Clinique St-Louis-Lariboisière, Université Denis Diderot, 75010 Paris, France
| | - Jean-Jacques Portal
- AP-HP, Unité de Recherche Clinique St-Louis-Lariboisière, Université Denis Diderot, 75010 Paris, France
| | - Mohamed Zerguine
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
| | - Lionel Carbillon
- AP-HP, Jean Verdier Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Obstetrics and Gynecology, 93140 Bondy, France
| | - Hélène Bihan
- AP-HP, Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, 93000 Bobigny, France
- LEPS (Laboratoire Educations et Promotion de la Santé) EA 3412-Université Paris 13, 93000 Bobigny, France
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Osafehinti D, Mulukutla SN, Hampe CS, Gaba R, Ram N, Weedon MN, Oram RA, Balasubramanyam A. Type 1 Diabetes Genetic Risk Score Differentiates Subgroups of Ketosis-Prone Diabetes. Diabetes Care 2023; 46:1778-1782. [PMID: 37506364 PMCID: PMC10516251 DOI: 10.2337/dc23-0622] [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: 04/09/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE To determine whether genetic risk for type 1 diabetes (T1D) differentiates the four Aβ subgroups of ketosis-prone diabetes (KPD), where A+ and A- define the presence or absence of islet autoantibodies and β+ and β- define the presence or absence of β-cell function. RESEARCH DESIGN AND METHODS We compared T1D genetic risk scores (GRS) of patients with KPD across subgroups, race/ethnicity, β-cell function, and glycemia. RESULTS Among 426 patients with KPD (54% Hispanic, 31% African American, 11% White), rank order of GRS was A+β- > A+β+ = A-β- > A-β+. GRS of A+β- KPD was lower than that of a T1D cohort, and GRS of A-β+ KPD was higher than that of a type 2 diabetes cohort. GRS was lowest among African American patients, with a similar distribution across KPD subgroups. CONCLUSIONS T1D genetic risk delineates etiologic differences among KPD subgroups. Patients with A+β- KPD have the highest and those with A-β+ KPD the lowest GRS.
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Affiliation(s)
- Deborah Osafehinti
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | | | - Ruchi Gaba
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Michael N. Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, and The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Richard A. Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, and The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
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Min R, Liao Y, Peng B. Development and validation of a novel nomogram for prediction of ketosis-prone type 2 diabetes. Front Endocrinol (Lausanne) 2023; 14:1235048. [PMID: 37829685 PMCID: PMC10565480 DOI: 10.3389/fendo.2023.1235048] [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: 06/05/2023] [Accepted: 08/31/2023] [Indexed: 10/14/2023] Open
Abstract
Background Ketosis-prone type 2 diabetes (KPD), as a unique emerging clinical entity, often has no clear inducement or obvious clinical symptoms at the onset of the disease. Failure to determine ketosis in time may lead to more serious consequences and even death. Therefore, our study aimed to develop and validate a novel nomogram to predict KPD. Methods In this retrospective study, clinical data of a total of 398 newly diagnosed type 2 diabetes in our hospital who met our research standards with an average age of 48.75 ± 13.86 years years old from January 2019 to December 2022 were collected. According to the occurrence of ketosis, there were divided into T2DM groups(228 cases)with an average age of 52.19 ± 12.97 years, of whom 69.74% were male and KPD groups (170cases)with an average age of 44.13 ± 13.72 years, of whom males account for 80.59%. Univariate and multivariate logistic regression analysis was performed to identify the independent influencing factors of KPD and then a novel prediction nomogram model was established based on these independent predictors visually by using R4.3. Verification and evaluation of predictive model performance comprised receiver-operating characteristic (ROC) curve, corrected calibration curve, and clinical decision curve (DCA). Results 4 primary independent predict factors of KPD were identified by univariate and multivariate logistic regression analysis and entered into the nomogram including age, family history, HbA1c and FFA. The model incorporating these 4 predict factors displayed good discrimination to predict KPD with the area under the ROC curve (AUC) of 0.945. The corrected calibration curve of the nomogram showed good fitting ability with an average absolute error =0.006 < 0.05, indicating a good accuracy. The decision analysis curve (DCA) demonstrated that when the risk threshold was between 5% and 99%, the nomogram model was more practical and accurate. Conclusion In our novel prediction nomogram model, we found that age, family history, HbA1c and FFA were the independent predict factors of KPD. The proposed nomogram built by these 4 predictors was well developed and exhibited powerful predictive performance for KPD with high discrimination, good accuracy, and potential clinical applicability, which may be a useful tool for early screening and identification of high-risk population of KPD and therefore help clinicians in making customized treatment strategy.
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Affiliation(s)
- Rui Min
- Department of Geriatrics, Wuhan Fourth Hospital, Wuhan, Hubei, China
| | - Yiqin Liao
- Department of Thyroid and Breast Surgery, Xianning Central Hospital, Xianning, Hubei, China
| | - Bocheng Peng
- Department of Pain, Wuhan Fourth Hospital, Wuhan, Hubei, China
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Jones AG, Shields BM, Oram RA, Dabelea DM, Hagopian WA, Lustigova E, Shah AS, Knupp J, Mottl AK, DÀgostino RB, Williams A, Marcovina SM, Pihoker C, Divers J, Redondo MJ. Clinical prediction models combining routine clinical measures identify participants with youth-onset diabetes who maintain insulin secretion in the range associated with type 2 diabetes: The SEARCH for Diabetes in Youth Study. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.27.23296128. [PMID: 37808789 PMCID: PMC10557841 DOI: 10.1101/2023.09.27.23296128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Objective With the high prevalence of pediatric obesity and overlapping features between diabetes subtypes, accurately classifying youth-onset diabetes can be challenging. We aimed to develop prediction models that, using characteristics available at diabetes diagnosis, can identify youth who will retain endogenous insulin secretion at levels consistent with type 2 diabetes (T2D). Methods We studied 2,966 youth with diabetes in the prospective SEARCH study (diagnosis age ≤19 years) to develop prediction models to identify participants with fasting c-peptide ≥250 pmol/L (≥0.75ng/ml) after >3 years (median 74 months) of diabetes duration. Models included clinical measures at baseline visit, at a mean diabetes duration of 11 months (age, BMI, sex, waist circumference, HDL-C), with and without islet autoantibodies (GADA, IA-2A) and a Type 1 Diabetes Genetic Risk Score (T1DGRS). Results Models using routine clinical measures with or without autoantibodies and T1DGRS were highly accurate in identifying participants with c-peptide ≥0.75 ng/ml (17% of participants; 2.3% and 53% of those with and without positive autoantibodies) (area under receiver operator curve [AUCROC] 0.95-0.98). In internal validation, optimism was very low, with excellent calibration (slope=0.995-0.999). Models retained high performance for predicting retained c-peptide in older youth with obesity (AUCROC 0.88-0.96), and in subgroups defined by self-reported race/ethnicity (AUCROC 0.88-0.97), autoantibody status (AUCROC 0.87-0.96), and clinically diagnosed diabetes types (AUCROC 0.81-0.92). Conclusion Prediction models combining routine clinical measures at diabetes diagnosis, with or without islet autoantibodies or T1DGRS, can accurately identify youth with diabetes who maintain endogenous insulin secretion in the range associated with type 2 diabetes.
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Affiliation(s)
| | | | | | | | | | | | - Amy S Shah
- University of Cincinnati & Cincinnati Children's Hospital Medical Center
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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.
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Van Rampelbergh J, Achenbach P, Leslie RD, Ali MA, Dayan C, Keymeulen B, Owen KR, Kindermans M, Parmentier F, Carlier V, Ahangarani RR, Gebruers E, Bovy N, Vanderelst L, Van Mechelen M, Vandepapelière P, Boitard C. First-in-human, double-blind, randomized phase 1b study of peptide immunotherapy IMCY-0098 in new-onset type 1 diabetes. BMC Med 2023; 21:190. [PMID: 37226224 DOI: 10.1186/s12916-023-02900-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) is a CD4+ T cell-driven autoimmune disease characterized by the destruction of insulin-producing pancreatic β-cells by CD8+ T cells. Achieving glycemic targets in T1D remains challenging in clinical practice; new treatments aim to halt autoimmunity and prolong β-cell survival. IMCY-0098 is a peptide derived from human proinsulin that contains a thiol-disulfide oxidoreductase motif at the N-terminus and was developed to halt disease progression by promoting the specific elimination of pathogenic T cells. METHODS This first-in-human, 24-week, double-blind phase 1b study evaluated the safety of three dosages of IMCY-0098 in adults diagnosed with T1D < 6 months before study start. Forty-one participants were randomized to receive four bi-weekly injections of placebo or increasing doses of IMCY-0098 (dose groups A/B/C received 50/150/450 μg for priming followed by three further administrations of 25/75/225 μg, respectively). Multiple T1D-related clinical parameters were also assessed to monitor disease progression and inform future development. Long-term follow-up to 48 weeks was also conducted in a subset of patients. RESULTS Treatment with IMCY-0098 was well tolerated with no systemic reactions; a total of 315 adverse events (AEs) were reported in 40 patients (97.6%) and were related to study treatment in 29 patients (68.3%). AEs were generally mild; no AE led to discontinuation of the study or death. No significant decline in C-peptide was noted from baseline to Week 24 for dose A, B, C, or placebo (mean change - 0.108, - 0.041, - 0.040, and - 0.012, respectively), suggesting no disease progression. CONCLUSIONS Promising safety profile and preliminary clinical response data support the design of a phase 2 study of IMCY-0098 in patients with recent-onset T1D. TRIAL REGISTRATION IMCY-T1D-001: ClinicalTrials.gov NCT03272269; EudraCT: 2016-003514-27; and IMCY-T1D-002: ClinicalTrials.gov NCT04190693; EudraCT: 2018-003728-35.
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Affiliation(s)
| | - Peter Achenbach
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Technical University Munich, Klinikum Rechts Der Isar, Munich, Germany
| | | | - Mohammad Alhadj Ali
- Diabetes Research Group, Cardiff University School of Medicine, Cardiff University, Cardiff, UK
| | - Colin Dayan
- Diabetes Research Group, Cardiff University School of Medicine, Cardiff University, Cardiff, UK
| | - Bart Keymeulen
- Member of Belgian Diabetes Registry, Academic Hospital and Diabetes Research Center, Vrije Universiteit Brussel, Brussels, Belgium
| | - Katharine R Owen
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, Churchill Hospital, Oxford, UK
| | | | | | - Vincent Carlier
- Imcyse S.A., Avenue Pré-Aily 14, Angleur, 4031, Liège, Belgium
| | | | | | - Nicolas Bovy
- Imcyse S.A., Avenue Pré-Aily 14, Angleur, 4031, Liège, Belgium
| | - Luc Vanderelst
- Imcyse S.A., Avenue Pré-Aily 14, Angleur, 4031, Liège, Belgium
| | | | | | - Christian Boitard
- Inserm U1016, Cochin Institute, Paris, France
- Medical Faculty, Université de Paris, Paris, France
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10
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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.
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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
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11
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Faruqi J, Balasubramanyam A. COVID-19 and diabetes mellitus: a review of the incidence, pathophysiology and management of diabetes during the pandemic. Expert Rev Endocrinol Metab 2023; 18:167-179. [PMID: 36797835 DOI: 10.1080/17446651.2023.2176300] [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: 11/19/2022] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
INTRODUCTION The COVID-19 pandemic has changed the landscape of modern medicine on a global scale. An emerging concern is the recognition of a bidirectional relationship between COVID-19 and diabetes. Diabetes is a risk factor for severe COVID-19 illness. Intriguingly, recent epidemiological and in vitro studies suggest that infection with SARS-CoV-2, the causative viral agent of COVID-19, is associated with new-onset diabetes and worsening diabetes control. These factors have affected the management of diabetes. AREAS COVERED This review provides an overview of our current understanding of the incidence and prevalence of diabetes in relation to the COVID-19 pandemic, highlights studies evaluating SARS-CoV-2's beta cell tropism and its effects on insulin secretion and sensitivity and evaluates the impact of the pandemic on diabetes management and metabolic control. EXPERT OPINION Epidemiological studies have noted an increase in the incidence of new-onset diabetes associated with COVID-19 in patients with phenotypes of type 1 diabetes, type 2 diabetes and Ketosis-Prone Diabetes. Prospective studies are needed to fully elucidate the association between COVID-19 and diabetes and to characterize persons at risk of developing diabetes after SARS-CoV-2 infection, identify those who should be screened for diabetes, and determine the natural histories of different forms of diabetes associated with COVID-19.
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Affiliation(s)
- Jordana Faruqi
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
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12
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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.
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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.
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13
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Thomas NJ, Walkey HC, Kaur A, Misra S, Oliver NS, Colclough K, Weedon MN, Johnston DG, Hattersley AT, Patel KA. The relationship between islet autoantibody status and the genetic risk of type 1 diabetes in adult-onset type 1 diabetes. Diabetologia 2023; 66:310-320. [PMID: 36355183 PMCID: PMC9807542 DOI: 10.1007/s00125-022-05823-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
AIMS/HYPOTHESIS The reason for the observed lower rate of islet autoantibody positivity in clinician-diagnosed adult-onset vs childhood-onset type 1 diabetes is not known. We aimed to explore this by assessing the genetic risk of type 1 diabetes in autoantibody-negative and -positive children and adults. METHODS We analysed GAD autoantibodies, insulinoma-2 antigen autoantibodies and zinc transporter-8 autoantibodies (ZnT8A) and measured type 1 diabetes genetic risk by genotyping 30 type 1 diabetes-associated variants at diagnosis in 1814 individuals with clinician-diagnosed type 1 diabetes (1112 adult-onset, 702 childhood-onset). We compared the overall type 1 diabetes genetic risk score (T1DGRS) and non-HLA and HLA (DR3-DQ2, DR4-DQ8 and DR15-DQ6) components with autoantibody status in those with adult-onset and childhood-onset diabetes. We also measured the T1DGRS in 1924 individuals with type 2 diabetes from the Wellcome Trust Case Control Consortium to represent non-autoimmune diabetes control participants. RESULTS The T1DGRS was similar in autoantibody-negative and autoantibody-positive clinician-diagnosed childhood-onset type 1 diabetes (mean [SD] 0.274 [0.034] vs 0.277 [0.026], p=0.4). In contrast, the T1DGRS in autoantibody-negative adult-onset type 1 diabetes was lower than that in autoantibody-positive adult-onset type 1 diabetes (mean [SD] 0.243 [0.036] vs 0.271 [0.026], p<0.0001) but higher than that in type 2 diabetes (mean [SD] 0.229 [0.034], p<0.0001). Autoantibody-negative adults were more likely to have the more protective HLA DR15-DQ6 genotype (15% vs 3%, p<0.0001), were less likely to have the high-risk HLA DR3-DQ2/DR4-DQ8 genotype (6% vs 19%, p<0.0001) and had a lower non-HLA T1DGRS (p<0.0001) than autoantibody-positive adults. In contrast to children, autoantibody-negative adults were more likely to be male (75% vs 59%), had a higher BMI (27 vs 24 kg/m2) and were less likely to have other autoimmune conditions (2% vs 10%) than autoantibody-positive adults (all p<0.0001). In both adults and children, type 1 diabetes genetic risk was unaffected by the number of autoantibodies (p>0.3). These findings, along with the identification of seven misclassified adults with monogenic diabetes among autoantibody-negative adults and the results of a sensitivity analysis with and without measurement of ZnT8A, suggest that the intermediate type 1 diabetes genetic risk in autoantibody-negative adults is more likely to be explained by the inclusion of misclassified non-autoimmune diabetes (estimated to represent 67% of all antibody-negative adults, 95% CI 61%, 73%) than by the presence of unmeasured autoantibodies or by a discrete form of diabetes. When these estimated individuals with non-autoimmune diabetes were adjusted for, the prevalence of autoantibody positivity in adult-onset type 1 diabetes was similar to that in children (93% vs 91%, p=0.4). CONCLUSIONS/INTERPRETATION The inclusion of non-autoimmune diabetes is the most likely explanation for the observed lower rate of autoantibody positivity in clinician-diagnosed adult-onset type 1 diabetes. Our data support the utility of islet autoantibody measurement in clinician-suspected adult-onset type 1 diabetes in routine clinical practice.
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Affiliation(s)
- Nicholas J Thomas
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Helen C Walkey
- Faculty of Medicine, Imperial College London, London, UK
| | - Akaal Kaur
- Faculty of Medicine, Imperial College London, London, UK
| | - Shivani Misra
- Faculty of Medicine, Imperial College London, London, UK
| | - Nick S Oliver
- Faculty of Medicine, Imperial College London, London, UK
| | - Kevin Colclough
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | - Michael N Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | - Andrew T Hattersley
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Kashyap A Patel
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK.
- Department of Diabetes and Endocrinology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
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14
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Tosur M, Gandolfo L, Balasubramanyam A, Naylor RN, Pollin TI, Rasouli N, Cromer SJ, Buse JB, Redondo MJ. Enrollment of underrepresented racial and ethnic groups in the Rare and Atypical Diabetes Network (RADIANT). J Clin Transl Sci 2023; 7:e47. [PMID: 36845305 PMCID: PMC9947614 DOI: 10.1017/cts.2022.529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 12/21/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Diabetes mellitus in underrepresented racial and ethnic groups (URG) is rapidly increasing in incidence and has worse outcomes than diabetes in non-Hispanic White individuals. Rare and Atypical Diabetes Network (RADIANT) established recruitment targets based on the racial and ethnic distribution of the USA to enroll a diverse study population. We examined participation of URG across RADIANT study stages and described strategies to enhance recruitment and retention of URG. Materials and Methods RADIANT is a multicenter NIH-funded study of people with uncharacterized forms of atypical diabetes. RADIANT participants consent online and progress through three sequential study stages, as eligible. Results We enrolled 601 participants with mean age 44 ± 16.8 years, 64.4% female. At Stage 1, 80.6% were White, 7.2% African American (AA), 12.2% other/more than one race, and 8.4% Hispanic. Enrollment of URG was significantly below preset targets across most stages. Referral sources differed by race (p < 0.001) but not ethnicity (p = 0.15). Most AA participants were referred by RADIANT investigators (58.5% vs. 24.5% in Whites), whereas flyers, news, social media, and family or friends were more frequent referral sources for White individuals (26.4% vs. 12.2% in AA). Ongoing initiatives to increase enrollment of URG in RADIANT include engaging with clinics/hospitals serving URG, screening electronic medical records, and providing culturally competent study coordination and targeted advertisement. Conclusions There is low participation of URG in RADIANT, potentially limiting the generalizability of its discoveries. Investigations into barriers and facilitators for recruitment and retention of URG in RADIANT, with implications for other studies, are ongoing.
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Affiliation(s)
- Mustafa Tosur
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- Children’s Nutrition Research Center, USDA/ARS, Houston, TX, USA
| | - Laura Gandolfo
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Rochelle N. Naylor
- Division of Adult and Pediatric Endocrinology Diabetes, and Metabolism, Departments of Pediatrics and Medicine, University of Chicago, Chicago, IL, USA
| | - Toni I. Pollin
- Departments of Medicine and Epidemiology & Public Health, University of Maryland, Baltimore, MD, USA
| | - Neda Rasouli
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, University of Colorado, Aurora, CO, USA
| | - Sara J. Cromer
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Maria J. Redondo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
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15
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Cromer SJ, Chen V, Han C, Marshall W, Emongo S, Greaux E, Majarian T, Florez JC, Mercader J, Udler MS. Algorithmic identification of atypical diabetes in electronic health record (EHR) systems. PLoS One 2022; 17:e0278759. [PMID: 36508462 PMCID: PMC9744270 DOI: 10.1371/journal.pone.0278759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022] Open
Abstract
AIMS Understanding atypical forms of diabetes (AD) may advance precision medicine, but methods to identify such patients are needed. We propose an electronic health record (EHR)-based algorithmic approach to identify patients who may have AD, specifically those with insulin-sufficient, non-metabolic diabetes, in order to improve feasibility of identifying these patients through detailed chart review. METHODS Patients with likely T2D were selected using a validated machine-learning (ML) algorithm applied to EHR data. "Typical" T2D cases were removed by excluding individuals with obesity, evidence of dyslipidemia, antibody-positive diabetes, or cystic fibrosis. To filter out likely type 1 diabetes (T1D) cases, we applied six additional "branch algorithms," relying on various clinical characteristics, which resulted in six overlapping cohorts. Diabetes type was classified by manual chart review as atypical, not atypical, or indeterminate due to missing information. RESULTS Of 114,975 biobank participants, the algorithms collectively identified 119 (0.1%) potential AD cases, of which 16 (0.014%) were confirmed after expert review. The branch algorithm that excluded T1D based on outpatient insulin use had the highest percentage yield of AD (13 of 27; 48.2% yield). Together, the 16 AD cases had significantly lower BMI and higher HDL than either unselected T1D or T2D cases identified by ML algorithms (P<0.05). Compared to the ML T1D group, the AD group had a significantly higher T2D polygenic score (P<0.01) and lower hemoglobin A1c (P<0.01). CONCLUSION Our EHR-based algorithms followed by manual chart review identified collectively 16 individuals with AD, representing 0.22% of biobank enrollees with T2D. With a maximum yield of 48% cases after manual chart review, our algorithms have the potential to drastically improve efficiency of AD identification. Recognizing patients with AD may inform on the heterogeneity of T2D and facilitate enrollment in studies like the Rare and Atypical Diabetes Network (RADIANT).
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Affiliation(s)
- Sara J. Cromer
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Northeastern University, Boston, Massachusetts, United States of America
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Victoria Chen
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Christopher Han
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - William Marshall
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Shekina Emongo
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Evelyn Greaux
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Tim Majarian
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Northeastern University, Boston, Massachusetts, United States of America
| | - Jose C. Florez
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Northeastern University, Boston, Massachusetts, United States of America
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Josep Mercader
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Northeastern University, Boston, Massachusetts, United States of America
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Miriam S. Udler
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Programs in Metabolism and Medical and Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts, United States of America
- Northeastern University, Boston, Massachusetts, United States of America
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
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16
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Abstract
The historical subclassification of diabetes into predominantly types 1 and 2 is well appreciated to inadequately capture the heterogeneity seen in patient presentations, disease course, response to therapy and disease complications. This review summarises proposed data-driven approaches to further refine diabetes subtypes using clinical phenotypes and/or genetic information. We highlight the benefits as well as the limitations of these subclassification schemas, including practical barriers to their implementation that would need to be overcome before incorporation into clinical practice.
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Affiliation(s)
- Aaron J Deutsch
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Program in Medical & Population Genetics, Broad Institute, Boston, MA, USA
- Program in Metabolism, Broad Institute, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Emma Ahlqvist
- Genomics, Diabetes and Endocrinology, Department of Clinical Sciences in Malmö, Lund University Diabetes Centre, Lund University, Malmö, Sweden.
| | - Miriam S Udler
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Program in Medical & Population Genetics, Broad Institute, Boston, MA, USA.
- Program in Metabolism, Broad Institute, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
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17
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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.
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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
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18
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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.
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A patient with ketosis-prone type 2 diabetes showing nearly normalized glucose tolerance after recovery from severe diabetic ketoacidosis. Diabetol Int 2022; 14:109-113. [PMID: 36636160 PMCID: PMC9829925 DOI: 10.1007/s13340-022-00599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/20/2022] [Indexed: 01/16/2023]
Abstract
Unprovoked A-β+ ketosis-prone type 2 diabetes (KPD) is characterized by the sudden onset of diabetic ketosis/ketoacidosis (DK/DKA) without precipitating factors, negative anti-islet autoantibodies ("A- "), and preservation of β-cell function ("β+ ") after recovery from DKA using insulin therapy. However, there have been few reports on glucose tolerance after recovery. We present a case of KPD with nearly normalized glucose tolerance after recovery from severe DKA. A 41-year-old obese woman first presented with unprovoked severe DKA, i.e., ketonuria, plasma glucose 570 mg/dL, pH 7.18, and HCO3 - 5.2 mmol/L, without anti-islet autoantibodies. She achieved insulin-free glycemic remission after recovery from DKA, leading to the diagnosis of KPD. Thereafter, 75 g oral glucose tolerance test showed impaired fasting glucose and time-in-range using intermittently scanned continuous glucose monitoring was 97% without medication. These findings suggest that, despite the initial severe DKA, some patients with KPD might achieve normalized glucose tolerance after recovery. The similar onset patterns of DKA necessitates appropriately distinguishing KPD from acute-onset type 1B (idiopathic) diabetes. Supplementary Information The online version contains supplementary material available at 10.1007/s13340-022-00599-6.
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20
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Patil SP. Atypical Diabetes and Management Considerations. Prim Care 2022; 49:225-237. [DOI: 10.1016/j.pop.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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21
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Satomura A, Oikawa Y, Haisa A, Suzuki S, Nakanishi S, Katsuki T, Shimada A. Clinical Significance of Insulin Peptide-specific Interferon-γ-related Immune Responses in Ketosis-prone Type 2 Diabetes. J Clin Endocrinol Metab 2022; 107:e2124-e2132. [PMID: 34922394 DOI: 10.1210/clinem/dgab912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Unprovoked A-β+ ketosis-prone type 2 diabetes (KPD) is characterized by the sudden onset of diabetic ketosis/ketoacidosis (DK/DKA) without precipitating factors, negative anti-islet autoantibodies ("A-"), and preservation of β-cell function ("β+") after recovery from DKA. Although this phenotype often appears with acute hyperglycemia and DK/DKA just like acute-onset type 1 diabetes (AT1D), the involvement of anti-islet immune responses remains unknown. OBJECTIVE We sought to clarify the immunological role of insulin-associated molecules in unprovoked A-β+ KPD. METHODS In this cross-sectional study, blood samples from 75 participants (42 with AT1D and 33 with KPD) were evaluated for interferon (IFN)-γ-secreting peripheral blood mononuclear cells (PBMCs) reactive to 4 insulin B-chain amino acid 9-23-related peptides (B:9-23rPep) using an enzyme-linked immunospot (ELISpot) assay. RESULTS Overall, 36.4% (12/33) of KPD participants showed positive IFN-γ ELISpot assay results; the positivity rate in KPD was similar to that in AT1D (38.1%; 16/42) and statistically significantly higher than the previously reported rate in type 2 diabetes (8%; 2/25; P < .0167). Moreover, B:9-23rPep-specific IFN-γ-producing PBMC frequency was negatively correlated with age and ad lib serum C-peptide levels in all KPD participants and positively correlated with glycated hemoglobin A1c level in KPD participants with positive IFN-γ ELISpot results. CONCLUSION These findings suggest the involvement of B:9-23rPep-specific IFN-γ-related immunoreactivity in the pathophysiology of some unprovoked A-β+ KPD. Moreover, increased immunoreactivity may reflect transiently decreased β-cell function and increased disease activity at the onset of DK/DKA, thereby playing a key role in DK/DKA development in this KPD phenotype.
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Affiliation(s)
- Atsushi Satomura
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Akifumi Haisa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Seiya Suzuki
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Shunpei Nakanishi
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Takeshi Katsuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo 108-0073, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
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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.
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Matsuura M, Sugawara D, Ichihashi K. A Pediatric Case of Ketosis-Prone Type 2 Diabetes Requiring Insulin Therapy. Cureus 2022; 14:e23305. [PMID: 35464505 PMCID: PMC9015063 DOI: 10.7759/cureus.23305] [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: 03/18/2022] [Indexed: 11/17/2022] Open
Abstract
In recent years, cases of diabetic ketoacidosis (DKA) or ketosis as the initial manifestation of diabetes with a similar clinical course to that of type 2 diabetes have been reported. This phenotype has been recognized as ketosis-prone type 2 diabetes (KPD). Most cases of KPD occur in adults, and the typical clinical course is that patients are often able to wean off insulin therapy after initial treatment. We report a pediatric case of ketosis-prone type 2 diabetes requiring insulin therapy with four years of follow-up. Our case suggests that patients with KPD may require strict management, including weight control, compared with patients with typical type 2 diabetes.
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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.
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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
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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.
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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
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Fu Y, Zhang C, Gu Y, Ge S, Li J, Feng J, Zhang L, Liu W, Chen H. Establishing reference intervals for islet autoantibodies in Han Chinese type 1 diabetes. Scandinavian Journal of Clinical and Laboratory Investigation 2021; 81:641-648. [PMID: 34779329 DOI: 10.1080/00365513.2021.2001564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Currently, islet autoantibodies (IAbs) constitute the most reliable marker for detecting the autoimmune process of type 1 diabetes (T1D). However, there are no appropriate reference intervals (RIs) to interpret the results of IAbs in China. In this study, we aimed to establish the RIs of four common IAbs based on the Han Chinese population and evaluate their clinical diagnostic values in patients with T1D. We collected 177 blood samples from healthy volunteers to detect the levels of IAbs directed against insulin (IAA), glutamic acid decarboxylase-65 (GADA), insulinoma antigen 2 (IA-2A), and zinc transporter-8 (ZnT8A) using a chemiluminescence immunoassay. RIs were calculated using nonparametric 95th percentile intervals in accordance with the Clinical and Laboratory Standards Institute guidelines, and their clinical diagnostic values were evaluated by detecting the levels of IAbs of 140 blood samples from patients with T1D in a clinical setting. We defined 138 individuals as the apparently healthy population from the 177 healthy volunteers based on the exclusion criteria. No association between the levels of the four IAbs and gender (p > .05) and age (p > .05) were found in the apparently healthy population. The combined RIs for GADA, IA-2A, ZnT8A, and IAA were 0-1.78 IU/mL, 0-3.91 IU/mL, 0-2.36 AU/mL, and 0-0.58 COI, respectively. Overall, the diagnostic efficiency for the four IAbs, especially for GADA and IAA, were improved by using the RIs established in this study. The RIs for IAbs established in this study will be a valuable tool for disease diagnosis and the therapeutic management of T1D in a clinical setting.
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Affiliation(s)
- Yu Fu
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Chen Zhang
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Yong Gu
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Shibin Ge
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Jianhua Li
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Jianlin Feng
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Li Zhang
- Operating Room of Outpatient Family Planning, Nanjing Maternal and Child Health Care Hospital, Nanjing, People's Republic of China
| | - Wei Liu
- Department of Nuclear Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
| | - Heng Chen
- Department of Endocrinology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, People's Republic of China
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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.
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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
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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.
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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
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29
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Adler A, Bennett P, Colagiuri Chair S, Gregg E, Narayan KMV, Inês Schmidt M, Sobngwi E, Tajima N, Tandon N, Unwin N, Wild S, Yudkin J, Levitt N, Mohan V, Montgomery S, Nyirenda MJ, Tuomilehto J, Den Boon S, Hocking S. REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS. Diabetes Res Clin Pract 2021:108972. [PMID: 34343595 DOI: 10.1016/j.diabres.2021.108972] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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Affiliation(s)
| | - Peter Bennett
- Phoenix Epidemiology & Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, USA
| | | | - Edward Gregg
- Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Eugene Sobngwi
- Faculté de Medecine et des Sciences Biomedicales et Centre de Biotechnologie, Université de Yaounde 1, Cameroon
| | - Naoko Tajima
- Jikei University School of Medicine, Tokyo, Japan
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Nigel Unwin
- Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados, and MRC Epidemiology Unit, University of Cambridge, UK
| | | | | | - Naomi Levitt
- Diabetic Medicine and Endocrinology, Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa
| | | | | | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute/London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
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30
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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.
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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.
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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.
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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.
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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.
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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
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Ekiz E, Celepkolu T, Karahan Y. An Important Form of Diabetes for Clinicians: Ketosis-Prone Diabetes. DUBAI DIABETES AND ENDOCRINOLOGY JOURNAL 2021. [DOI: 10.1159/000513667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Ketosis-prone diabetes (KPD) is defined as a hybrid form of diabetes mellitus, which is predominantly seen in overweight-to-obese men. Although the diagnosis is based on diabetic ketoacidosis (DKA) as a presenting feature, which also is characteristic of type 1 diabetes, the course of the disease differs from type 1. Recognition of this form by the clinicians is important as these patients are negative for autoantibodies and share the characteristics of type 2 diabetes during follow-up. Here we report 2 cases of KPD presenting with DKA and maintaining normoglycemia without insulin after receiving short-term intensive insulin treatment.
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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.
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Affiliation(s)
- Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA;
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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.
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Affiliation(s)
- Åke Sjöholm
- Department of Internal Medicine, Region Gävleborg, Gavle, Sweden
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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]
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Sato Y, Kakizawa M, Aso SI, Takayama M, Yamashita K, Miyamoto T, Aizawa T. Startling hyperglycaemia with transient beta cell stunning in a patient with type 2 diabetes. Endocr J 2020; 67:95-98. [PMID: 31597815 DOI: 10.1507/endocrj.ej19-0305] [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] [Indexed: 11/23/2022] Open
Abstract
A 59-year-old woman unaware of having diabetes was transferred due to coma. Upon discovery at home, her consciousness on the Glasgow Coma Scale was E1V2M4, BP 95/84 mmHg, body temperature 34.7°C. On arrival at ER, height was 1.63 m, weight 97 kg, plasma glucose (PG) 1,897 mg/dL, HbA1c 13.6%, osmolality 421 mosm/kg, arterial pH 7.185, lactate 6.34 mmol/L, β-hydroxybutyrate 7.93 mmol/L. With saline and regular insulin infusion, PG was lowered to 1,440 mg/dL at 2 hours and then to 250 mg/dL by Day 3, and consciousness normalized by Day 5. On admission, serum immunoreactive insulin (IRI) was undetectable (<0.03 U/mL), C-peptide immunoreactivity (CPR) undetectable (<0.003 ng/mL), and anti-glutamic acid decarboxylase antibody negative. Following the above-described treatment, fasting PG was 186 mg/dL and CPR 1.94 ng/mL, respectively, on Day 14; 2-h post-breakfast PG 239 mg/dL and CPR 6.28 ng/mL, respectively, on Day 18. The patient discharged on Day 18 with 1,800 kcal diet, 32 U insulin glargine and 40 mg gliclazide. Fifteen months later at outpatient clinic, her HbA1c was 6.9% and 2-h post-breakfast PG 123 mg/dL and CPR 5.30 ng/dL with 750 mg metformin, 10 mg gliclazide and 18 U insulin glargine. Transient, but total cessation of insulin secretion was documented in a patient with type 2 diabetes under severe metabolic decompensation. Swift, sustained recovery of insulin release indicated that lack of insulin at the time of emergency was due to secretory failure, i.e., unresponsive exocytotic machinery or depletion of releasable insulin, rather than loss of beta cells.
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Affiliation(s)
- Yuka Sato
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Masaki Kakizawa
- Department of Neurology, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Shin-Ichi Aso
- Department of Cardiovascular Medicine, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Masayuki Takayama
- Clinical Laboratory Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | - Koh Yamashita
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
| | | | - Toru Aizawa
- Diabetes Centre, Aizawa Hospital, Matsumoto, 390-8510, Japan
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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.
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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
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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.
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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
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Abstract
PURPOSE OF REVIEW Type 2 diabetes (T2D), which accounts for the vast majority of diabetes cases, is essentially a diagnosis of exclusion in current clinical practice. Therefore, it is not surprising that T2D is heterogenous in terms of patients' clinical presentation, disease course, and response to treatment. This review summarizes published attempts to improve diabetes subclassification, with a particular focus on the role of genetics. RECENT FINDINGS A handful of diabetes subclassification schemas have been proposed using clinical data (patient characteristics and laboratory values), with some subgroups associated with distinct management trends or complication risks. However, phenotypically driven classifications suffer from dependencies on time of variable measurement and are not readily linked to disease mechanism. Germline genetic data, in contrast, are essentially unchanged over a person's lifetime and rooted in mechanism. Clustering of T2D genetic loci has identified at least five groupings of loci representing mechanisms of disease that may aid in deconstructing heterogeneity of T2D, but further work is needed to determine clinical utility. Exciting progress in subclassification of diabetes has demonstrated initial steps in deconstructing disease heterogeneity. Incorporation of genetics into classification schemas will require additional research but has the potential to improve our understanding and management of T2D, both as a single disease and as a part of an integrated metabolic disease network.
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Affiliation(s)
- Miriam S Udler
- Massachusetts General Hospital Diabetes Center, 50 Staniford St, Suite 340, Boston, MA, 02114, USA.
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Thewjitcharoen Y, Plianpan P, Chotjirat A, Nakasatien S, Chotwanvirat P, Wanothayaroj E, Krittiyawong S, Himathongkam T. Clinical characteristics and outcomes of care in adult patients with diabetic ketoacidosis: A retrospective study from a tertiary diabetes center in Thailand. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY 2019; 16:100188. [PMID: 31011538 PMCID: PMC6462756 DOI: 10.1016/j.jcte.2019.100188] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 03/29/2019] [Accepted: 04/09/2019] [Indexed: 12/17/2022]
Abstract
Background Diabetic ketoacidosis (DKA) is a metabolic catastrophe which could occur in any type of diabetes. Even when fundamental key points of DKA treatment had been followed, some differences exist in treatment protocols in each physician, highlighting the need to assess adherence to DKA guideline. Aim This study aimed to examine trend of hospitalized DKA patients and outcomes of treatment over a decade at Theptarin Hospital, a multi-discipline based diabetes center in Thailand. Method A retrospective study of DKA episodes admitted over a 14-year period (2005–2018) was done. Clinical characteristics, laboratory data, type of diabetes, severity of DKA were collected and analyzed. Results A total of 94 DKA episodes occurred in 81 diabetic patients (females 61.5%, mean age 47.4 ± 20.4 years, T1DM 41.5%, T2DM 50.0%, Ketosis-prone diabetes 8.5%, baseline A1C 10.8 ± 3.0%). While infection was the common precipitating factor in T2DM, omission of insulin was the usual precipitating factor in T1DM. During ongoing management, 26.6% of patients developed hypokalemia and supplementation was not prescribed as per protocol in this group of patients. Almost 13% of patients experienced hypoglycemia in the first 24 h. Median time to resolution of DKA was 8.5 h. Four T2DM patients expired from the precipitating cause of DKA which accounted for mortality rate at 4.3% in our study. Conclusions Inadequate metabolic monitoring and iatrogenic hypoglycemia remain areas of concern for DKA management. Occurrence of hypokalemia was related to poor adherence to protocol guidance on potassium supplementation. A strengthened educational program for nursing and medical staffs should be emphasized.
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D'Elia JA, Mulla C, Liu J, Weinrauch LA. Variations in glucose/C-peptide ratio in patients with type 2 diabetes associated with renal function. Diabetes Res Clin Pract 2019; 150:1-7. [PMID: 30794834 DOI: 10.1016/j.diabres.2019.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 02/01/2019] [Accepted: 02/15/2019] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Accurate dosing of medications for glycemic control is a challenge for clinicians in diabetic patients with kidney disease. Diminishing glomerular filtration rates are associated with decreased renal clearance of insulin and increased prevalence of hypoglycemic episodes. Measurement of glucose/C peptide ratios may be useful to guide dosing in those patients who receive powerful insulin secretogogues as glomerular function decreases with age and disease. METHODS In order to determine the relationship between glucose, C-peptide and renal function, we reviewed the records of patients with type 2 diabetes followed in our kidney hypertension clinic who met the following criteria: age 35-90 years, requirement of medications to control glycemia, at least 4 simultaneous measurements of C peptide, HbA1c, creatinine and blood glucose. RESULTS 87 patients (67 males, 20 females), ages 67.1 ± 10.6 years, BMI 32.5 ± 5.2, A1c 8.2 ± 1.2%, eGFR 73 ± 27.2 ml/min, had glucose/C-peptide ratios 60.7 ± 46.4. 59% of the total group were taking insulin secretogogues. Patients were divided into groups based upon mean eGFR and use or absence of insulin secretogogues. Glucose C-peptide ratios were lowest in the quartile of patients with the lowest eGFR (<50 ml/min). CONCLUSION Diminished renal function and advanced age are associated with the lowest glucose/C-peptide ratios, independent of achieved glycemic control. With similar use of secretogogues, glucose/C-peptide ratio were lower when eGFR was ≤49 ml/min compared to >50-80 ml/min. Use of secretogogues was associated with decreased glucose/C-peptide levels. In patients with reduced renal function (eGFR < 50 ml/min), use of insulin secretogogues may be associated with lower glucose/C-peptide ratios associated with higher risks for hypoglycemic reactions.
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Affiliation(s)
- John A D'Elia
- Kidney and Hypertension Section, E.P. Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA, USA
| | - Christopher Mulla
- Kidney and Hypertension Section, E.P. Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA, USA
| | - Jiankang Liu
- Clinical Endpoint Committee, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02215, USA
| | - Larry A Weinrauch
- Kidney and Hypertension Section, E.P. Joslin Research Laboratory, Joslin Diabetes Center, Boston, MA, USA; Clinical Endpoint Committee, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA 02215, USA.
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Oram RA, Sims EK, Evans-Molina C. Beta cells in type 1 diabetes: mass and function; sleeping or dead? Diabetologia 2019; 62:567-577. [PMID: 30767048 PMCID: PMC6688846 DOI: 10.1007/s00125-019-4822-4] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/27/2018] [Indexed: 12/12/2022]
Abstract
Histological analysis of donor pancreases coupled with measurement of serum C-peptide in clinical cohorts has challenged the idea that all beta cells are eventually destroyed in type 1 diabetes. These findings have raised a number of questions regarding how the remaining beta cells have escaped immune destruction, whether pools of 'sleeping' or dysfunctional beta cells could be rejuvenated and whether there is potential for new growth of beta cells. In this Review, we describe histological and in vivo evidence of persistent beta cells in type 1 diabetes and discuss the limitations of current methods to distinguish underlying beta cell mass in comparison with beta cell function. We highlight that evidence for new beta cell growth in humans many years from diagnosis is limited, and that this growth may be very minimal if at all present. We review recent contributions to the debate around beta cell abnormalities contributing to the pathogenesis of type 1 diabetes. We also discuss evidence for restoration of beta cell function, as opposed to mass, in recent-onset type 1 diabetes, but highlight the absence of data supporting functional recovery in the setting of long-duration diabetes. Finally, future areas of research are suggested to help resolve the source and phenotype of residual beta cells that persist in some, but not all, people with type 1 diabetes.
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Affiliation(s)
- Richard A Oram
- RILD Level 3, Institute of Biomedical and Clinical Science, University of Exeter Medical School, Royal Devon and Exeter Hospital, Barrack Road, Exeter, EX2 5DW, UK.
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School, Exeter, UK.
- The Academic Renal Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Emily K Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- The Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
- The Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
- Department of Medicine, Indiana University School of Medicine, 635 Barnhill Drive, MS 2031A, Indianapolis, IN, 46202, USA.
- Roudebush VA Medical Center, Indianapolis, IN, USA.
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Aung ET, Koshy RM, Jacob K. Diabetic ketoacidosis in a patient with type 2 diabetes precipitated by infection, steroids and SGLT2 inhibitor. PRACTICAL DIABETES 2019. [DOI: 10.1002/pdi.2217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Pilla SJ, Balasubramanyam A, Knowler WC, Lazo M, Nathan DM, Pi-Sunyer X, Clark JM, Maruthur NM. Islet autoantibody positivity in overweight and obese adults with type 2 diabetes. Autoimmunity 2019; 51:408-416. [PMID: 30661481 DOI: 10.1080/08916934.2018.1547711] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Islet autoantibodies are typically associated with type 1 diabetes, but have been found in patients diagnosed with type 2 diabetes in whom they are associated with lower adiposity. The significance of autoantibody positivity in overweight and obese patients is not well understood. The aim of this study was to determine the prevalence and clinical significance of islet autoantibodies in overweight/obese adults diagnosed with type 2 diabetes. This study includes 204 participants at one site of the multicenter Look AHEAD (Action for Health in Diabetes) trial (ClinicalTrials.gov identifier: NCT00017953) which randomized overweight/obese adults diagnosed with type 2 diabetes to an intensive lifestyle intervention or diabetes support and education. We measured antibodies to glutamic acid decarboxylase, insulinoma antigen-2, and zinc transporter 8. Participants with and without autoantibodies were compared with respect to baseline clinical features, and longitudinal changes in weight, hemoglobin A1c, and antihyperglycemic medications. We found that 13 participants (6.4%) were autoantibody positive, including six of 47 participants (12.8%) with BMI ≥40 kg/m2. At baseline, autoantibody positive participants had higher HDL cholesterol (1.27 vs. 1.09 mmol/L, p = .034) and lower fasting C-peptide (0.32 vs. 0.57 nmol/L, p = .049). Over four years, autoantibody positive participants lost 5.1 kg more weight than autoantibody negative participants (p = .056). Longitudinal changes in hemoglobin A1c did not differ by autoantibody status, though autoantibody positive participants were more likely to increase the number of antihyperglycemic medications or initiate insulin (p = .011). In conclusion, islet autoantibodies were present in 6.4% of overweight/obese adults with type 2 diabetes including those with severe obesity, and were associated with distinct clinical features. The effect of autoantibody positivity on weight loss interventions requires further study.
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Affiliation(s)
- Scott J Pilla
- a Department of Medicine, Division of General Internal Medicine , The Johns Hopkins University School of Medicine, Baltimore , MD , USA
| | | | - William C Knowler
- c National Institute of Diabetes and Digestive and Kidney Diseases , Phoenix , AZ , USA
| | - Mariana Lazo
- a Department of Medicine, Division of General Internal Medicine , The Johns Hopkins University School of Medicine, Baltimore , MD , USA.,d Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - David M Nathan
- e Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
| | | | - Jeanne M Clark
- a Department of Medicine, Division of General Internal Medicine , The Johns Hopkins University School of Medicine, Baltimore , MD , USA.,d Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
| | - Nisa M Maruthur
- a Department of Medicine, Division of General Internal Medicine , The Johns Hopkins University School of Medicine, Baltimore , MD , USA.,d Department of Epidemiology , The Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Sjöholm Å. Ketosis-Prone Type 2 Diabetes: A Case Series. Front Endocrinol (Lausanne) 2019; 10:684. [PMID: 31749761 PMCID: PMC6843078 DOI: 10.3389/fendo.2019.00684] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 09/20/2019] [Indexed: 12/12/2022] Open
Abstract
Ketosis-prone type 2 diabetes ("Flatbush diabetes") carries features of both classical type 1 and type 2 diabetes and is highly prevalent in African populations. The disease, which is highly ketosis-prone, but neither chronically insulinopenic nor autoimmune, is discussed regarding pathogenesis, diagnosis and treatment from a patient case perspective.
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Gaba R, Mehta P, Balasubramanyam A. Evaluation and management of ketosis-prone diabetes. Expert Rev Endocrinol Metab 2019; 14:43-48. [PMID: 30612498 DOI: 10.1080/17446651.2019.1561270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/17/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Patients presenting with diabetic ketoacidosis (DKA) who lack the classic phenotype of autoimmune type 1 diabetes have become increasingly identified in recent decades. This has led to the recognition of heterogeneous syndromes of 'ketosis-prone diabetes' (KPD). Evaluation and optimal management of KPD differs from that of 'typical' type 1 or type 2 diabetes. Awareness of these differences and a systematic approach to diagnosis and treatment can improve glycemic control and prevent both acute and chronic complications of diabetes. AREAS COVERED This article reviews the Aß classification scheme ('A' for autoantibody status and 'ß' for beta cell functional reserve) which accurately delineates subgroups of KPD, and addresses the relevance of defining these subgroups for clinical outcomes and long-term insulin dependence. Subsequently, the detailed evaluation and management of KPD patients after their index DKA episode is described. EXPERT COMMENTARY Among patients presenting with DKA, it is important to diagnose specific subgroups of KPD and not assume that they represent exclusively patients with autoimmune type 1 diabetes. The Aß classification is an accurate aid to diagnosis, and permits optimal management of the subgroups (e.g., insulin treatment for the ß- subgroups; follow-up testing and a range of treatment options for the ß+ subgroups).
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Affiliation(s)
- Ruchi Gaba
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Paras Mehta
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Ashok Balasubramanyam
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
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Mulukutla SN, Acevedo-Calado M, Hampe CS, Pietropaolo M, Balasubramanyam A. Autoantibodies to the IA-2 Extracellular Domain Refine the Definition of "A+" Subtypes of Ketosis-Prone Diabetes. Diabetes Care 2018; 41:2637-2640. [PMID: 30327357 PMCID: PMC6245211 DOI: 10.2337/dc18-0613] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 09/10/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Autoantibodies directed against tyrosine phosphatase IA-2 antibody (IA-2 Ab) are diagnostic for autoimmune type 1 diabetes. Conventional assays target the intracellular domain of IA-2. Among patients with ketosis-prone diabetes (KPD), characterized by presentation with diabetic ketoacidosis (DKA), >60% of adults lack three classic islet autoantibodies-IA-2, GAD65, and ZnT8 Abs-associated with type 1 diabetes. We aimed to determine whether apparently autoantibody-negative ("A-") KPD patients possess occult IA-2 Ab directed against full-length IA-2 (IA-2FL) or its extracellular domain (IA-2EC). RESEARCH DESIGN AND METHODS We developed an assay that targets IA-2FL and IA-2EC and used it to analyze 288 subjects with A- KPD. RESULTS Ten A- KPD patients were positive for IA-2EC Ab (3.5%), and three were also positive for IA-2FL Ab (1.0%), similar to frequencies in type 1 and type 2 diabetes. CONCLUSIONS Measurement of IA-2FL Ab and IA-2EC Ab improves the accuracy of the Aβ classification of KPD patients.
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Affiliation(s)
- Surya N Mulukutla
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Maria Acevedo-Calado
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Christiane S Hampe
- Division of Metabolism, Endocrinology and Nutrition, Department of Medicine, University of Washington, Seattle, WA
| | - Massimo Pietropaolo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Ashok Balasubramanyam
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX
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Abstract
PURPOSE OF REVIEW Ketosis-prone diabetes or Flatbush diabetes has been widely recognized as a clinical entity since 1984. Most of the early clinical studies focused on African American or Afro-Caribbean individuals. It is now being recognized as an important clinical entity in sub-Saharan Africans, Asian and Indian populations, and Hispanic populations. Major questions remain as to its pathogenesis and whether it is a unique type of diabetes or a subset of more severe type 2 diabetes with greater loss of insulin action in target tissues. This review summarizes the main clinical and mechanistic studies to improve the understanding of ketosis-prone (Flatbush) diabetes. RECENT FINDINGS Little data are available on the magnitude of KPD in the different susceptible populations. It is relatively common in black populations. KPD is defined as a syndrome in which diabetes commences with ketoacidosis in individuals who are GAD and anti-islet cell antibody negative and have no known precipitating causes. The patients present during middle age, are overweight or mildly obese, and in many reports are more likely to be male. After intensive initial insulin therapy, many patients become insulin independent and can be well controlled on diet alone or diet plus oral medications. The clinical course of KPD is like that of patients with type 2 diabetes rather than that of type 1 diabetes. Little differences are found in the clinical characteristics and clinical outcomes between patients presenting with KPD and those presenting with severe hyperglycemia with no ketoacidosis. The mechanisms responsible for the development of ketosis-prone diabetes as well its remission remain unknown.
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Affiliation(s)
- Harold E. Lebovitz
- 0000 0001 0693 2202grid.262863.bDivision of Endocrinology, Department of Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 1205, Brooklyn, NY 11203 USA
| | - Mary Ann Banerji
- 0000 0001 0693 2202grid.262863.bDivision of Endocrinology, Department of Medicine, State University of New York Health Science Center at Brooklyn, 450 Clarkson Ave., Box 1205, Brooklyn, NY 11203 USA
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