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Thomas NJ, Jones AG. The challenges of identifying and studying type 1 diabetes in adults. Diabetologia 2023; 66:2200-2212. [PMID: 37728732 PMCID: PMC10628058 DOI: 10.1007/s00125-023-06004-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 07/14/2023] [Indexed: 09/21/2023]
Abstract
Diagnosing type 1 diabetes in adults is difficult since type 2 diabetes is the predominant diabetes type, particularly with an older age of onset (approximately >30 years). Misclassification of type 1 diabetes in adults is therefore common and will impact both individual patient management and the reported features of clinically classified cohorts. In this article, we discuss the challenges associated with correctly identifying adult-onset type 1 diabetes and the implications of these challenges for clinical practice and research. We discuss how many of the reported differences in the characteristics of autoimmune/type 1 diabetes with increasing age of diagnosis are likely explained by the inadvertent study of mixed populations with and without autoimmune aetiology diabetes. We show that when type 1 diabetes is defined by high-specificity methods, clinical presentation, islet-autoantibody positivity, genetic predisposition and progression of C-peptide loss remain broadly similar and severe at all ages and are unaffected by onset age within adults. Recent clinical guidance recommends routine islet-autoantibody testing when type 1 diabetes is clinically suspected or in the context of rapid progression to insulin therapy after a diagnosis of type 2 diabetes. In this moderate or high prior-probability setting, a positive islet-autoantibody test will usually confirm autoimmune aetiology (type 1 diabetes). We argue that islet-autoantibody testing of those with apparent type 2 diabetes should not be routinely undertaken as, in this low prior-prevalence setting, the positive predictive value of a single-positive islet antibody for autoimmune aetiology diabetes will be modest. When studying diabetes, extremely high-specificity approaches are needed to identify autoimmune diabetes in adults, with the optimal approach depending on the research question. We believe that until these recommendations are widely adopted by researchers, the true phenotype of late-onset type 1 diabetes will remain largely misunderstood.
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Affiliation(s)
- Nicholas J Thomas
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Angus G Jones
- Department of Clinical and Biological Sciences, University of Exeter, Exeter, UK.
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK.
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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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Chen W, Chen X, Zhang M, Huang Z. The association of human leukocyte antigen class II (HLA II) haplotypes with the risk of Latent autoimmune diabetes of adults (LADA): Evidence based on available data. Gene 2020; 767:145177. [PMID: 32998048 DOI: 10.1016/j.gene.2020.145177] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 09/23/2020] [Indexed: 12/11/2022]
Abstract
AIMS Latent autoimmune diabetes in adult (LADA), classified as between type 1 and type 2 diabetes mellitus, has received widespread attention. A number of studies have investigated the association between HLA DQA-DQB, DRB-DQB haplotypes and the onset of LADA. However, the conclusions remained inconsistent. Therefore, this study aims to clarify the impact of these HLA haplotypes on the pathogenesis of LADA. METHODS Systematic searches were carried out on the Medline, PubMed, Embase and Wan Fang respectively to investigate the association of LADA with HLA DQA-DQB, DRB-DQB up to June 05, 2020. We performed this retrospective research using meta-analysis. RESULTS The pooled results demonstrated that in Chinese, DQA1*05-DQB1*0201, DQA1*03-DQB1*0401, and DQA1*03-DQB1*0303 were statistically significantly associated with increasing the risk of LADA (P < 0.001), while DQA1*0102-DQB1*0602 was statistically significantly correlated with decreasing the susceptibility to the disease (P = 0.003). However, there was no obvious association found between DQA1*0201-DQB1*0201 (P = 0.984), DQA1*03-DQB1*0302 (P = 0.110), DQA1*0601-DQB1*0301 (P = 0.398) and LADA. In Japanese, DRB1*0802-DQB1*0302 (P = 0.003) and DRB1*0901-DQB1*0303 (P = 0.001), but not DRB1*0405-DQB1*0401 (P = 0.136), were found to be a risk factor for LADA. As for Caucasian, both DRB1*03-DQB1*0201 and DRB1*04-DQB1*0302 were predisposed to the development of LADA with a statistical significance (P < 0.001). CONCLUSION In all, HLA DQA-DQB, HLA DRB-DQB haplotypes might play a role in the risk of LADA, which could provide an improved understanding of LADA pathogenesis and the detection of susceptible HLA haplotypes in the diagnosis and therapy of this disease.
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Affiliation(s)
- Wenjun Chen
- Key Laboratory of Big Data Mining and Precision Drug Design of Guangdong Medical University, Key Laboratory for Research and Development of Natural Drugs of Guangdong Province, School of Pharmacy, Dongguan, Guangdong 523808, China; The Second School of Clinical Medicine, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Xinlin Chen
- Key Laboratory of Big Data Mining and Precision Drug Design of Guangdong Medical University, Key Laboratory for Research and Development of Natural Drugs of Guangdong Province, School of Pharmacy, Dongguan, Guangdong 523808, China; The Second School of Clinical Medicine, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Minting Zhang
- Key Laboratory of Big Data Mining and Precision Drug Design of Guangdong Medical University, Key Laboratory for Research and Development of Natural Drugs of Guangdong Province, School of Pharmacy, Dongguan, Guangdong 523808, China; The Second School of Clinical Medicine, Guangdong Medical University, Dongguan, Guangdong 523808, China
| | - Zunnan Huang
- Key Laboratory of Big Data Mining and Precision Drug Design of Guangdong Medical University, Key Laboratory for Research and Development of Natural Drugs of Guangdong Province, School of Pharmacy, Dongguan, Guangdong 523808, China; Marine Medical Research Institute of Guangdong Zhanjiang, Zhanjiang, Guangdong 524023, China.
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Heneberg P, Kocková L, Čecháková M, Daňková P, Černá M. Autoimmunity-Associated PTPN22 Polymorphisms in Latent Autoimmune Diabetes of the Adult Differ from Those of Type 1 Diabetes Patients. Int Arch Allergy Immunol 2018; 177:57-68. [DOI: 10.1159/000489225] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 04/11/2018] [Indexed: 12/16/2022] Open
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N SK, Subhakumari KN. Role of anti-GAD, anti-IA2 antibodies and C-peptide in differentiating latent autoimmune diabetes in adults from type 2 diabetes mellitus. Int J Diabetes Dev Ctries 2015. [DOI: 10.1007/s13410-015-0451-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Abstract
OBJECTIVE In contrast with childhood-onset type 1 diabetes, the genetics of autoimmune diabetes in adults are not well understood. We have therefore investigated the genetics of diabetes diagnosed in adults positive for autoantibodies. RESEARCH DESIGN AND METHODS GAD autoantibodies (GADAs), insulinoma-associated antigen-2 antibodies (IA-2As), and islet cell autoantibodies were measured at time of diagnosis. Autoantibody-positive diabetic subjects (n = 1,384) and population-based control subjects (n = 2,235) were genotyped at 20 childhood-onset type 1 diabetes loci and FCRL3, GAD2, TCF7L2, and FTO. RESULTS PTPN22 (1p13.2), STAT4 (2q32.2), CTLA4 (2q33.2), HLA (6p21), IL2RA (10p15.1), INS (11p15.5), ERBB3 (12q13.2), SH2B3 (12q24.12), and CLEC16A (16p13.13) were convincingly associated with autoimmune diabetes in adults (P ≤ 0.002), with consistent directions of effect as reported for pediatric type 1 diabetes. No evidence of an HLA-DRB1*03/HLA-DRB1*04 (DR3/4) genotype effect was obtained (P = 0.55), but it remained highly predisposing (odds ratio 26.22). DR3/4 was associated with a lower age at diagnosis of disease, as was DR4 (P = 4.67 × 10(-6)) but not DR3. DR3 was associated with GADA positivity (P = 6.03 × 10(-6)) but absence of IA-2A (P = 3.22 × 10(-7)). DR4 was associated with IA-2A positivity (P = 5.45 × 10(-6)). CONCLUSIONS Our results are consistent with the hypothesis that the genetics of autoimmune diabetes in adults and children are differentiated by only relatively few age-dependent genetic effects. The slower progression toward autoimmune insulin deficiency in adults is probably due to a lower genetic load overall combined with subtle variation in the HLA class II gene associations and autoreactivity.
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Affiliation(s)
- Joanna M M Howson
- Department of Medical Genetics, Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Cambridge, U.K.
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Abstract
The Banting Medal for Scientific Achievement Award is the American Diabetes Association's highest scientific award and honors an individual who has made significant, long-term contributions to the understanding of diabetes, its treatment, and/or prevention. The award is named after Nobel Prize winner Sir Frederick Banting, who codiscovered insulin treatment for diabetes. Dr. Eisenbarth received the American Diabetes Association's Banting Medal for Scientific Achievement at the Association's 69th Scientific Sessions, June 5–9, 2009, in New Orleans, Louisiana. He presented the Banting Lecture, An Unfinished Journey—Type 1 Diabetes—Molecular Pathogenesis to Prevention , on Sunday, June 7, 2009.
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Affiliation(s)
- George S Eisenbarth
- Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center, Aurora, Colorado, USA.
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Raj SM, Howson JMM, Walker NM, Cooper JD, Smyth DJ, Field SF, Stevens HE, Todd JA. No association of multiple type 2 diabetes loci with type 1 diabetes. Diabetologia 2009; 52:2109-16. [PMID: 19455305 PMCID: PMC2738846 DOI: 10.1007/s00125-009-1391-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 04/16/2009] [Indexed: 01/29/2023]
Abstract
AIMS/HYPOTHESIS We used recently confirmed type 2 diabetes gene regions to investigate the genetic relationship between type 1 and type 2 diabetes, in an average of 7,606 type 1 diabetic individuals and 8,218 controls, providing >80% power to detect effects as small as an OR of 1.11 at a false-positive rate of 0.003. METHODS The single nucleotide polymorphisms (SNPs) with the most convincing evidence of association in 12 type 2 diabetes-associated gene regions, PPARG, CDKAL1, HNF1B, WFS1, SLC30A8, CDKN2A-CDKN2B, IGF2BP2, KCNJ11, TCF7L2, FTO, HHEX-IDE and THADA, were analysed in type 1 diabetes cases and controls. PPARG and HHEX-IDE were additionally tested for association in 3,851 type 1 diabetes families. Tests for interaction with HLA class II genotypes, autoantibody status, sex, and age-at-diagnosis of type 1 diabetes were performed with all 12 gene regions. RESULTS Only PPARG and HHEX-IDE showed any evidence of association with type 1 diabetes cases and controls (p = 0.004 and p = 0.003, respectively; p > 0.05 for other SNPs). The potential association of PPARG was supported by family analyses (p = 0.003; p (combined) = 1.0 x 10(-4)). No SNPs showed evidence of interaction with any covariate (p > 0.05). CONCLUSIONS/INTERPRETATION We found no convincing genetic link between type 1 and type 2 diabetes. An association of PPARG (rs1801282/Pro12Ala) could be consistent with its known function in inflammation. Hence, our results reinforce evidence suggesting that type 1 diabetes is a disease of the immune system, rather than being due to inherited defects in beta cell function or regeneration or insulin resistance.
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Affiliation(s)
- S. M. Raj
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - J. M. M. Howson
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - N. M. Walker
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - J. D. Cooper
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - D. J. Smyth
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - S. F. Field
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - H. E. Stevens
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
| | - J. A. Todd
- Juvenile Diabetes Research Foundation/Wellcome Trust Diabetes and Inflammation Laboratory, Cambridge Institute for Medical Research, University of Cambridge, Wellcome Trust/MRC building, Hills Road, Cambridge, CB2 0XY UK
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Codner E, Rocha A, Deng L, Martínez-Aguayo A, Godoy C, Mericq V, Chung WK. Mild fasting hyperglycemia in children: high rate of glucokinase mutations and some risk of developing type 1 diabetes mellitus. Pediatr Diabetes 2009; 10:382-8. [PMID: 19309449 PMCID: PMC2864306 DOI: 10.1111/j.1399-5448.2009.00499.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Incidental hyperglycemia in children generates concern about the presence of preclinical type 1 diabetes mellitus (T1DM). OBJECTIVE To genetically evaluate two common forms of maturity-onset diabetes of youth (MODY), the short-term prognosis in children with mild hyperglycemia, and a positive family history of diabetes mellitus. SUBJECTS Asymptomatic children and adolescents (n = 14), younger than 15 yr, with fasting hyperglycemia, a positive family history of mild non-progressive hyperglycemia, and negative pancreatic autoantibodies were studied. PATIENTS AND METHODS Glucokinase gene (GCK) and hepatocyte nuclear factor 1 alpha gene (HNF1A) causing two common forms of MODY were sequenced. The clinical outcome was evaluated after a follow-up period of 2.8 +/- 1.3 yr. RESULTS GCK mutations were present in seven children. The confirmation of this diagnosis allowed discontinuation of insulin in two families and oral medications in three families. Mutations of HNF1A were not detected in any of the families. During the follow-up period, all the GCK mutation carrier children remained asymptomatic without medication and the last hemoglobin A1c levels were 6.4 +/- 0.7%. In the GCK-negative children (n = 7), one developed T1DM, corresponding to 7.2% of the total group. Mild fasting hyperglycemia persisted during follow-up in four GCK-negative children and normalized in the remaining two. CONCLUSIONS The presence of mild persistent hyperglycemia in any patient without autoantibodies should lead to genetic analysis of GCK, particularly if there is a positive family history. Furthermore, those without GCK mutations should be followed with repeat autoantibody testing, and other genetic types of diabetes should be considered if hyperglycemia worsens.
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Affiliation(s)
- Ethel Codner
- Institute of Maternal and Child Research (IDIMI), School of Medicine, University of Chile, Santiago, Chile.
| | - Ana Rocha
- Institute of Maternal and Child Research (I.D.I.M.I.), School of Medicine, University of Chile, Santiago, Chile
| | - Liyong Deng
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Alejandro Martínez-Aguayo
- Department of Pediatrics, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Claudia Godoy
- Department of Pediatrics, Hospital Sótero del Río, Santiago, Chile
| | - Verónica Mericq
- Institute of Maternal and Child Research (I.D.I.M.I.), School of Medicine, University of Chile, Santiago, Chile
| | - Wendy K Chung
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
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