1
|
Inkeri J, Harjutsalo V, Martola J, Putaala J, Groop PH, Gordin D, Thorn LM. No correlation between carotid intima-media thickness and long-term glycemic control in individuals with type 1 diabetes. Acta Diabetol 2024; 61:441-449. [PMID: 38071692 DOI: 10.1007/s00592-023-02211-y] [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: 10/01/2023] [Accepted: 11/07/2023] [Indexed: 03/27/2024]
Abstract
AIMS To determine whether carotid intima-media thickness (CIMT), a surrogate marker of cardiovascular disease (CVD), is associated with long-term blood glucose control in individuals with type 1 diabetes (T1D). METHODS We recruited 508 individuals (43.4% men; median age 46.1, IQR 37.8-55.9 years) with T1D (median diabetes duration of 30.4, IQR 21.2-40.8 years) in a cross-sectional retrospective sub-study, part of the Finnish Diabetic Nephropathy (FinnDiane) Study. Glycated hemoglobin (HbA1c) data were collected retrospectively over the course of ten years (HbA1c-meanoverall) prior to the clinical study visit that included a clinical examination, biochemical sampling, and ultrasound of the common carotid arteries. RESULTS Individuals with T1D had a median CIMT of 606 μm (IQR 538-683 μm) and HbA1c of 8.0% (7.3-8.8%) during the study visit and HbA1c-meanoverall of 8.0% (IQR 7.3-8.8%). CIMT did not correlate with HbA1c (p = 0.228) at visit or HbA1c-meanoverall (p = 0.063). After controlling for relevant factors in multivariable linear regression analysis, only age was associated with CIMT (p < 0.001). After further dividing CIMT into quartiles, no correlation between long-term glucose control and CIMT (%, 1st 8.1 [IQR 7.2-8.9] vs 4th 7.9 [7.4-8.7], p = 0.730) was found. CONCLUSIONS We observed no correlation between long-term blood glucose control and CIMT in individuals with T1D. This finding suggests that the development of early signs of macrovascular atherosclerosis is not strongly affected by the glycemic control in people with T1D.
Collapse
Affiliation(s)
- Jussi Inkeri
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki, P.O. Box 63 (C318b), 00014, Helsinki, Finland
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
| | - Valma Harjutsalo
- Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki, P.O. Box 63 (C318b), 00014, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juha Martola
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Jukka Putaala
- Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Per-Henrik Groop
- Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki, P.O. Box 63 (C318b), 00014, Helsinki, Finland.
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland.
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, Australia.
| | - Daniel Gordin
- Minerva Foundation Institute for Medical Research, Helsinki, Finland
- Department of Nephrology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lena M Thorn
- Folkhälsan Research Center, Biomedicum Helsinki, University of Helsinki, P.O. Box 63 (C318b), 00014, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, University of Helsinki, Helsinki, Finland
- Department of General Practice and Primary Health Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|
2
|
Serés-Noriega T, Perea V, Amor AJ. Screening for Subclinical Atherosclerosis and the Prediction of Cardiovascular Events in People with Type 1 Diabetes. J Clin Med 2024; 13:1097. [PMID: 38398409 PMCID: PMC10889212 DOI: 10.3390/jcm13041097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/09/2024] [Accepted: 02/12/2024] [Indexed: 02/25/2024] Open
Abstract
People with type 1 diabetes (T1D) have a high cardiovascular disease (CVD) risk, which remains the leading cause of death in this population. Despite the improved control of several classic risk factors, particularly better glycaemic control, cardiovascular morbidity and mortality continue to be significantly higher than in the general population. In routine clinical practice, estimating cardiovascular risk (CVR) in people with T1D using scales or equations is often imprecise because much of the evidence comes from pooled samples of people with type 2 diabetes (T2D) and T1D or from extrapolations of studies performed on people with T2D. Given that T1D onsets at a young age, prolonged exposure to the disease and its consequences (e.g., hyperglycaemia, changes in lipid metabolism or inflammation) have a detrimental impact on cardiovascular health. Therefore, it is critical to have tools that allow for the early identification of those individuals with a higher CVR and thus be able to make the most appropriate management decisions in each case. In this sense, atherosclerosis is the prelude to most cardiovascular events. People with diabetes present pathophysiological alterations that facilitate atherosclerosis development and that may imply a greater vulnerability of atheromatous plaques. Screening for subclinical atherosclerosis using various techniques, mainly imaging, has proven valuable in predicting cardiovascular events. Its use enables the reclassification of CVR and, therefore, an individualised adjustment of therapeutic management. However, the available evidence in people with T1D is scarce. This narrative review provides and updated overview of the main non-invasive tests for detecting atherosclerosis plaques and their association with CVD in people with T1D.
Collapse
Affiliation(s)
- Tonet Serés-Noriega
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, 08036 Barcelona, Spain
| | - Verónica Perea
- Endocrinology and Nutrition Department, Hospital Universitari Mútua de Terrassa, 08221 Terrassa, Spain
| | - Antonio J. Amor
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, 08036 Barcelona, Spain
| |
Collapse
|
3
|
Zhang L, Yang L, Zhou Z. Data-based modeling for hypoglycemia prediction: Importance, trends, and implications for clinical practice. Front Public Health 2023; 11:1044059. [PMID: 36778566 PMCID: PMC9910805 DOI: 10.3389/fpubh.2023.1044059] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Background and objective Hypoglycemia is a key barrier to achieving optimal glycemic control in people with diabetes, which has been proven to cause a set of deleterious outcomes, such as impaired cognition, increased cardiovascular disease, and mortality. Hypoglycemia prediction has come to play a role in diabetes management as big data analysis and machine learning (ML) approaches have become increasingly prevalent in recent years. As a result, a review is needed to summarize the existing prediction algorithms and models to guide better clinical practice in hypoglycemia prevention. Materials and methods PubMed, EMBASE, and the Cochrane Library were searched for relevant studies published between 1 January 2015 and 8 December 2022. Five hypoglycemia prediction aspects were covered: real-time hypoglycemia, mild and severe hypoglycemia, nocturnal hypoglycemia, inpatient hypoglycemia, and other hypoglycemia (postprandial, exercise-related). Results From the 5,042 records retrieved, we included 79 studies in our analysis. Two major categories of prediction models are identified by an overview of the chosen studies: simple or logistic regression models based on clinical data and data-based ML models (continuous glucose monitoring data is most commonly used). Models utilizing clinical data have identified a variety of risk factors that can lead to hypoglycemic events. Data-driven models based on various techniques such as neural networks, autoregressive, ensemble learning, supervised learning, and mathematical formulas have also revealed suggestive features in cases of hypoglycemia prediction. Conclusion In this study, we looked deep into the currently established hypoglycemia prediction models and identified hypoglycemia risk factors from various perspectives, which may provide readers with a better understanding of future trends in this topic.
Collapse
|
4
|
Jiang ZZ, Zhu JB, Shen HL, Zhao SS, Tang YY, Tang SQ, Liu XT, Jiang TA. A High Triglyceride-Glucose Index Value Is Associated With an Increased Risk of Carotid Plaque Burden in Subjects With Prediabetes and New-Onset Type 2 Diabetes: A Real-World Study. Front Cardiovasc Med 2022; 9:832491. [PMID: 35310963 PMCID: PMC8927542 DOI: 10.3389/fcvm.2022.832491] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/09/2022] [Indexed: 12/30/2022] Open
Abstract
Background The triglyceride-glucose (TyG) index has been proposed as a convincing indicator of insulin resistance and has been found to be associated with atherosclerosis among diabetic patients. However, the relationship between the TyG index and arteriosclerosis in subjects with prediabetes and new-onset type 2 diabetes (T2D) remains uncertain. The purpose of this study was to assess the degree of carotid plaque burden in patients with prediabetes and new-onset T2D and to investigate the association between the TyG index and the degree of carotid plaque burden in this population. Methods This was a cross-sectional observational study that included 716 subjects aged 40–70 years old with prediabetes or new-onset T2D. Demographic, anthropometric, and laboratory measurements were collected. Participants underwent carotid arteriosclerosis evaluation by ultrasonography, and the degree of atherosclerosis was evaluated according to the carotid plaque burden. The TyG index was calculated. Results The population was stratified into high or low TyG index groups according to the median TyG index value. Higher values were associated with a higher BMI and waist circumference as well as higher total cholesterol, triglyceride, low-density lipoprotein cholesterol, plasma glucose, glycated hemoglobin, fasting C-peptide, and C-reactive protein levels (P < 0.001). The high TyG index group had a higher atherosclerotic plaque burden than the low TyG index group (P < 0.001). Multiclassification logistic regression analysis showed that the TyG index was positively associated with a high plaque burden [odds ratio (OR): 16.706, 95% confidence interval (CI): 3.988–69.978, P = 0.000], while no association was found between the TyG index and a low/moderate plaque burden. This association remained consistent in the subgroup analysis. In multiple linear regression analysis, sex, age, and the TyG index were found to be independently associated with carotid plaque burden. For each unit increase in the TyG index, the risk of a high carotid plaque burden increased 1.595-fold. Conclusion A high TyG index was positively associated with a high carotid plaque burden in subjects with prediabetes and new-onset T2D. Clinicians should pay close attention to the TyG index to help these patients receive the greatest benefit from early intervention.
Collapse
Affiliation(s)
- Zhen-zhen Jiang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Jian-bo Zhu
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Hua-liang Shen
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Shan-shan Zhao
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Yun-yi Tang
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Shao-qi Tang
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
| | - Xia-tian Liu
- Department of Ultrasound, Shaoxing People's Hospital (Shaoxing Hospital, Zhejiang University School of Medicine), Shaoxing, China
- Xia-tian Liu
| | - Tian-an Jiang
- Department of Ultrasound Medicine, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Pulsed Power Translational Medicine of Zhejiang Province, Hangzhou, China
- Zhejiang University Cancer Center, Zhejiang, China
- *Correspondence: Tian-an Jiang
| |
Collapse
|
5
|
Frigerio B, Werba JP, Amato M, Ravani A, Sansaro D, Coggi D, Vigo L, Tremoli E, Baldassarre D. Traditional Risk Factors are Causally Related to Carotid Intima-Media Thickness Progression: Inferences from Observational Cohort Studies and Interventional Trials. Curr Pharm Des 2020; 26:11-24. [PMID: 31838990 DOI: 10.2174/1381612825666191213120339] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 12/02/2019] [Indexed: 12/24/2022]
Abstract
In the present review, associations between traditional vascular risk factors (VRFs) and carotid intimamedial thickness progression (C-IMTp) as well as the effects of therapies for VRFs control on C-IMTp were appraised to infer causality between each VRF and C-IMTp. Cohort studies indicate that smoking, binge drinking, fatness, diabetes, hypertension and hypercholesterolemia are associated with accelerated C-IMTp. An exception is physical activity, with mixed data. Interventions for the control of obesity, diabetes, hypertension and hypercholesterolemia decelerate C-IMTp. Conversely, scarce information is available regarding the effect of smoking cessation, stop of excessive alcohol intake and management of the metabolic syndrome. Altogether, these data support a causative role of several traditional VRFs on C-IMTp. Shortcomings in study design and/or ultrasonographic protocols may account for most negative studies, which underlines the importance of careful consideration of methodological aspects in investigations using C-IMTp as the outcome.
Collapse
Affiliation(s)
| | - José P Werba
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Mauro Amato
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | | | | | - Daniela Coggi
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita di Milano, Milan, Italy
| | - Lorenzo Vigo
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Elena Tremoli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Dipartimento di Scienze Farmacologiche e Biomolecolari, Universita di Milano, Milan, Italy
| | - Damiano Baldassarre
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Medical Biotechnology and Translational Medicine, Università di Milano, Milan, Italy
| |
Collapse
|
6
|
Yu X, Bian B, Huang J, Yao W, Wu X, Huang J, Wang J, Yang Q, Ning X. Determinants of carotid intima-media thickness in asymptomatic elders: a population-based cross-sectional study in rural China. Postgrad Med 2020; 132:544-550. [PMID: 32297560 DOI: 10.1080/00325481.2020.1757266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: To examine the mean carotid intima-media thickness (CIMT) and potentially relevant determinants of increased CIMT in elders. Method: Stroke-free and cardiovascular disease-free residents aged ≥65 years were recruited in a low-income population in China. B-mode ultrasonography was performed to measure CIMT. Results: A total of 1039 individuals (47.9% men) were recruited. The mean CIMT value was 0.60 (SD: 0.09) mm. The mean CIMT was 24.07 (SEM: 6.52) µm greater in men than in women (P < 0.001) and 28.29 (SEM: 7.47) µm greater in patients with hypertension than in those without hypertension (P < 0.001). Moreover, the mean CIMT increased by 1.53 (SEM: 0.49) µm for each 1-year increase in age (P = 0.002). However, the mean CIMT decreased by 5.55 (SEM: 2.40) μm and 6.45 (SEM: 2.62) μm for every 1-mmol/L increase in triglyceride concentration and the high-density lipoprotein cholesterol: low-density lipoprotein cholesterol ratio, respectively (P < 0.05). However, high triglyceride level was negatively associated with mean CIMT only among individuals without metabolic syndrome (P = 0.036). Discussion: These findings suggest that there is an urgent need to delay atherosclerosis progression and reduce the stroke burden by managing hypertension, especially for men. Moreover, to decrease the stroke burden in rural China, caution is advised regarding lipid-lowering treatment in elderly patients without metabolic syndrome.
Collapse
Affiliation(s)
- Xuefang Yu
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Bo Bian
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Jinyong Huang
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Wei Yao
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Xianming Wu
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Jingjing Huang
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Jinghua Wang
- Department of Neurology, Tianjin Medical University General Hospital , Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute , Tianjin, China.,Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin Neurological Institute , Tianjin, China
| | - Qing Yang
- Department of Cardiology, Tianjin Medical University General Hospital , Tianjin, China
| | - Xianjia Ning
- Department of Neurology, Tianjin Medical University General Hospital , Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute , Tianjin, China.,Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City, Tianjin Neurological Institute , Tianjin, China
| |
Collapse
|
7
|
Pastore I, Bolla AM, Montefusco L, Lunati ME, Rossi A, Assi E, Zuccotti GV, Fiorina P. The Impact of Diabetes Mellitus on Cardiovascular Risk Onset in Children and Adolescents. Int J Mol Sci 2020; 21:ijms21144928. [PMID: 32664699 PMCID: PMC7403998 DOI: 10.3390/ijms21144928] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/20/2022] Open
Abstract
The prevalence of diabetes mellitus is rising among children and adolescents worldwide. Cardiovascular diseases are the main cause of morbidity and mortality in diabetic patients. We review the impact of diabetes on establishing, during childhood and adolescence, the premises for cardiovascular diseases later in life. Interestingly, it seems that hyperglycemia is not the only factor that establishes an increased cardiovascular risk in adolescence. Other factors have been recognized to play a role in triggering the onset of latent cardiovascular diseases in the pediatric population. Among these cardiovascular risk factors, some are modifiable: glucose variability, hypoglycemia, obesity, insulin resistance, waist circumference, hypertension, dyslipidemia, smoking alcohol, microalbuminuria and smoking. Others are unmodifiable, such as diabetes duration and family history. Among the etiological factors, subclinical endothelial dysfunction represents one of the earliest key players of atherosclerosis and it can be detected during early ages in patients with diabetes. A better assessment of cardiovascular risk in pediatric population still represents a challenge for clinicians, and thus further efforts are required to properly identify and treat pediatric patients who may suffer from cardiovascular disease later in early adulthood.
Collapse
Affiliation(s)
- Ida Pastore
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Andrea Mario Bolla
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Laura Montefusco
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Maria Elena Lunati
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Antonio Rossi
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
| | - Emma Assi
- International Center for T1D, Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science L. Sacco, University of Milan, 20157 Milan, Italy;
| | - Gian Vincenzo Zuccotti
- Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, DIBIC, Università di Milano and Department of Pediatrics, Buzzi Children’s Hospital, 20157 Milan, Italy;
| | - Paolo Fiorina
- Division of Endocrinology, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy; (I.P.); (A.M.B.); (L.M.); (M.E.L.); (A.R.)
- International Center for T1D, Pediatric Clinical Research Center Romeo ed Enrica Invernizzi, Department of Biomedical and Clinical Science L. Sacco, University of Milan, 20157 Milan, Italy;
- Nephrology Division, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-617-919-2624
| |
Collapse
|
8
|
Błaszkowska M, Shalimova A, Wolnik B, Orłowska-Kunikowska E, Graff B, Hoffmann M, Nilsson P, Wolf J, Narkiewicz K. Subclinical macroangiopathic target organ damage in type 1 diabetes mellitus patients. Blood Press 2020; 29:344-356. [PMID: 32460564 DOI: 10.1080/08037051.2020.1770054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE We have summarized key studies regarding the assessment of subclinical macroangiopathic target organ damage (TOD) in type 1 diabetes mellitus (T1DM). RESULTS Although chronic complications resulting from hyperglycemia, in particular macroangiopathies, are still the first cause of death in T1DM, there has been growing recognition of the role of hypoglycemia in cardiovascular morbidity and mortality. Subclinical TOD diagnosis ensures early implementation of the complex management aiming at either partial reversal of these complications or at least its downturn. To better identify patients with early TODs, several non-invasive diagnostic techniques are employed, including the ultrasonographic assessment of the intima-media thickness (IMT), computed tomography (CT) for coronary artery calcium (CAC) scores, and pulse wave velocity (PWV) measurement for arterial stiffness evaluation. Various studies reported that T1DM patients present an increased IMT. An increasing IMT fairly correlates with the cardiovascular (CV) events risk even after the adjustment to age, diabetes duration, quality of glucose control as well as the presence of hypertension, and chronic complications. Another, well established marker of the organ damage - CAC score is recommended by ACC/AHA guidelines to assess the overall CV risk in T1DM. Also, the arterial stiffness evaluation with PWV may further improve CV risk prediction, which has been reported in multiple studies including the Framingham Heart Study. CONCLUSIONS There is shortage of data from prospective studies which could confirm the benefits of early treatment initiation based on the presence of the subclinical organ damage in T1DM. Most evidence comes from T2DM trials, where effective preventive measures were identified i.e.: smoking cessation, reasonable blood glucose control, efficacious hypertension treatment, and dyslipidemia management, as well as renoprotection. There is still a field for further research to see if routine assessment of asymptomatic vascular damage and early implementation of aggressive treatment would reduce mortality excess from CVD in T1DM.
Collapse
Affiliation(s)
- Magdalena Błaszkowska
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Anna Shalimova
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland.,Department of Internal Medicine N1, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Bogumił Wolnik
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | | | - Beata Graff
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Michał Hoffmann
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Peter Nilsson
- Department of Clinical Sciences, Lund University, Skane University Hospital, Malmö, Sweden
| | - Jacek Wolf
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Faculty of Medicine, Gdansk, Poland
| |
Collapse
|
9
|
Braffett BH, Lorenzi GM, Cowie CC, Gao X, Bainbridge KE, Cruickshanks KJ, Kramer JR, Gubitosi-Klug RA, Larkin ME, Barnie A, Lachin JM, Schade DS. RISK FACTORS FOR HEARING IMPAIRMENT IN TYPE 1 DIABETES. Endocr Pract 2019; 25:1243-1254. [PMID: 31412233 DOI: 10.4158/ep-2019-0193] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Objective: Studies have demonstrated that glycated hemoglobin (HbA1c) is a significant predictor of hearing impairment in type 1 diabetes. We identified additional factors associated with hearing impairment in participants with type 1 diabetes from the Diabetes Control and Complications Trial and its observational follow-up, the Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study. Methods: A total of 1,150 DCCT/EDIC participants were recruited for the Hearing Study. A medical history, physical measurements, and a self-administered hearing questionnaire were obtained. Audiometry was performed by study-certified personnel and assessed centrally. Logistic regression models assessed the association of risk factors and comorbidities with speech- and high-frequency hearing impairment. Results: Mean age was 55 ± 7 years, duration of diabetes 34 ± 5 years, and DCCT/EDIC HbA1c 7.9 ± 0.9% (63 mmol/mol). In multivariable models, higher odds of speech-frequency impairment were significantly associated with older age, higher HbA1c, history of noise exposure, male sex, and higher triglycerides. Higher odds of high-frequency impairment were associated with older age, male sex, history of noise exposure, higher skin intrinsic florescence (SIF) as a marker of tissue glycation, higher HbA1c, nonprofessional/nontechnical occupations, sedentary activity, and lower low-density-lipoprotein cholesterol. Among participants who previously completed computed tomography and carotid ultrasonography, coronary artery calcification (CAC) >0 and carotid intima-medial thickness were significantly associated with high-but not speech-frequency impairment. Conclusion: Consistent with previous reports, male sex, age, several metabolic factors, and noise exposure are independently associated with hearing impairment. The association with SIF further emphasizes the importance of glycemia-as a modifiable risk factor-over time. In addition, the macrovascular contribution of CAC is novel and important. Abbreviations: AER = albumin excretion rate; CAC = coronary artery calcification; CVD = cardiovascular disease; DCCT/EDIC = Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications; eGFR = estimated glomerular filtration rate; ETDRS = Early Treatment Diabetic Retinopathy Study; HbA1c = glycated hemoglobin; HDL = high-density lipoprotein; IMT = intima-media thickness; LDL = low-density lipoprotein; NHANES = National Health and Nutrition Examination Survey; OR = odds ratio; SIF = skin intrinsic fluorescence; T1D = type 1 diabetes.
Collapse
|
10
|
Basu A, Bebu I, Jenkins AJ, Stoner JA, Zhang Y, Klein RL, Lopes-Virella MF, Garvey WT, Budoff MJ, Alaupovic P, Lyons TJ. Serum apolipoproteins and apolipoprotein-defined lipoprotein subclasses: a hypothesis-generating prospective study of cardiovascular events in T1D. J Lipid Res 2019; 60:1432-1439. [PMID: 31203233 DOI: 10.1194/jlr.p090647] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 05/29/2019] [Indexed: 12/26/2022] Open
Abstract
APOB, APOC3, and APOE and apolipoprotein-defined lipoprotein subclasses (ADLSs; based on qualitative apolipoprotein complement) have been associated with dyslipidemia and CVD. Our main objective was to define associations of serum apolipoproteins and ADLSs with "any CVD" and "major atherosclerotic cardiovascular events" (MACEs) in a prospective study of T1D. Serum apolipoproteins and ADLSs (14 biomarkers in total) were measured in sera (obtained between 1997 and 2000) from a subset (n = 465) of the Epidemiology of Diabetes Interventions and Complications cohort. Prospective associations of "any CVD" (myocardial infarction, stroke, confirmed angina, silent myocardial infarction, revascularization, or congestive heart failure) and MACEs (fatal or nonfatal myocardial infarction or stroke), over 5,943 and 6,180 patient-years follow-up, respectively, were investigated using Cox proportional hazards models that were unadjusted and adjusted for risk factors. During 15 years of follow-up, 50 "any CVD" events and 24 MACEs occurred. Nominally significant positive univariate associations with "any CVD" were APOB, APOC3 and its subfractions [heparin precipitate, heparin-soluble (HS)], and ADLS-defined Lp-B. In adjusted analyses, APOC3-HS remained nominally significant. Nominally significant positive univariate associations with MACEs were APOC3 and its subfractions and Lp-B:C; those with total APOC3 and APOC3-HS persisted in adjusted analyses. However, these associations did not reach significance after adjusting for multiple testing. There were no significant associations of APOA1, APOA2, APOE, or other ADLSs with either "any CVD" or MACEs. These hypothesis-generating data suggest that total serum APOC3 and APOC3 in HDL are potentially important predictive biomarkers for any CVD and MACEs in adults with T1D.
Collapse
Affiliation(s)
- Arpita Basu
- Department of Kinesiology and Nutrition Sciences, University of Nevada, Las Vegas, Las Vegas, NV
| | - Ionut Bebu
- The Biostatistics Center Milken Institute School of Public Health, The George Washington University, Rockville, MD
| | - Alicia J Jenkins
- NHMRC Clinical Trials Centre University of Sydney, Camperdown, Sydney, Australia
| | - Julie A Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ying Zhang
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Richard L Klein
- Division of Endocrinology Medical University of South Carolina, Charleston, SC.,The Ralph H. Johnson Veterans Affairs Medical Center Charleston, SC
| | - Maria F Lopes-Virella
- Division of Endocrinology Medical University of South Carolina, Charleston, SC.,The Ralph H. Johnson Veterans Affairs Medical Center Charleston, SC
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Matthew J Budoff
- Division of Cardiology Los Angeles Biomedical Research Institute, Torrance, CA
| | | | - Timothy J Lyons
- Division of Endocrinology Medical University of South Carolina, Charleston, SC
| | | |
Collapse
|
11
|
Adeva-Andany MM, Funcasta-Calderón R, Fernández-Fernández C, Ameneiros-Rodríguez E, Domínguez-Montero A. Subclinical vascular disease in patients with diabetes is associated with insulin resistance. Diabetes Metab Syndr 2019; 13:2198-2206. [PMID: 31235157 DOI: 10.1016/j.dsx.2019.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/22/2019] [Indexed: 12/30/2022]
Abstract
Patients with diabetes experience increased cardiovascular risk that is not fully explained by deficient glycemic control or traditional cardiovascular risk factors such as smoking and hypercholesterolemia. Asymptomatic patients with diabetes show structural and functional vascular damage that includes impaired vasodilation, arterial stiffness, increased intima-media thickness and calcification of the arterial wall. Subclinical vascular injury associated with diabetes predicts subsequent manifestations of cardiovascular disease, such as ischemic heart disease, peripheral artery disease and stroke. Noninvasive detection of subclinical vascular disease is commonly used to estimate cardiovascular risk associated to diabetes. Longitudinal studies in normotensive subjects show that arterial stiffness at baseline is associated with a greater risk for future hypertension independently of established risk factors. In patients with type 2 diabetes, vascular disease begins to develop during the latent phase of insulin resistance, long before the clinical diagnosis of diabetes. In contrast, patients with type 1 diabetes do not manifest vascular injury when they are first diagnosed due to insulin deficiency, as they lack the preceding period of insulin resistance. These findings suggest that insulin resistance plays an important role in the development of early vascular disease associated with diabetes. Cross-sectional and prospective studies confirm that insulin resistance is associated with subclinical vascular injury in patients with diabetes, independently of standard cardiovascular risk factors. Asymptomatic vascular disease associated with diabetes begins to occur early in life having been documented in children and adolescents. Insulin resistance should be considered a therapeutic target in order to prevent the vascular complications associated with diabetes.
Collapse
Affiliation(s)
- María M Adeva-Andany
- Internal Medicine Department, Hospital General Juan Cardona, C/ Pardo Bazán S/n, 15406, Ferrol, Spain.
| | - Raquel Funcasta-Calderón
- Internal Medicine Department, Hospital General Juan Cardona, C/ Pardo Bazán S/n, 15406, Ferrol, Spain
| | | | - Eva Ameneiros-Rodríguez
- Internal Medicine Department, Hospital General Juan Cardona, C/ Pardo Bazán S/n, 15406, Ferrol, Spain
| | - Alberto Domínguez-Montero
- Internal Medicine Department, Hospital General Juan Cardona, C/ Pardo Bazán S/n, 15406, Ferrol, Spain
| |
Collapse
|
12
|
Braffett BH, Dagogo-Jack S, Bebu I, Sivitz WI, Larkin M, Kolterman O, Lachin JM. Association of Insulin Dose, Cardiometabolic Risk Factors, and Cardiovascular Disease in Type 1 Diabetes During 30 Years of Follow-up in the DCCT/EDIC Study. Diabetes Care 2019; 42:657-664. [PMID: 30728218 PMCID: PMC6429630 DOI: 10.2337/dc18-1574] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/08/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study demonstrated the beneficial effects of intensive therapy on atherosclerosis and clinical cardiovascular disease (CVD) outcomes. The current analyses evaluated the relationship between longitudinal changes in insulin dose and CVD risk factors and outcomes. RESEARCH DESIGN AND METHODS A total of 1,441 participants were randomly assigned to intensive or conventional diabetes therapy during the DCCT. After an average of 6.5 years of follow-up, 96% of the surviving cohort enrolled in the EDIC observational study, which included annual visits with detailed medical history, physical examination, and laboratory testing. CVD events were adjudicated by a review committee. Generalized linear mixed models and Cox proportional hazards regression models were used to assess the association between insulin dose and cardiometabolic risk factors and CVD risk, respectively, over a total of 30 years. RESULTS Higher insulin doses were significantly associated with a less favorable cardiometabolic risk profile (higher BMI, pulse rate, and triglycerides and lower HDL cholesterol) with the exception of lower diastolic blood pressure and lower LDL cholesterol. In a minimally adjusted model, a 0.1 unit/kg body wt/day increase in insulin dose was associated with a 6% increased risk of any CVD (95% CI 3, 9). However, the association with insulin dose was no longer significant after adjustment for other CVD risk factors. CONCLUSIONS During DCCT/EDIC, higher insulin doses were associated with adverse trends in several cardiometabolic risk factors, even after multivariable adjustment, but not with incident CVD outcomes.
Collapse
Affiliation(s)
| | - Samuel Dagogo-Jack
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, Memphis, TN
| | - Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, MD
| | - William I Sivitz
- Division of Endocrinology and Metabolism, Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Mary Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA
| | | | | |
Collapse
|
13
|
Jenkins A, Januszewski A, O’Neal D. The early detection of atherosclerosis in type 1 diabetes: why, how and what to do about it. Cardiovasc Endocrinol Metab 2019; 8:14-27. [PMID: 31646294 PMCID: PMC6739889 DOI: 10.1097/xce.0000000000000169] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/22/2019] [Indexed: 12/11/2022]
Abstract
The major cause of morbidity and often premature mortality in people with type I diabetes (T1D) is cardiovascular disease owing to accelerated atherosclerosis. We review publications relating to the rationale behind, and clinical tests for, detecting and treating early atherosclerosis in people with T1D. Currently available tools for atherosclerosis assessment include risk equations using vascular risk factors, arterial intima-media thickness, the ankle-brachial index, coronary artery calcification and angiography, and for more advanced lesions, intravascular ultrasound and optical coherence tomography. Evolving research tools include risk equations incorporating novel clinical, biochemical and molecular tests; vascular MRI and molecular imaging. As yet there is little information available to quantify early atherosclerosis. With better means to control the vascular risk factors, such as hypertension, dyslipidaemia and glycaemic control, and emerging therapies to control novel risk factors, further epidemiologic and clinical trials are merited to facilitate the translation into clinical practice of robust means to detect, monitor and treat early atherosclerosis in those with T1D.
Collapse
Affiliation(s)
- Alicia Jenkins
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales
- Department of Endocrinology, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | - Andrzej Januszewski
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales
- Department of Endocrinology, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| | - David O’Neal
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales
- Department of Endocrinology, St. Vincent’s Hospital, Fitzroy, Victoria, Australia
| |
Collapse
|
14
|
Adeva-Andany MM, Martínez-Rodríguez J, González-Lucán M, Fernández-Fernández C, Castro-Quintela E. Insulin resistance is a cardiovascular risk factor in humans. Diabetes Metab Syndr 2019; 13:1449-1455. [PMID: 31336505 DOI: 10.1016/j.dsx.2019.02.023] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 02/12/2019] [Indexed: 01/08/2023]
Abstract
Diabetes is a common metabolic disorder associated to elevated cardiovascular morbidity and mortality that is not explained by hyperglycemia or traditional cardiovascular risk factors such as smoking or hypercholesterolemia. Intensive glycemic control with insulin that achieves near-normal glycemia does not reduce significantly macrovascular complications compared with conventional glycemic control. Cardiovascular disease continues to develop in patients with diabetes despite adequate glycemic control. In contrast, intensive control with metformin (leading to insulin resistance improvement) reduces diabetes complications, including cardiovascular events, suggesting that enhancement of insulin sensitivity rather than plasma glucose level has a major role improving diabetes outcomes. Accordingly, insulin resistance estimated by glucose tolerance tests is better predictor of future cardiovascular events than fasting glucose level in nondiabetic individuals. Insulin resistance precedes for decades the clinical onset of type 2 diabetes and deteriorates metabolic control of type 1 diabetes. Numerous investigations including cross-sectional and prospective studies, meta-analyses, and systematic reviews provide compelling evidence that insulin resistance by itself is a cardiovascular risk factor in a variety of population groups, including the general population and patients with diabetes. Several estimations of insulin resistance have been consistently associated with elevated rate of cardiovascular events independently of other cardiovascular risk factors and diabetes status. The clinical expression of insulin resistance (the metabolic syndrome or any of its components including obesity, hyperinsulinemia, hypertension, and dyslipemia) has been related to cardiovascular disease as well. An estimation conducted by the Archimedes model confirms that insulin resistance is the most important single cause of coronary artery disease.
Collapse
Affiliation(s)
- María M Adeva-Andany
- Internal Medicine Department, Hospital General Juan Cardona, c/ Pardo Bazán s/n, 15406, Ferrol, Spain.
| | - Julia Martínez-Rodríguez
- Internal Medicine Department, Hospital General Juan Cardona, c/ Pardo Bazán s/n, 15406, Ferrol, Spain
| | - Manuel González-Lucán
- Internal Medicine Department, Hospital General Juan Cardona, c/ Pardo Bazán s/n, 15406, Ferrol, Spain
| | | | - Elvira Castro-Quintela
- Internal Medicine Department, Hospital General Juan Cardona, c/ Pardo Bazán s/n, 15406, Ferrol, Spain
| |
Collapse
|
15
|
Babar G, Clements M, Dai H, Raghuveer G. Assessment of biomarkers of inflammation and premature atherosclerosis in adolescents with type-1 diabetes mellitus. J Pediatr Endocrinol Metab 2019; 32:109-113. [PMID: 30710485 DOI: 10.1515/jpem-2018-0192] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 10/15/2018] [Indexed: 12/24/2022]
Abstract
Background Type-1 diabetes mellitus (T1DM) causes endothelial dysfunction and early atherosclerosis, which can result in premature coronary artery disease. The aim of this study was to determine the impact of glycemic control, vascular oxidative stress and inflammation on vascular health in adolescents with T1DM. Methods This was a cross-sectional study in adolescents with age- and sex-matched T1DM who were ≥12 years and were at least 2 years post-diagnosis. Recruitment was balanced to include individuals with hemoglobin A1c (HbA1c) ≤8.5% (n=27) or with HbA1c ≥9.5% (n=25). Biomarkers of inflammation were measured in the blood including C-reactive protein (CRP), interleukin-6 (IL-6), intercellular adhesion molecule-1 (ICAM-1), E-selectin, fibrinogen and tumor necrosis factor-α (TNF-α). Carotid intima media thickness (cIMT) and peripheral arterial tonometry (PAT) were assessed. Results Plasma E-selectin level was significantly different between the two groups with higher levels in the group with HbA1c ≥9.5% (65.0±27.7 ng/mL vs. 48.8±21.5 ng/mL, p=0.02). Though cIMT and PAT were not significantly different between the groups, Pearson correlation showed a significant direct relationship between rising HbA1c and mean right cIMT (p=0.02; r=0.37), PAT (p=0.03, r=0.31) and fibrinogen (p=0.03, r=0.03). Conclusions Elevated E-selectin level is an early marker of oxidative stress in T1DM patients with an elevated HbA1c level. Suboptimal glycemic control as evidenced by a rising HbA1c causes early atherosclerosis.
Collapse
Affiliation(s)
- Ghufran Babar
- Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Mark Clements
- Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | - Hongying Dai
- Children's Mercy Hospitals and Clinics, Kansas City, MO, USA
| | | |
Collapse
|
16
|
Survival and Metabolic Function of Syngeneic Mouse Islet Grafts Transplanted Into the Hepatic Sinus Tract. Transplantation 2018; 102:1850-1856. [DOI: 10.1097/tp.0000000000002289] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
|
17
|
Lo C, Toyama T, Wang Y, Lin J, Hirakawa Y, Jun M, Cass A, Hawley CM, Pilmore H, Badve SV, Perkovic V, Zoungas S. Insulin and glucose-lowering agents for treating people with diabetes and chronic kidney disease. Cochrane Database Syst Rev 2018; 9:CD011798. [PMID: 30246878 PMCID: PMC6513625 DOI: 10.1002/14651858.cd011798.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Diabetes is the commonest cause of chronic kidney disease (CKD). Both conditions commonly co-exist. Glucometabolic changes and concurrent dialysis in diabetes and CKD make glucose-lowering challenging, increasing the risk of hypoglycaemia. Glucose-lowering agents have been mainly studied in people with near-normal kidney function. It is important to characterise existing knowledge of glucose-lowering agents in CKD to guide treatment. OBJECTIVES To examine the efficacy and safety of insulin and other pharmacological interventions for lowering glucose levels in people with diabetes and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 12 February 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at head-to-head comparisons of active regimens of glucose-lowering therapy or active regimen compared with placebo/standard care in people with diabetes and CKD (estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) were eligible. DATA COLLECTION AND ANALYSIS Four authors independently assessed study eligibility, risk of bias, and quality of data and performed data extraction. Continuous outcomes were expressed as post-treatment mean differences (MD). Adverse events were expressed as post-treatment absolute risk differences (RD). Dichotomous clinical outcomes were presented as risk ratios (RR) with 95% confidence intervals (CI). MAIN RESULTS Forty-four studies (128 records, 13,036 participants) were included. Nine studies compared sodium glucose co-transporter-2 (SGLT2) inhibitors to placebo; 13 studies compared dipeptidyl peptidase-4 (DPP-4) inhibitors to placebo; 2 studies compared glucagon-like peptide-1 (GLP-1) agonists to placebo; 8 studies compared glitazones to no glitazone treatment; 1 study compared glinide to no glinide treatment; and 4 studies compared different types, doses or modes of administration of insulin. In addition, 2 studies compared sitagliptin to glipizide; and 1 study compared each of sitagliptin to insulin, glitazars to pioglitazone, vildagliptin to sitagliptin, linagliptin to voglibose, and albiglutide to sitagliptin. Most studies had a high risk of bias due to funding and attrition bias, and an unclear risk of detection bias.Compared to placebo, SGLT2 inhibitors probably reduce HbA1c (7 studies, 1092 participants: MD -0.29%, -0.38 to -0.19 (-3.2 mmol/mol, -4.2 to -2.2); I2 = 0%), fasting blood glucose (FBG) (5 studies, 855 participants: MD -0.48 mmol/L, -0.78 to -0.19; I2 = 0%), systolic blood pressure (BP) (7 studies, 1198 participants: MD -4.68 mmHg, -6.69 to -2.68; I2 = 40%), diastolic BP (6 studies, 1142 participants: MD -1.72 mmHg, -2.77 to -0.66; I2 = 0%), heart failure (3 studies, 2519 participants: RR 0.59, 0.41 to 0.87; I2 = 0%), and hyperkalaemia (4 studies, 2788 participants: RR 0.58, 0.42 to 0.81; I2 = 0%); but probably increase genital infections (7 studies, 3086 participants: RR 2.50, 1.52 to 4.11; I2 = 0%), and creatinine (4 studies, 848 participants: MD 3.82 μmol/L, 1.45 to 6.19; I2 = 16%) (all effects of moderate certainty evidence). SGLT2 inhibitors may reduce weight (5 studies, 1029 participants: MD -1.41 kg, -1.8 to -1.02; I2 = 28%) and albuminuria (MD -8.14 mg/mmol creatinine, -14.51 to -1.77; I2 = 11%; low certainty evidence). SGLT2 inhibitors may have little or no effect on the risk of cardiovascular death, hypoglycaemia, acute kidney injury (AKI), and urinary tract infection (low certainty evidence). It is uncertain whether SGLT2 inhibitors have any effect on death, end-stage kidney disease (ESKD), hypovolaemia, fractures, diabetic ketoacidosis, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, DPP-4 inhibitors may reduce HbA1c (7 studies, 867 participants: MD -0.62%, -0.85 to -0.39 (-6.8 mmol/mol, -9.3 to -4.3); I2 = 59%) but may have little or no effect on FBG (low certainty evidence). DPP-4 inhibitors probably have little or no effect on cardiovascular death (2 studies, 5897 participants: RR 0.93, 0.77 to 1.11; I2 = 0%) and weight (2 studies, 210 participants: MD 0.16 kg, -0.58 to 0.90; I2 = 29%; moderate certainty evidence). Compared to placebo, DPP-4 inhibitors may have little or no effect on heart failure, upper respiratory tract infections, and liver impairment (low certainty evidence). Compared to placebo, it is uncertain whether DPP-4 inhibitors have any effect on eGFR, hypoglycaemia, pancreatitis, pancreatic cancer, or discontinuation due to adverse effects (very low certainty evidence).Compared to placebo, GLP-1 agonists probably reduce HbA1c (7 studies, 867 participants: MD -0.53%, -1.01 to -0.06 (-5.8 mmol/mol, -11.0 to -0.7); I2 = 41%; moderate certainty evidence) and may reduce weight (low certainty evidence). GLP-1 agonists may have little or no effect on eGFR, hypoglycaemia, or discontinuation due to adverse effects (low certainty evidence). It is uncertain whether GLP-1 agonists reduce FBG, increase gastrointestinal symptoms, or affect the risk of pancreatitis (very low certainty evidence).Compared to placebo, it is uncertain whether glitazones have any effect on HbA1c, FBG, death, weight, and risk of hypoglycaemia (very low certainty evidence).Compared to glipizide, sitagliptin probably reduces hypoglycaemia (2 studies, 551 participants: RR 0.40, 0.23 to 0.69; I2 = 0%; moderate certainty evidence). Compared to glipizide, sitagliptin may have had little or no effect on HbA1c, FBG, weight, and eGFR (low certainty evidence). Compared to glipizide, it is uncertain if sitagliptin has any effect on death or discontinuation due to adverse effects (very low certainty).For types, dosages or modes of administration of insulin and other head-to-head comparisons only individual studies were available so no conclusions could be made. AUTHORS' CONCLUSIONS Evidence concerning the efficacy and safety of glucose-lowering agents in diabetes and CKD is limited. SGLT2 inhibitors and GLP-1 agonists are probably efficacious for glucose-lowering and DPP-4 inhibitors may be efficacious for glucose-lowering. Additionally, SGLT2 inhibitors probably reduce BP, heart failure, and hyperkalaemia but increase genital infections, and slightly increase creatinine. The safety profile for GLP-1 agonists is uncertain. No further conclusions could be made for the other classes of glucose-lowering agents including insulin. More high quality studies are required to help guide therapeutic choice for glucose-lowering in diabetes and CKD.
Collapse
Affiliation(s)
- Clement Lo
- Monash UniversityMonash Centre for Health Research and Implementation, School of Public Health and Preventive MedicineClaytonVICAustralia
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
| | - Tadashi Toyama
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
- Kanazawa University HospitalDivision of NephrologyKanazawaJapan
| | - Ying Wang
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Jin Lin
- Beijing Friendship Hospital, Capital Medical UniversityDepartment of Critical Care Medicine95 Yong‐An Road, Xuan Wu DistrictBeijingChina100050
| | - Yoichiro Hirakawa
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | - Min Jun
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Alan Cass
- Menzies School of Health ResearchPO Box 41096CasuarinaNTAustralia0811
| | - Carmel M Hawley
- Princess Alexandra HospitalDepartment of NephrologyIpswich RoadWoolloongabbaQLDAustralia4102
| | - Helen Pilmore
- Auckland HospitalDepartment of Renal MedicinePark RoadGraftonAucklandNew Zealand
- University of AucklandDepartment of MedicineGraftonNew Zealand
| | - Sunil V Badve
- St George HospitalDepartment of Renal MedicineKogarahNSWAustralia
| | - Vlado Perkovic
- The George Institute for Global Health, UNSW SydneyRenal and Metabolic DivisionNewtownNSWAustralia2050
| | - Sophia Zoungas
- Monash HealthDiabetes and Vascular Medicine UnitClaytonVICAustralia
- Monash UniversityDivision of Metabolism, Ageing and Genomics, School of Public Health and Preventive MedicinePrahanVICAustralia
- The George Institute for Global Health, UNSW SydneyProfessorial UnitNewtownNSWAustralia
| | | |
Collapse
|
18
|
Shahzad K, Gadi I, Nazir S, Al-Dabet MM, Kohli S, Bock F, Breitenstein L, Ranjan S, Fuchs T, Halloul Z, Nawroth PP, Pelicci PG, Braun-Dullaeus RC, Camerer E, Esmon CT, Isermann B. Activated protein C reverses epigenetically sustained p66 Shc expression in plaque-associated macrophages in diabetes. Commun Biol 2018; 1:104. [PMID: 30271984 PMCID: PMC6123684 DOI: 10.1038/s42003-018-0108-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 07/03/2018] [Indexed: 12/21/2022] Open
Abstract
Impaired activated protein C (aPC) generation is associated with atherosclerosis and diabetes mellitus. Diabetes-associated atherosclerosis is characterized by the hyperglycaemic memory, e.g., failure of disease improvement despite attenuation of hyperglycaemia. Therapies reversing the hyperglycaemic memory are lacking. Here we demonstrate that hyperglycaemia, but not hyperlipidaemia, induces the redox-regulator p66Shc and reactive oxygen species (ROS) in macrophages. p66Shc expression, ROS generation, and a pro-atherogenic phenotype are sustained despite restoring normoglycemic conditions. Inhibition of p66Shc abolishes this sustained pro-atherogenic phenotype, identifying p66Shc-dependent ROS in macrophages as a key mechanism conveying the hyperglycaemic memory. The p66Shc-associated hyperglycaemic memory can be reversed by aPC via protease-activated receptor-1 signalling. aPC reverses glucose-induced CpG hypomethylation within the p66Shc promoter by induction of the DNA methyltransferase-1 (DNMT1). Thus, epigenetically sustained p66Shc expression in plaque macrophages drives the hyperglycaemic memory, which-however-can be reversed by aPC. This establishes that reversal of the hyperglycaemic memory in diabetic atherosclerosis is feasible.
Collapse
Affiliation(s)
- Khurrum Shahzad
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany.
- Department of Biotechnology, University of Sargodha, Sargodha, 40100, Pakistan.
| | - Ihsan Gadi
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Sumra Nazir
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Moh'd Mohanad Al-Dabet
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Shrey Kohli
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Fabian Bock
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
- Department of Medicine, Vanderbilt University Medical Center, 37232, Nashville, TN, USA
| | - Lukas Breitenstein
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Satish Ranjan
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Tina Fuchs
- Institute for Clinical Chemistry, University of Heidelberg Medical Faculty Mannheim, 68167, Mannheim, Germany
| | - Zuhir Halloul
- Division of Vascular Surgery, Department of General, Abdominal and Vascular Surgery Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Peter P Nawroth
- Department of Internal Medicine I and Clinical Chemistry, German Diabetes Center (DZD), University of Heidelberg, 69120, Heidelberg, Germany
| | - Pier Giuseppe Pelicci
- Department of Experimental Oncology, European Institute of Oncology, Via Ripamonti, 435, 20141, Milan, Italy
| | - Ruediger C Braun-Dullaeus
- Department of Internal Medicine, Division of Cardiology and Angiology, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany
| | - Eric Camerer
- INSERM U970, Paris Cardiovascular Research Centre, 75015, Paris, France
| | - Charles T Esmon
- Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, and Department of Pathology and Department of Biochemistry & Molecular Biology, University of Oklahoma Health Sciences Center, Oklahoma City, 73104, OK, USA
| | - Berend Isermann
- Institute of Clinical Chemistry and Pathobiochemistry, Otto-von-Guericke-University, Leipziger Straße 44, 39120, Magdeburg, Germany.
| |
Collapse
|
19
|
Lee M, Hong N, Lee YH, Kang ES, Cha BS, Lee BW. Elevated N-acetyl-β-d-glucosaminidase, a urinary tubular damage marker, is a significant predictor of carotid artery atherosclerosis in type 1 diabetes, independent of albuminuria: A cross-sectional study. J Diabetes Complications 2018; 32:777-783. [PMID: 29980431 DOI: 10.1016/j.jdiacomp.2018.05.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 05/03/2018] [Accepted: 05/27/2018] [Indexed: 01/07/2023]
Abstract
AIMS Recent evidence has shown that renal tubulointerstitial injuries play an important role in diabetic nephropathy. In this study, we evaluated the association between urinary N-acetyl-β-d-glucosaminidase (uNAG), an early renal tubular damage marker, and carotid artery atherosclerosis in patients with type 1 diabetes (T1D). METHODS This was a cross-sectional study of 88 patients with T1D. Demographic and laboratory data; urinary indices, including urinary NAG-to-creatinine ratio (uNCR), and albumin-to-creatinine ratio (uACR); and carotid ultrasonography were investigated. RESULTS Eighty-eight subjects were divided into three groups based on uNCR tertiles. Subjects belonging to the highest tertile of uNCR had the highest average mean and maximum carotid intima-media thickness (IMT). An elevated uNCR was also significantly correlated with increased average mean and maximum carotid IMT, whereas an elevated uACR was not. Even after adjusting for confounding factors, uNCR continued to be a meaningful predictive marker for increased average mean and maximum IMT. Conversely, the uACR could not predict carotid IMT after adjustment for confounding factors. CONCLUSIONS Elevated levels of uNAG are significantly associated with carotid artery atherosclerosis in patients with T1D independently of albuminuria, a marker of glomerular damage.
Collapse
Affiliation(s)
- Minyoung Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| | - Namki Hong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| | - Yong-Ho Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| | - Eun Seok Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| | - Bong Soo Cha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| | - Byung-Wan Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Graduate School, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seodaemun-gu, Seoul 03722, South Korea.
| |
Collapse
|
20
|
Lilje C, Cronan JC, Schwartzenburg EJ, Owers EM, Clesi P, Gomez R, Stender S, Hempe J, Chalew SA, Cardinale JP. Intima-media thickness at different arterial segments in pediatric type 1 diabetes patients and its relationship with advanced glycation end products. Pediatr Diabetes 2018; 19:450-456. [PMID: 28664608 DOI: 10.1111/pedi.12557] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/09/2017] [Accepted: 06/06/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with type 1 diabetes mellitus (T1DM) are at risk for premature atherosclerosis (AS), which has its origin in childhood. Carotid intima-media thickness (IMT) is an established surrogate marker for subclinical AS in adults. The first macroscopically detectable AS changes, however, begin in the abdominal aorta. Advanced glycation end products (AGE) predict microvascular complications in diabetes. OBJECTIVES To assess the sensitivity for early macrovascular changes of brachial, femoral, and aortic IMT compared to conventional carotid IMT in pediatric T1DM patients ; and the relationship of IMT with AGE. METHODS Using high-resolution external ultrasound, carotid, brachial, femoral, and aortic IMT were prospectively analyzed in children and adolescents with established T1DM and in controls (Ctrls). AGE were estimated by skin intrinsic fluorescence (SIF). Other established cardiovascular risk factors were excluded. RESULTS Seventy-six subjects (T1DM = 38; Ctrls = 38) with a mean age of 13.1 ± 4.0 years (6-19, median 13) qualified for analysis. Carotid, brachial, femoral, and aortic IMT analyses were feasible in 100%, 74%, 84%, and 92% of subjects, respectively. Aortic and femoral IMT were increased in T1DM patients (0.60 ± 0.11 vs 0.52 ± 0.10 mm, P < .001; and 0.41 ± 0.07 vs 0.36 ± 0.07 mm, P < .01, respectively) while carotid and brachial IMT were not. AGE levels were elevated in T1DM patients and correlated with aortic IMT only. The influence of AGE on aIMT did not remain significant after adjusting for T1DM and age in our small population. CONCLUSION We found aortic IMT-and to a lesser degree femoral IMT-to be more sensitive than carotid and brachial IMT for detecting early macrovascular changes in pediatric T1DM patients.
Collapse
Affiliation(s)
- Christian Lilje
- Department of Pediatrics (Cardiology), Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Julie C Cronan
- School of Medicine, Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Elridge J Schwartzenburg
- School of Medicine, Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Elizabeth M Owers
- School of Medicine, Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Patrice Clesi
- Clinical Trials Center, Children's Hospital, New Orleans, Louisiana
| | - Ricardo Gomez
- Department of Pediatrics (Endocrinology), Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Sarah Stender
- Department of Pediatrics (Endocrinology), Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - James Hempe
- Department of Pediatrics (Endocrinology), Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Stuart A Chalew
- Department of Pediatrics (Endocrinology), Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| | - Jeffrey P Cardinale
- School of Medicine, Louisiana State University Health Sciences Center, Children's Hospital, New Orleans, Louisiana
| |
Collapse
|
21
|
Basu A, Jenkins AJ, Stoner JA, Zhang Y, Klein RL, Lopes-Virella MF, Garvey WT, Schade DS, Wood J, Alaupovic P, Lyons TJ. Apolipoprotein-defined lipoprotein subclasses, serum apolipoproteins, and carotid intima-media thickness in T1D. J Lipid Res 2018; 59:872-883. [PMID: 29576550 DOI: 10.1194/jlr.p080143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/15/2018] [Indexed: 01/24/2023] Open
Abstract
Circulating apolipoprotein-defined lipoprotein subclasses (ADLS) and apolipoproteins predict vascular events in the general and type 2 diabetes populations, but data in T1D are limited. We examined associations of ADLS, serum apolipoproteins, and conventional lipids with carotid intima-media thickness (IMT) measured contemporaneously and 6 years later in 417 T1D participants [men: n = 269, age 42 ± 6 y (mean ± SD); women: n = 148, age 39 ± 8 y] in the Epidemiology of Diabetes Interventions and Complications study, the follow-up of the Diabetes Control and Complications Trial (DCCT). Date were analyzed by multiple linear regression stratified by sex, and adjusted for time-averaged hemoglobin A1C, diabetes duration, hypertension, BMI, albuminuria, DCCT randomization, smoking, statin treatment, and ultrasound devices. In cross-sectional analyses, lipoprotein B (Lp-B), Lp-B:C, Lp-B:E+Lp-B:C:E, Apo-A-II, Apo-B, Apo-C-III-HP (heparin precipitate; i.e., Apo-C-III in Apo-B-containing lipoproteins), and Apo-E were positively associated with common and/or internal carotid IMT in men, but only Apo-C-III (total) was (positively) associated with internal carotid IMT in women. In prospective analyses, Lp-B, Apo-B, and Apo-C-III-HP were positively associated with common and/or internal carotid IMT in men, while Lp-A1:AII and Apo-A1 were inversely associated with internal carotid IMT in women. The only significant prospective association between conventional lipids and IMT was between triacylglycerols and internal carotid IMT in men. ADLS and apolipoprotein concentrations may provide sex-specific biomarkers and suggest mechanisms for IMT in people with T1D.
Collapse
Affiliation(s)
- Arpita Basu
- Department of Kinesiology and Nutrition Sciences, University of Nevada Las Vegas, Las Vegas, NV
| | - Alicia J Jenkins
- National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Camperdown, Sydney, NSW, Australia
| | - Julie A Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Ying Zhang
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Richard L Klein
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC.,The Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - Maria F Lopes-Virella
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC.,The Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - David S Schade
- Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM
| | - Jamie Wood
- Department of Pediatrics, Case Western Reserve University School of Medicine, Cleveland, OH
| | | | - Timothy J Lyons
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC
| | | |
Collapse
|
22
|
Polak JF, O'Leary DH. Carotid Intima-Media Thickness as Surrogate for and Predictor of CVD. Glob Heart 2018; 11:295-312.e3. [PMID: 27741977 DOI: 10.1016/j.gheart.2016.08.006] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 07/29/2016] [Accepted: 08/04/2016] [Indexed: 12/17/2022] Open
Abstract
Carotid artery intima-media thickness (IMT) is a noninvasive measurement of the artery wall thickness, inclusive of atherosclerotic plaque, obtained using ultrasound imaging. In the MESA (Multi-Ethnic Study of Atherosclerosis) study, IMT measurements are used as a surrogate for subclinical cardiovascular disease and as a variable predictive of cardiovascular events. IMT measurements of the common carotid artery are available in more than 99% of the MESA population and are predictive of cardiovascular events. More importantly, IMT and plaque thickness measurements made in the internal carotid artery and carotid bulb are also available in more than 98% of the population and are also strongly predictive of cardiovascular events. This article reviews the techniques used to obtain the MESA IMT values, compares them to those made in other epidemiological studies, and summarizes how they have been used in the MESA study as both surrogates for and predictors of cardiovascular disease.
Collapse
Affiliation(s)
- Joseph F Polak
- Department of Radiology, Tufts Medical Center, Boston, MA, USA; Ultrasound Reading Center, Boston, MA, USA.
| | | |
Collapse
|
23
|
Cengiz E, Cheng P, Ruedy KJ, Kollman C, Tamborlane W, Klingensmith G, Gal RL, Silverstein J, Lee J, Redondo MJ, Beck RW. Clinical outcomes in youth beyond the first year of type 1 diabetes: Results of the Pediatric Diabetes Consortium (PDC) type 1 diabetes new onset (NeOn) study. Pediatr Diabetes 2017; 18:566-573. [PMID: 27758023 PMCID: PMC5397378 DOI: 10.1111/pedi.12459] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Current data are limited on the course of type 1 diabetes (T1D) in children and adolescents through the first few years of diabetes. The Pediatric Diabetes Consortium T1D new onset (NeOn) Study was undertaken to prospectively assess natural history and clinical outcomes in children treated at 7 US diabetes centers from the time of diagnosis. This paper describes clinical outcomes in the T1D NeOn cohort during the first 3 years postdiagnosis. RESULTS A total of 1048 participants (mean age 9.2 years, 49% female, 65% non-Hispanic White) were enrolled between July 2009 and April 2011. Mean glycated hemoglobin (HbA1c) (±SD) was 7.2% (55 mmol/mol) at 3 months, followed by a progressive rise to 8.4% (68 mmol/mol) at 36 months postdiagnosis, with only 30% of participants achieving target HbA1c<7.5% (58 mmol/mol). The percentage of participants in partial remission estimated by insulin dose adjusted HbA1c [HbA1c % + (4×insulin dose unit/kg/24 h)] ≤9 sharply declined from 23% at 12 months to 7% at 36 months. The percentage of participants developing diabetic ketoacidosis (DKA) was 1% in the first year after diagnosis, increasing to 6% in years 2 and 3. CONCLUSIONS These results demonstrate the gradual decline in glycemic control due to waning residual endogenous insulin secretion with increasing duration of T1D in children and adolescents. These data indicate the need to translate recent advances in automated insulin delivery, new insulin analogs, and adjunctive pharmacologic agents into novel treatment strategies to maintain optimal glycemic control even early in the course of T1D.
Collapse
Affiliation(s)
- Eda Cengiz
- Yale University, Department of Pediatric Endocrinology, New Haven, CT, US, 06520
| | - Peiyao Cheng
- Jaeb Center for Health Research, Tampa, FL, US, 33647
| | | | - Craig Kollman
- Jaeb Center for Health Research, Tampa, FL, US, 33647
| | - William Tamborlane
- Yale University, Department of Pediatric Endocrinology, New Haven, CT, US, 06520
| | - Georgeanna Klingensmith
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Department of Pediatrics, Aurora, CO, US, 80045
| | - Robin L. Gal
- Jaeb Center for Health Research, Tampa, FL, US, 33647
| | - Janet Silverstein
- University of Florida, Pediatric Endocrinology, Gainesville, FL, US, 32605
| | - Joyce Lee
- University of Michigan, Pediatric Endocrinology, Ann Arbor, MI, US, 48109
| | - Maria J. Redondo
- Texas Children's Hospital, Baylor College of Medicine, Pediatric Diabetes and Endocrinology Section, Houston, TX, US, 77030
| | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, FL, US, 33647
| | | |
Collapse
|
24
|
Burger D, Turner M, Xiao F, Munkonda MN, Akbari S, Burns KD. High glucose increases the formation and pro-oxidative activity of endothelial microparticles. Diabetologia 2017; 60:1791-1800. [PMID: 28601907 DOI: 10.1007/s00125-017-4331-2] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/18/2017] [Indexed: 01/03/2023]
Abstract
AIMS/HYPOTHESIS Individuals with diabetes exhibit increases in circulating endothelial microparticles (eMPs, also referred to as endothelial microvesicles), which are associated with endothelial dysfunction and a heightened risk of cardiovascular complications. We have shown that eMPs are markers and mediators of vascular injury although their role in diabetes is unclear. We hypothesised that the composition and biological activity of eMPs are altered in response to high glucose exposure. We assessed the effects of high glucose on eMP formation, composition and signalling in cultured HUVECs. METHODS eMPs were isolated from the media of HUVECs cultured under conditions of normal glucose (eMPNG), high glucose (eMPHG) or osmotic control of L-glucose (eMPLG). eMP size, concentration and surface charge were assessed by nanoparticle tracking analysis and flow cytometry. eMP protein composition was assessed by liquid chromatography-tandem mass spectrometry, and eMP-mediated effects on coagulation, reactive oxygen species (ROS) production and vessel function were assessed. RESULTS Exposure of HUVECs to high glucose for 24 h caused a threefold increase in eMP formation, increased mean particle size (269 ± 18 nm vs 226 ± 11 nm) and decreased surface charge. Compared with eMPNG or eMPLG, eMPHG possessed approximately threefold greater pro-coagulant activity, stimulated HUVEC ROS production to a greater extent (~250% of eMPNG) and were more potent inhibitors of endothelial-dependent relaxation. Proteomic analysis of eMPs identified 1212 independent proteins of which 68 were exclusively found in eMPHG. Gene ontology analysis revealed that eMPHG-exclusive proteins were associated with signalling pathways related to blood coagulation, cell signalling and immune cell activation. CONCLUSIONS/INTERPRETATION Our results indicate that elevated glucose is a potent stimulus for eMP formation that also alters their molecular composition leading to increased bioactivity. Such effects may contribute to progressive endothelial injury and subsequent cardiovascular complications in diabetes.
Collapse
Affiliation(s)
- Dylan Burger
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada.
- Department of Cellular and Molecular Medicine, University of Ottawa, 2513-451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
| | - Maddison Turner
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, 2513-451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Fengxia Xiao
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada
| | - Mercedes N Munkonda
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada
| | - Shareef Akbari
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, 2513-451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Kevin D Burns
- Kidney Research Centre, Ottawa Hospital Research Institute, University of Ottawa, 1967 Riverside Drive, Room 535, Ottawa, ON, K1H 7W9, Canada.
- Department of Cellular and Molecular Medicine, University of Ottawa, 2513-451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.
- Division of Nephrology, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada.
| |
Collapse
|
25
|
Petrie JR, Chaturvedi N, Ford I, Brouwers MCGJ, Greenlaw N, Tillin T, Hramiak I, Hughes AD, Jenkins AJ, Klein BEK, Klein R, Ooi TC, Rossing P, Stehouwer CDA, Sattar N, Colhoun HM. Cardiovascular and metabolic effects of metformin in patients with type 1 diabetes (REMOVAL): a double-blind, randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2017; 5:597-609. [PMID: 28615149 PMCID: PMC5641446 DOI: 10.1016/s2213-8587(17)30194-8] [Citation(s) in RCA: 220] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Metformin might reduce insulin requirement and improve glycaemia in patients with type 1 diabetes, but whether it has cardiovascular benefits is unknown. We aimed to investigate whether metformin treatment (added to titrated insulin therapy) reduced atherosclerosis, as measured by progression of common carotid artery intima-media thickness (cIMT), in adults with type 1 diabetes at increased risk for cardiovascular disease. METHODS REMOVAL was a double-blind, placebo-controlled trial undertaken at 23 hospital diabetes clinics in five countries (Australia, Canada, Denmark, the Netherlands, and the UK). Adults aged 40 years and older with type 1 diabetes of at least 5 years' duration and at least three of ten specific cardiovascular risk factors were randomly assigned (via an interactive voice response system) to oral metformin 1000 mg twice daily or placebo. Participants and site staff were masked to treatment allocation. The primary outcome was averaged mean far-wall cIMT, quantified annually for 3 years, analysed in a modified intention-to-treat population (all randomly assigned participants with post-randomisation data available for the outcome of interest at any given timepoint, irrespective of subsequent adherence or study participation), using repeated measures regression. Secondary outcomes were HbA1c, LDL cholesterol, estimated glomerular filtration rate (eGFR), incident microalbuminuria (not reported), incident retinopathy, bodyweight, insulin dose, and endothelial function, also analysed in all participants with post-randomisation data available for the outcome of interest at any given timepoint. This trial is registered with ClinicalTrials.gov, number NCT01483560. FINDINGS Between Dec 14, 2011, and June 24, 2014, 493 participants entered a 3 month run-in to optimise risk factor and glycaemic control (single-blind placebo in the final month). Of 428 randomly assigned patients, 219 were allocated to metformin and 209 to placebo. Progression of mean cIMT was not significantly reduced with metformin (-0·005 mm per year, 95% CI -0·012 to 0·002; p=0·1664), although maximal cIMT (a prespecified tertiary outcome) was significantly reduced (-0·013 mm per year, -0·024 to -0·003; p=0·0093). HbA1c (mean 8·1% [SD 0·9] for metformin and 8·0% [0·8] for placebo at baseline) was reduced on average over 3 years by metformin (-0·13%, 95% CI -0·22 to -0·037; p=0·0060), but this was accounted for by a reduction at the 3-month timepoint (-0·24%, -0·34 to -0·13; p<0·0001) that was not sustained thereafter (p=0·0163 for visit-by-treatment interaction). Bodyweight (-1·17 kg, 95% CI -1·66 to -0·69; p<0·0001) and LDL cholesterol (-0·13 mmol/L, -0·24 to -0·03; p=0·0117) were reduced with metformin over 3 years of treatment, and eGFR was increased (4·0 mL/min per 1·73m2, 2·19 to 5·82; p<0·0001). Insulin requirement was not reduced on average over 3 years (-0·005 units per kg, 95% CI -0·022 to 0·012; p=0·545), but there was a significant visit-by-treatment interaction (p=0·0018). There was no effect on endothelial function as measured by reactive hyperaemia index, or on retinopathy. Discontinuation of treatment in 59 (27%) participants on metformin versus 26 (12%) on placebo (p=0·0002) was mainly due to an excess of gastrointestinal adverse effects, and there was no increase in hypoglycaemia with metformin. Five deaths occurred among patients allocated to metformin and two occurred among those allocated to placebo; none were judged by site principal investigators to be related to study medication. INTERPRETATION These data do not support use of metformin to improve glycaemic control in adults with long-standing type 1 diabetes as suggested by current guidelines, but suggest that it might have a wider role in cardiovascular risk management. FUNDING JDRF.
Collapse
Affiliation(s)
- John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.
| | - Nishi Chaturvedi
- Institute of Cardiovascular Science, University College London, London, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Martijn C G J Brouwers
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Therese Tillin
- Institute of Cardiovascular Science, University College London, London, UK
| | | | - Alun D Hughes
- Institute of Cardiovascular Science, University College London, London, UK
| | - Alicia J Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Barbara E K Klein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ronald Klein
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Teik C Ooi
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
| | - Peter Rossing
- Steno Diabetes Center Copenhagen and University of Copenhagen, Copenhagen, Denmark
| | - Coen D A Stehouwer
- Department of Internal Medicine and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre, Maastricht, Netherlands
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
26
|
Ruospo M, Saglimbene VM, Palmer SC, De Cosmo S, Pacilli A, Lamacchia O, Cignarelli M, Fioretto P, Vecchio M, Craig JC, Strippoli GFM. Glucose targets for preventing diabetic kidney disease and its progression. Cochrane Database Syst Rev 2017; 6:CD010137. [PMID: 28594069 PMCID: PMC6481869 DOI: 10.1002/14651858.cd010137.pub2] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diabetes is the leading cause of end-stage kidney disease (ESKD) around the world. Blood pressure lowering and glucose control are used to reduce diabetes-associated disability including kidney failure. However there is a lack of an overall evidence summary of the optimal target range for blood glucose control to prevent kidney failure. OBJECTIVES To evaluate the benefits and harms of intensive (HbA1c < 7% or fasting glucose levels < 120 mg/dL versus standard glycaemic control (HbA1c ≥ 7% or fasting glucose levels ≥ 120 mg/dL for preventing the onset and progression of kidney disease among adults with diabetes. SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register up to 31 March 2017 through contact with the Information Specialist using search terms relevant to this review. Studies contained in the Specialised Register are identified through search strategies specifically designed for CENTRAL, MEDLINE, and EMBASE; handsearching conference proceedings; and searching the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials evaluating glucose-lowering interventions in which people (aged 14 year or older) with type 1 or 2 diabetes with and without kidney disease were randomly allocated to tight glucose control or less stringent blood glucose targets. DATA COLLECTION AND ANALYSIS Two authors independently assessed studies for eligibility and risks of bias, extracted data and checked the processes for accuracy. Outcomes were mortality, cardiovascular complications, doubling of serum creatinine (SCr), ESKD and proteinuria. Confidence in the evidence was assessing using GRADE. Summary estimates of effect were obtained using a random-effects model, and results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes, and mean difference (MD) and 95% CI for continuous outcomes. MAIN RESULTS Fourteen studies involving 29,319 people with diabetes were included and 11 studies involving 29,141 people were included in our meta-analyses. Treatment duration was 56.7 months on average (range 6 months to 10 years). Studies included people with a range of kidney function. Incomplete reporting of key methodological details resulted in uncertain risks of bias in many studies. Using GRADE assessment, we had moderate confidence in the effects of glucose lowering strategies on ESKD, all-cause mortality, myocardial infarction, and progressive protein leakage by kidney disease and low or very low confidence in effects of treatment on death related to cardiovascular complications and doubling of serum creatinine (SCr).For the primary outcomes, tight glycaemic control may make little or no difference to doubling of SCr compared with standard control (4 studies, 26,874 participants: RR 0.84, 95% CI 0.64 to 1.11; I2= 73%, low certainty evidence), development of ESKD (4 studies, 23,332 participants: RR 0.62, 95% CI 0.34 to 1.12; I2= 52%; low certainty evidence), all-cause mortality (9 studies, 29,094 participants: RR 0.99, 95% CI 0.86 to 1.13; I2= 50%; moderate certainty evidence), cardiovascular mortality (6 studies, 23,673 participants: RR 1.19, 95% CI 0.73 to 1.92; I2= 85%; low certainty evidence), or sudden death (4 studies, 5913 participants: RR 0.82, 95% CI 0.26 to 2.57; I2= 85%; very low certainty evidence). People who received treatment to achieve tighter glycaemic control probably experienced lower risks of non-fatal myocardial infarction (5 studies, 25,596 participants: RR 0.82, 95% CI 0.67 to 0.99; I2= 46%, moderate certainty evidence), onset of microalbuminuria (4 studies, 19,846 participants: RR 0.82, 95% CI 0.71 to 0.93; I2= 61%, moderate certainty evidence), and progression of microalbuminuria (5 studies, 13,266 participants: RR 0.59, 95% CI 0.38 to 0.93; I2= 75%, moderate certainty evidence). In absolute terms, tight versus standard glucose control treatment in 1,000 adults would lead to between zero and two people avoiding non-fatal myocardial infarction, while seven adults would avoid experiencing new-onset albuminuria and two would avoid worsening albuminuria. AUTHORS' CONCLUSIONS This review suggests that people who receive intensive glycaemic control for treatment of diabetes had comparable risks of kidney failure, death and major cardiovascular events as people who received less stringent blood glucose control, while experiencing small clinical benefits on the onset and progression of microalbuminuria and myocardial infarction. The adverse effects of glycaemic management are uncertain. Based on absolute treatment effects, the clinical impact of targeting an HbA1c < 7% or blood glucose < 6.6 mmol/L is unclear and the potential harms of this treatment approach are largely unmeasured.
Collapse
Affiliation(s)
- Marinella Ruospo
- DiaverumMedical Scientific OfficeLundSweden
- Amedeo Avogadro University of Eastern PiedmontDivision of Nephrology and Transplantation, Department of Translational MedicineVia Solaroli 17NovaraItaly28100
| | | | - Suetonia C Palmer
- University of Otago ChristchurchDepartment of Medicine2 Riccarton AvePO Box 4345ChristchurchNew Zealand8140
| | - Salvatore De Cosmo
- Scientific Institute CSSDepartment of MedicineViale CappucciniSan Giovanni RotondoItaly71013
| | - Antonio Pacilli
- Scientific Institute CSSDepartment of MedicineViale CappucciniSan Giovanni RotondoItaly71013
| | - Olga Lamacchia
- University of FoggiaDepartment of EndocrinologyFoggiaItaly
| | | | | | | | - Jonathan C Craig
- The University of SydneySydney School of Public HealthEdward Ford Building A27SydneyNSWAustralia2006
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Giovanni FM Strippoli
- DiaverumMedical Scientific OfficeLundSweden
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- Diaverum AcademyBariItaly
| | | |
Collapse
|
27
|
Gao L, Bai L, Shi M, Ni J, Lu H, Wu Y, Tu J, Ning X, Wang J, Li Y. Association between carotid intima-media thickness and fasting blood glucose level: A population-based cross-sectional study among low-income adults in rural China. J Diabetes Investig 2017; 8:788-797. [PMID: 28160451 PMCID: PMC5668475 DOI: 10.1111/jdi.12639] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/08/2017] [Accepted: 01/25/2017] [Indexed: 12/29/2022] Open
Abstract
Aims/Introduction Carotid intima‐media thickness (CIMT) is an established predictor of cardiovascular disease and stroke. We aimed to identify the association between CIMT and blood glucose, as well as the risk factors associated with increased CIMT in a low‐income Chinese population. Materials and Methods Stroke‐free and cardiovascular disease‐free residents aged ≥45 years were recruited. B‐mode ultrasonography was carried out to measure CIMT. Results There were 2,643 participants (71.0%) in the normal group, 549 (14.7%) in the impaired fasting glucose group and 533 (14.3%) in the diabetes mellitus group. The determinants of increased CIMT were older age; male sex; low education; hypertension; smoking; high levels of systolic blood pressure, fasting blood glucose and low‐density lipoprotein cholesterol; and low levels of diastolic blood pressure, triglycerides and high‐density lipoprotein cholesterol, after adjusting for covariates. Age and hypertension were the common risk factors for increased CIMT in all three groups. Furthermore, male sex, smoking and high low‐density lipoprotein cholesterol level were positively associated with the mean CIMT in the normal group; high triglycerides levels were negatively associated with the mean CIMT in the impaired fasting glucose group; and alcohol consumption was an independent risk factor for mean CIMT in the diabetes mellitus group. Hypertension was the greatest risk factor for increased CIMT. Conclusions These findings suggest that it is crucial to manage and control traditional risk factors in low‐income populations in China in order to decelerate the recent dramatic increase in stroke incidence, and to reduce the burden of stroke.
Collapse
Affiliation(s)
- Liu Gao
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Lingling Bai
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China
| | - Min Shi
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China
| | - Jingxian Ni
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China
| | - Hongyan Lu
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Yanan Wu
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China
| | - Jun Tu
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China
| | - Xianjia Ning
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China.,Center of Clinical Epidemiology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Jinghua Wang
- Department of Neurology, Tianjin Medical University General Hospital, Heping District, Tianjin, China.,Department of Epidemiology, Tianjin Neurological Institute, Heping District, Tianjin, China.,Center of Clinical Epidemiology, Tianjin Medical University General Hospital, Heping District, Tianjin, China
| | - Yukun Li
- Department of Endocrinology, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| |
Collapse
|
28
|
Taskiran B, Cansu GB, Bahadir E, Mutluay R. Role of Vitamin D in Intima Media Thickness in Patients with Type 1 Diabetes Mellitus. J Natl Med Assoc 2017; 109:14-20. [PMID: 28259209 DOI: 10.1016/j.jnma.2017.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 12/26/2016] [Accepted: 01/06/2017] [Indexed: 12/24/2022]
Abstract
Increased carotid intima media thickness indicates subclinical atherosclerosis. We evaluated the relation between vitamin D level and intima media thickness in patients with type 1 DM. 93 patients (female/male: 48/45, aged 31.5 ± 11.9 years, A1c 9.48 ± 2.43, vitamin D [15.9 (12.1-19.2)]) with type 1 DM were included into the study. Common carotid artery IMT was measured by real time B mode ultrasonography (MyLab 70 XVG, Esaote SpA, Genoa, Italy). Vitamin D was measured using radioimmunassay. Male and female patients (n = 14, 15%) had similar rates of plaque presence (p = 0.377). IMT was similar according to gender. IMT [0.45 (0.40-0.50)] was positively correlated with age, duration of diabetes, creatinine, LDL/HDL ratio, and ALP. Median IMT was higher in current smokers, patients with retinopathy, and nephropathy, and overweight/obese patients. IMT was not different according to vitamin D status. However calcium level corrected for albumin was in positive correlation with mean IMT (r = 0.221, p = 0.033). We detected high frequency of vitamin D deficiency (78%) defined as less than 20 ng/ml. Vitamin D and diabetes control defined as A1c have no effect on intima media thickness in type 1 DM. Traditional cardiovascular risk factors including age, duration of DM, smoking, and BMI adversely affect intima media thickness.
Collapse
Affiliation(s)
- Bengur Taskiran
- Department of Endocrinology, Yunus Emre State Hospital, Eskisehir, Turkey.
| | - Guven B Cansu
- Department of Endocrinology, Yunus Emre State Hospital, Eskisehir, Turkey
| | - Eylem Bahadir
- Department of Radiology, Yunus Emre State Hospital, Eskisehir, Turkey
| | - Ruya Mutluay
- Department of Nephrology, Yunus Emre State Hospital, Eskisehir, Turkey
| |
Collapse
|
29
|
Yamagishi SI, Nakamura N, Matsui T. Glycation and cardiovascular disease in diabetes: A perspective on the concept of metabolic memory. J Diabetes 2017; 9:141-148. [PMID: 27556881 DOI: 10.1111/1753-0407.12475] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 07/25/2016] [Accepted: 08/20/2016] [Indexed: 12/16/2022] Open
Abstract
Epidemiological studies have suggested that cumulative diabetic exposure, namely prolonged exposure to chronic hyperglycemia, contributes to the increased risk of cardiovascular disease (CVD) in diabetes. The formation and accumulation of advanced glycation end-products (AGEs) have been known to progress under hyperglycemic conditions. Because AGEs-modified collagens are hardly degraded and remain in diabetic vessels, kidneys and the heart for a long time, even after glycemic control has been achieved, AGEs could become a marker reflecting cumulative diabetic exposure. Furthermore, there is a growing body of evidence that an interaction between AGEs and the receptor for AGEs (RAGE) plays a role in the pathogenesis of CVD. In addition, AGEs induce the expression of RAGE, thus leading to sustained activation of the AGEs-RAGE axis in diabetes. Herein we review the pathological role of the AGEs-RAGE axis in CVD, focusing particularly on the phenomenon of metabolic memory, and discuss the potential clinical usefulness of measuring circulating and tissue levels of AGEs accumulation to evaluate diabetic macrovascular complications.
Collapse
Affiliation(s)
- Sho-Ichi Yamagishi
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume, Japan
| | - Nobutaka Nakamura
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume, Japan
| | - Takanori Matsui
- Department of Pathophysiology and Therapeutics of Diabetic Vascular Complications, Kurume University School of Medicine, Kurume, Japan
| |
Collapse
|
30
|
Brahma MK, Pepin ME, Wende AR. My Sweetheart Is Broken: Role of Glucose in Diabetic Cardiomyopathy. Diabetes Metab J 2017; 41:1-9. [PMID: 28236380 PMCID: PMC5328690 DOI: 10.4093/dmj.2017.41.1.1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 10/11/2016] [Indexed: 01/09/2023] Open
Abstract
Despite overall reductions in heart disease prevalence, the risk of developing heart failure has remained 2-fold greater among people with diabetes. Growing evidence has supported that fluctuations in glucose level and uptake contribute to cardiovascular disease (CVD) by modifying proteins, DNA, and gene expression. In the case of glucose, clinical studies have shown that increased dietary sugars for healthy individuals or poor glycemic control in diabetic patients further increased CVD risk. Furthermore, even after decades of maintaining tight glycemic control, susceptibility to disease progression can persist following a period of poor glycemic control through a process termed "glycemic memory." In response to chronically elevated glucose levels, a number of studies have identified molecular targets of the glucose-mediated protein posttranslational modification by the addition of an O-linked N-acetylglucosamine to impair contractility, calcium sensitivity, and mitochondrial protein function. Additionally, elevated glucose contributes to dysfunction in coupling glycolysis to glucose oxidation, pentose phosphate pathway, and polyol pathway. Therefore, in the "sweetened" environment associated with hyperglycemia, there are a number of pathways contributing to increased susceptibly to "breaking" the heart of diabetics. In this review we will discuss the unique contribution of glucose to heart disease and recent advances in defining mechanisms of action.
Collapse
Affiliation(s)
- Manoja K Brahma
- Division of Molecular and Cellular Pathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark E Pepin
- Division of Molecular and Cellular Pathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Biomedical Engineering, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Adam R Wende
- Division of Molecular and Cellular Pathology, Department of Pathology, The University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
31
|
Anderson JJ, Li T, Sharrow DJ. Insights into mortality patterns and causes of death through a process point of view model. Biogerontology 2017; 18:149-170. [PMID: 27885527 PMCID: PMC5290203 DOI: 10.1007/s10522-016-9669-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 11/15/2016] [Indexed: 12/15/2022]
Abstract
Process point of view (POV) models of mortality, such as the Strehler-Mildvan and stochastic vitality models, represent death in terms of the loss of survival capacity through challenges and dissipation. Drawing on hallmarks of aging, we link these concepts to candidate biological mechanisms through a framework that defines death as challenges to vitality where distal factors defined the age-evolution of vitality and proximal factors define the probability distribution of challenges. To illustrate the process POV, we hypothesize that the immune system is a mortality nexus, characterized by two vitality streams: increasing vitality representing immune system development and immunosenescence representing vitality dissipation. Proximal challenges define three mortality partitions: juvenile and adult extrinsic mortalities and intrinsic adult mortality. Model parameters, generated from Swedish mortality data (1751-2010), exhibit biologically meaningful correspondences to economic, health and cause-of-death patterns. The model characterizes the twentieth century epidemiological transition mainly as a reduction in extrinsic mortality resulting from a shift from high magnitude disease challenges on individuals at all vitality levels to low magnitude stress challenges on low vitality individuals. Of secondary importance, intrinsic mortality was described by a gradual reduction in the rate of loss of vitality presumably resulting from reduction in the rate of immunosenescence. Extensions and limitations of a distal/proximal framework for characterizing more explicit causes of death, e.g. the young adult mortality hump or cancer in old age are discussed.
Collapse
Affiliation(s)
| | - Ting Li
- Renmin University of China, Beijing, China
| | | |
Collapse
|
32
|
Gore MO, McGuire DK. A Test in Context. J Am Coll Cardiol 2016; 68:2479-2486. [DOI: 10.1016/j.jacc.2016.08.070] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 08/19/2016] [Accepted: 08/23/2016] [Indexed: 01/15/2023]
|
33
|
de Andrade CRM, Silva ELC, da Matta MDFB, Castier MB, Rosa MLG, Gomes MB. Vascular or chronological age: which is the better marker to estimate the cardiovascular risk in patients with type 1 diabetes? Acta Diabetol 2016; 53:925-933. [PMID: 27528365 DOI: 10.1007/s00592-016-0891-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
Abstract
AIMS To evaluate whether using vascular age (VA) instead of chronological age (CA) in the Framingham score would enhance the cardiovascular disease (CVD) risk estimation in patients with type 1 diabetes (T1D). METHODS This was a cross-sectional study comprising 58 T1D patients and 38 control subjects matched by age, gender and body mass index. To estimate the VA, we used carotid intima-media thickness normality estimation tables that took into account age, gender and ethnic group. RESULTS Compared to the control group, T1D patients had an older VA with an 8.8-year difference (p < 0.001), a higher CVD risk stratification comparing CA and VA (p < 0.001). In the group of T1D patients, there was a 9.4-year difference between VA and CA (p < 0.001), mainly due to a greater increase in women compared to men (11.2 vs 6.4 years, respectively) and 29.3 % of the patients with T1D increased their CVD risk stratification using VA as a parameter. Still, in the group of T1D patients, women had a higher increase in VA for each 1-year increase in CA than men (1.2 years vs 0.8 years, respectively, p < 0.001). This difference persisted as we compared women with T1D with women in the control group (0.4 years), p = 0.006. CONCLUSIONS T1D patients have an increased VA, a marker of subclinical atherosclerosis. The use of VA age may contribute to the identification of high CVD risk in T1D. In patients with T1D, a younger chronological age, particularly in women, might not be a protective factor for CVD.
Collapse
Affiliation(s)
- Carlos Roberto Moraes de Andrade
- Endocrinology Department, University Hospital of Fluminense Federal University, Rio de Janeiro, Brazil.
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Avenida 28 de Setembro, 77, 3° andar, Rio de Janeiro, RJ, CEP 20.551-030, Brazil.
- , Avenida Prof. Florestan Fernandes 1036 Bl.16 ap.503, Camboinhas, Niterói, Rio de Janeiro, CEP 24358-580, Brazil.
| | - Eliete Leão Clemente Silva
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Avenida 28 de Setembro, 77, 3° andar, Rio de Janeiro, RJ, CEP 20.551-030, Brazil
| | - Maria de Fátima Bevilaqua da Matta
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Avenida 28 de Setembro, 77, 3° andar, Rio de Janeiro, RJ, CEP 20.551-030, Brazil
| | - Marcia Bueno Castier
- Department of Internal Medicine, Cardiology Unit, State University Hospital of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria Luiza Garcia Rosa
- Epidemiology and Biomaths, University Hospital of Fluminense Federal University, Rio de Janeiro, Brazil
| | - Marília Brito Gomes
- Department of Internal Medicine, Diabetes Unit, State University Hospital of Rio de Janeiro, Avenida 28 de Setembro, 77, 3° andar, Rio de Janeiro, RJ, CEP 20.551-030, Brazil
| |
Collapse
|
34
|
Fusaro MFGS, Zanini JLSS, Silva IN. Increased carotid intima-media thickness in Brazilian adolescents with type 1 diabetes mellitus. Diabetol Metab Syndr 2016; 8:74. [PMID: 27895720 PMCID: PMC5106830 DOI: 10.1186/s13098-016-0190-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 11/05/2016] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Increased carotid intima-media thickness (CIMT), a marker of subclinical atherosclerosis, is an independent predictor of future cardiovascular events, and has been reported in children with various chronic diseases, including type 1 diabetes mellitus (DM1). OBJECTIVES Evaluate CIMT and its association with cardiovascular risk factors in Brazilian adolescents with DM1. METHODS Cross-sectional study of 118 adolescents, 57 with DM1 and no chronic complications related to the disease, and 61 healthy individuals. Clinical, biochemical, and high-resolution B-mode ultrasonographic evaluations according to the Consensus Statement of the American Society of Echocardiography CIMT Task Force were performed. RESULTS Adolescents with diabetes (66.6% female) were 14.5 ± 2.9 years old and had 9.0 ± 4.0 years of disease duration. The healthy adolescents (62.3% female) were 14.3 ± 2.6 years old. All the adolescents had blood pressure within their reference ranges. In 66% of DM1 adolescents the systolic blood pressure was >50th percentile. Increased CIMT was observed in adolescents with diabetes compared with those in the control group: 0.53 vs 0.51 mm (p < 0.004) on the right side, and 0.55 vs 0.51 mm (p < 0.001) on the left side. CIMT presented independent and positive associations with diabetes duration, total cholesterol level, low-density lipoprotein cholesterol level, and systolic blood pressure percentile in DM1 adolescents. CONCLUSIONS Increased CIMT was observed in young Brazilian adolescents with DM1, and was associated with cardiovascular risk factors. CIMT assessment may be useful for the early identification and monitoring of cardiovascular risk in this age group.
Collapse
Affiliation(s)
- Maria Fernanda Gontijo Sepulveda Fusaro
- Divisão de Endocrinologia Infantil e do Adolescente-Departamento de Pediatria, Faculdade de Medicina/Hospital das Clínicas, Universidade Federal de Minas Gerais, Av Alfredo Balena 190, s/267, Belo Horizonte, MG 30130-100 Brazil
| | - Jovita Lane Soares Santos Zanini
- Department of Anatomy and Image, Hospital das Clínicas, Medical School, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Ivani Novato Silva
- Divisão de Endocrinologia Infantil e do Adolescente-Departamento de Pediatria, Faculdade de Medicina/Hospital das Clínicas, Universidade Federal de Minas Gerais, Av Alfredo Balena 190, s/267, Belo Horizonte, MG 30130-100 Brazil
| |
Collapse
|
35
|
de Boer IH, Gao X, Cleary PA, Bebu I, Lachin JM, Molitch ME, Orchard T, Paterson AD, Perkins BA, Steffes MW, Zinman B. Albuminuria Changes and Cardiovascular and Renal Outcomes in Type 1 Diabetes: The DCCT/EDIC Study. Clin J Am Soc Nephrol 2016; 11:1969-1977. [PMID: 27797889 PMCID: PMC5108190 DOI: 10.2215/cjn.02870316] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/14/2016] [Indexed: 01/30/2023]
Abstract
BACKGROUND AND OBJECTIVES In trials of people with type 2 diabetes, albuminuria reduction with renin-angiotensin system inhibitors is associated with lower risks of cardiovascular events and CKD progression. We tested whether progression or remission of microalbuminuria is associated with cardiovascular and renal risk in a well characterized cohort of type 1 diabetes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We studied 1441 participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications study. Albumin excretion rate (AER) was quantified annually or biennially for up to 30 years. For each participant, albuminuria status was defined over time as normoalbuminuria (AER continuously <30 mg/d), sustained microalbuminuria (AER, 30-299 mg/d on two consecutive visits), macroalbuminuria (AER≥300 mg/d), or remitted microalbuminuria (transition from sustained microalbuminuria to AER<30 mg/d on two consecutive visits). We tested associations of time-updated albuminuria status with adjudicated clinical cardiovascular events, the development of reduced GFR (<60 ml/min per 1.73 m2 on two consecutive visits), and subclinical cardiovascular disease. RESULTS At least one cardiovascular event occurred in 184 participants, and 98 participants developed reduced eGFR. Compared with normoalbuminuria, sustained microalbuminuria, remitted microalbuminuria, and macroalbuminuria were each associated with higher risk of cardiovascular events (adjusted hazard ratios [HRs] and 95% confidence intervals [95% CIs]: 1.79 [1.13 to 2.85], 2.62 [1.68 to 4.07], and 2.65 [1.68 to 4.19], respectively) and reduced eGFR (adjusted HRs [95% CIs], 5.26 [2.43 to 11.41], 4.36 [1.80 to 10.57], and 54.35 [30.79 to 95.94], respectively). Compared with sustained microalbuminuria, remission to normoalbuminuria was not associated with reduced risk of cardiovascular events (adjusted HR, 1.33; 95% CI, 0.68 to 2.59) or reduced eGFR (adjusted HR, 1.75; 95% CI, 0.56 to 5.49). Compared with normoalbuminuria, sustained microalbuminuria, remitted microalbuminuria, and macroalbuminuria were associated with greater carotid intima-media thickness, and macroalbuminuria was associated with a greater degree of coronary artery calcification. CONCLUSIONS In type 1 diabetes, microalbuminuria and macroalbuminuria are associated with higher risks of cardiovascular disease and reduced eGFR, but achieving a remission of established microalbuminuria to normoalbuminuria does not appear to improve outcomes.
Collapse
Affiliation(s)
- Ian H de Boer
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
| | - Xiaoyu Gao
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Patricia A Cleary
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - Ionut Bebu
- Biostatistics Center, The George Washington University, Rockville, Maryland
| | - John M Lachin
- Division of Nephrology and Kidney Research Institute, University of Washington, Seattle, Washington
- Biostatistics Center, The George Washington University, Rockville, Maryland
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University, Chicago, Illinois
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
- Dalla Lana School of Public Health, Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Endocrinology and Metabolism, University of Toronto and University Health Network, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mark E Molitch
- Division of Endocrinology, Metabolism & Molecular Medicine, Northwestern University, Chicago, Illinois
| | - Trevor Orchard
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrew D Paterson
- Dalla Lana School of Public Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bruce A Perkins
- Division of Endocrinology and Metabolism, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Michael W Steffes
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota; and
| | - Bernard Zinman
- Lunenfeld Tanenbaum Research Institute, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
36
|
Miranda JJ, Taype-Rondan A, Tapia JC, Gastanadui-Gonzalez MG, Roman-Carpio R. Hair follicle characteristics as early marker of Type 2 Diabetes. Med Hypotheses 2016; 95:39-44. [PMID: 27692164 PMCID: PMC5073072 DOI: 10.1016/j.mehy.2016.08.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 08/14/2016] [Indexed: 01/17/2023]
Abstract
Type 2 Diabetes mellitus (DM2) includes a continuum of metabolic disorders characterized by hyperglycemia that causes several chronic long-term complications such as coronary artery disease, peripheral arterial disease, nephropathy, and neuropathy. The hair follicle could reveal signs of early vascular impairment, yet its relationship to early metabolic injuries has been largely ignored. We propose that in earlier stages of the continuum of DM2-related metabolic disorders, a group of susceptible patients who do not yet meet the diagnostic criteria to be considered as persons with DM2 may present chronic vascular impairment and end organ damage, including hair follicle damage, which can be evaluated to identify an early risk marker. This hypothesis is based in the association found between insulin resistance and alopecia in non-diabetic persons, and the hair loss on the lower limbs as a manifestation of long-term peripheral arterial disease among subjects with DM2. In order to test this hypothesis, studies are required to evaluate if hair follicle characteristics are related to and can predict hyperglycemic complications, and if they do so, which feature of the hair follicle, such as hair growth, best characterizes such DM2-related conditions. If this hypothesis were proven to be true, significant advances towards a personalized approach for early prevention strategies and management of DM2 would be made. By focusing on the hair follicles, early stages of metabolic-related organ damage could be identified using non-invasive low-cost techniques. In so doing, this approach could provide early identification of DM2-susceptible individuals and lead to the early initiation of adequate primary prevention strategies to reduce or avoid the onset of large internal organ damage.
Collapse
Affiliation(s)
- J Jaime Miranda
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru.
| | - Alvaro Taype-Rondan
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jose Carlos Tapia
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru; CONEVID, Unidad de Conocimiento y Evidencia, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maria Gabriela Gastanadui-Gonzalez
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ricardo Roman-Carpio
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru; School of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
| |
Collapse
|
37
|
Coprogression of Cardiovascular Risk Factors in Type 1 Diabetes During 30 Years of Follow-up in the DCCT/EDIC Study. Diabetes Care 2016; 39:1621-30. [PMID: 27436274 PMCID: PMC5001148 DOI: 10.2337/dc16-0502] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 06/16/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Diabetes Control and Complications Trial (DCCT)/Epidemiology of Diabetes Interventions and Complications (EDIC) study has demonstrated the beneficial effect of intensive therapy on atherosclerosis and clinical cardiovascular outcomes, while identifying hyperglycemia as a dominant risk factor for type 1 diabetes. The current analyses evaluate the extent to which glycemic exposure influences long-term changes in established risk factors for cardiovascular disease (CVD) among patients with type 1 diabetes. RESEARCH DESIGN AND METHODS The DCCT study randomized 1,441 participants to receive intensive or conventional diabetes therapy; and after an average of 6.5 years of follow-up, 96% of the surviving cohort enrolled in the EDIC observational study for an additional 20 years of follow-up. Annual visits included a detailed medical history and physical examination. Blood and urine samples were collected and assayed centrally. Longitudinal models for repeated measurements were used. RESULTS Higher HbA1c level was a significant correlate of the longitudinal changes in all of the traditional CVD risk factors over the 30-year follow-up. The strongest longitudinal associations were among the lipid measurements and concurrent glycemia. CONCLUSIONS A better understanding of the interrelationships between diabetes-related risk factors and traditional CVD risk factors may assist with the development of targeted treatment regimens for persons with type 1 diabetes who are at risk for CVD.
Collapse
|
38
|
van der Heyden JC, Birnie E, Bovenberg SA, Cabezas MC, van der Meulen N, Mul D, Veeze HJ, Aanstoot HJ. Do traditional cardiovascular risk factors solely explain intima-media thickening in youth with type 1 diabetes? J Diabetes Complications 2016; 30:1137-43. [PMID: 27217021 DOI: 10.1016/j.jdiacomp.2016.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 03/24/2016] [Accepted: 03/25/2016] [Indexed: 12/30/2022]
Abstract
AIMS The aim of this study was to assess age-specific carotid intima-media thickness (cIMT) in children and adolescents with type 1 diabetes and to investigate associations between cIMT, age, classical cardiovascular disease (CVD) and other risk factors. METHODS This study included a cross-sectional analysis of cIMT in 178 patients with type 1 diabetes and 208 healthy controls across age categories. In patients, the impact of gender, socio-economic status, ethnicity, current and historical body mass index, blood pressure, hemoglobin A1c, high-density lipoprotein, and low-density lipoprotein cholesterol on cIMT was studied in a retrospective follow-up cohort study. RESULTS Median cIMT was equally greater in patients versus controls across all age categories (P≤0.03). Regression models in patients confirmed a lack of association between cIMT and classical CVD risk factors. CONCLUSIONS Children and adolescents with type 1 diabetes showed greater cIMT than controls in all age categories. Increased cIMT did not seem to be consistently associated with classical adult CVD risk factors, adding to the current debate in pediatrics about the impact on classical CVD risk factors to the development of subclinical atherosclerosis in type 1 diabetes. Future studies are warranted to determine if cIMT could assist in predicting macrovascular complications of type 1 diabetes.
Collapse
Affiliation(s)
- Josine C van der Heyden
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands; Department of Pediatric Endocrinology, Sophia Children's Hospital, Erasmus MC, University Medical Centre, Rotterdam, Netherlands; Department of Pediatrics, Sint Franciscus Gasthuis, Rotterdam, Netherlands.
| | - Erwin Birnie
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands; University of Groningen, University Medical Center Groningen, Department of Genetics, Groningen, Netherlands
| | - Sarah A Bovenberg
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| | | | | | - Dick Mul
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| | - Henk J Veeze
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| | - Henk-Jan Aanstoot
- Diabeter, Center for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, Netherlands
| |
Collapse
|
39
|
The pecking order of skin Advanced Glycation Endproducts (AGEs) as long-term markers of glycemic damage and risk factors for micro- and subclinical macrovascular disease progression in Type 1 diabetes. Glycoconj J 2016; 33:569-79. [PMID: 27342131 DOI: 10.1007/s10719-016-9702-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 06/04/2016] [Accepted: 06/07/2016] [Indexed: 12/17/2022]
Abstract
To date more than 20 glycation products were identified, of which ~15 in the insoluble human skin collagen fraction. The goal of this review is to streamline 30 years of research and ask a set of important questions: in Type 1 diabetes which glycation products correlate best with 1) past mean glycemia 2) reversibility with improved glycemic control, 2) cross-sectional severity of retinopathy, nephropathy and neuropathy and 3) the future long-term risk of progression of micro- and subclinical macrovascular disease. The trio of glycemia related glycation markers furosine (FUR)/fructose-lysine (FL), glucosepane and methylglyoxal hydroimidazolone (MG-H1) emerges as extraordinarily strong predictors of existing and future microvascular disease progression risk despite adjustment for both past and prospective A1c levels. X(2) values are up to 25.1, p values generally less than 0.0001, and significance remains after adjustment for various factors such as A1c, former treatment group, log albumin excretion rate, abnormal autonomic nerve function and LDL levels at baseline. In contrast, subclinical cardiovascular progression is more weakly correlated with AGEs/glycemia with X(2) values < 5.0 and p values generally < 0.05 after all adjustments. Except for future carotid intima-media thickness, which correlates with total AGE burden (MG-H1, pentosidine, fluorophore LW-1 and decreased collagen solubility), adjusted FUR and Collagen Fluorescence (CLF) are the strongest markers for future coronary artery calcium deposition, while cardiac hypertrophy is associated with LW-1 and CLF adjusted for A1c. We conclude that a robust clinical skin biopsy AGE risk panel for microvascular disease should include at least FUR/FL, glucosepane and MG-H1, while a macrovascular disease risk panel should include at least FL/FUR, MG-H1, LW-1 and CLF.
Collapse
|
40
|
Peña AS, Maftei O, Harrington J, Anderson J, Hirte C, Gent R, Couper J. Lack of evidence for progression of atherosclerosis during puberty in type 1 diabetes. Pediatr Diabetes 2016; 17:199-205. [PMID: 25683127 DOI: 10.1111/pedi.12265] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 01/22/2015] [Accepted: 01/23/2015] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Children with type 1 diabetes have early changes in vascular structure with increased aortic intima-media thickness (aIMT) or carotid IMT (cIMT). aIMT may be an earlier, more sensitive marker; however, longitudinal data in type 1 diabetes are lacking. This study will aim to evaluate changes in vascular structure (aIMT and cIMT) over 2 yr during puberty in children with type 1 diabetes and compare them with those in healthy children. RESEARCH DESIGN AND METHODS A total of 110 children (aged 10-18 yr, 55 males) participated in a prospective cohort study, including 77 children with type 1 diabetes and 33 age- and sex-matched healthy children. Ultrasound assessments of aIMT and cIMT; and clinical and biochemical data were collected at baseline and 2 yr later. RESULTS Mean and maximal aIMT or cIMT did not worsen over time in children with type 1 diabetes compared with healthy children. Longer duration of diabetes related to an increase in aIMT. Improvement in HDL cholesterol and leptin related to a decrease in aIMT. Higher baseline IMT related to an improvement in IMT in children with type 1 diabetes (mean and maximal aIMT: β = -0.52, p < 0.001; β = -0.49, p = 0.001, and mean and maximal cIMT: β = -0.36, p = 0.003; β = -0.40, p = 0.001), independent of cardiovascular risk factors. CONCLUSIONS Aortic and carotid IMT does not deteriorate during puberty in children with type 1 diabetes. This has implications for the design of interventional studies in this important age group.
Collapse
Affiliation(s)
- Alexia S Peña
- Robinson Research Institute and Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, 5006, Australia.,Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Oana Maftei
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Jennifer Harrington
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Jemma Anderson
- Robinson Research Institute and Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, 5006, Australia.,Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Craig Hirte
- Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Roger Gent
- Medical Imaging, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| | - Jennifer Couper
- Robinson Research Institute and Discipline of Paediatrics, University of Adelaide, Adelaide, South Australia, 5006, Australia.,Endocrinology and Diabetes Centre, Women's and Children's Hospital, Adelaide, South Australia, 5006, Australia
| |
Collapse
|
41
|
Basu A, Jenkins AJ, Zhang Y, Stoner JA, Klein RL, Lopes-Virella MF, Timothy Garvey W, Lyons TJ. Data on carotid intima-media thickness and lipoprotein subclasses in type 1 diabetes from the Diabetes Control and Complications Trial and the Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC). Data Brief 2015; 6:33-8. [PMID: 26759826 PMCID: PMC4683326 DOI: 10.1016/j.dib.2015.11.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 11/09/2015] [Accepted: 11/16/2015] [Indexed: 11/30/2022] Open
Abstract
Type 1 diabetes (T1DM) is associated with increased risk of macrovascular complications. We examined longitudinal associations of serum conventional lipids and nuclear magnetic resonance (NMR)-determined lipoprotein subclasses with carotid intima-media thickness (IMT) in adults with T1DM (n=455) enrolled in the Diabetes Control and Complications Trial (DCCT). Data on serum lipids and lipoproteins were collected at DCCT baseline (1983-89) and were correlated with common and internal carotid IMT determined by ultrasonography during the observational follow-up of the DCCT, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, at EDIC 'Year 1' (199-1996) and EDIC 'Year 6' (1998-2000). This article contains data on the associations of DCCT baseline lipoprotein profiles (NMR-based VLDL & chylomicrons, IDL/LDL and HDL subclasses and 'conventional' total, LDL-, HDL-, non-HDL-cholesterol and triglycerides) with carotid IMT at EDIC Years 1 and 6, stratified by gender. The data are supplemental to our original research article describing detailed associations of DCCT baseline lipids and lipoprotein profiles with EDIC Year 12 carotid IMT (Basu et al. in press) [1].
Collapse
Affiliation(s)
- Arpita Basu
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Alicia J Jenkins
- Section of Endocrinology & Diabetes, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; University of Sydney, NHMRC Clinical Trials Centre, Camperdown, Sydney, NSW, Australia
| | - Ying Zhang
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Julie A Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Richard L Klein
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC, USA; The Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Maria F Lopes-Virella
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC, USA; The Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy J Lyons
- Section of Endocrinology & Diabetes, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Centre for Experimental Medicine, Queen's University of Belfast, Belfast, UK
| | | |
Collapse
|
42
|
Basu A, Jenkins AJ, Zhang Y, Stoner JA, Klein RL, Lopes-Virella MF, Garvey WT, Lyons TJ. Nuclear magnetic resonance-determined lipoprotein subclasses and carotid intima-media thickness in type 1 diabetes. Atherosclerosis 2015; 244:93-100. [PMID: 26600440 DOI: 10.1016/j.atherosclerosis.2015.10.106] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Dyslipidemia has been linked to vascular complications of Type 1 diabetes (T1DM). We investigated the prospective associations of nuclear magnetic resonance-determined lipoprotein subclass profiles (NMR-LSP) and conventional lipid profiles with carotid intima-media thickness (IMT) in T1DM. METHODS NMR-LSP and conventional lipids were measured in a subset of Diabetes Control and Complications Trial (DCCT) participants (n = 455) at study entry ('baseline', 1983-89), and were related to carotid IMT determined by ultrasonography during the observational follow-up of the DCCT, the Epidemiology of Diabetes Interventions and Complications (EDIC) study, at EDIC Year 12 (2004-2006). Associations were defined using multiple linear regression stratified by gender, and following adjustment for HbA1c, diabetes duration, body mass index, albuminuria, DCCT randomization group, smoking status, statin use, and ultrasound devices. RESULTS In men, significant positive associations were observed between some baseline NMR-subclasses of LDL (total IDL/LDL and large LDL) and common and/or internal carotid IMT, and between conventional total- and LDL-cholesterol and non-HDL-cholesterol and common carotid IMT, at EDIC Year 12; these persisted in adjusted analyses (p < 0.05). Large LDL particles and conventional triglycerides were positively associated with common carotid IMT changes over 12 years (p < 0.05). Inverse associations of mean HDL diameter and large HDL concentrations, and positive associations of small LDL with common and/or internal carotid IMT (all p < 0.05) were found, but did not persist in adjusted analyses. No significant associations were observed in women. CONCLUSION NMR-LSP-derived LDL particles, in addition to conventional lipid profiles, may help in identifying men with T1DM at highest risk for vascular disease.
Collapse
Affiliation(s)
- Arpita Basu
- Department of Nutritional Sciences, Oklahoma State University, Stillwater, OK, USA
| | - Alicia J Jenkins
- Section of Endocrinology & Diabetes, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; University of Sydney, NHMRC Clinical Trials Centre, Camperdown, Sydney, NSW, Australia
| | - Ying Zhang
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Julie A Stoner
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Richard L Klein
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC, USA; The Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Maria F Lopes-Virella
- Division of Endocrinology, Medical University of South Carolina, Charleston, SC, USA; The Ralph H Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - W Timothy Garvey
- Department of Nutrition Sciences, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy J Lyons
- Section of Endocrinology & Diabetes, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA; Centre for Experimental Medicine, Queen's University of Belfast, Belfast, UK.
| | | |
Collapse
|
43
|
Petersen KS, Clifton PM, Blanch N, Keogh JB. Effect of improving dietary quality on carotid intima media thickness in subjects with type 1 and type 2 diabetes: a 12-mo randomized controlled trial. Am J Clin Nutr 2015; 102:771-9. [PMID: 26354542 DOI: 10.3945/ajcn.115.112151] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Accepted: 08/04/2015] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND People with diabetes are at a heightened risk of cardiovascular disease compared with the general population. To our knowledge, randomized controlled trials investigating the effect of improving dietary quality on carotid intima media thickness, a marker of subclinical atherosclerosis and predictor of cardiovascular disease, have not been conducted in populations with diabetes. OBJECTIVE We aimed to determine whether increasing fruit (+1 serving; 150 g/d), vegetable (+2 servings; 150 g/d), and dairy (+1 serving; 200-250 g/d) intakes slows 12-mo common carotid artery intima media thickness (CCA IMT) progression, compared with a control group continuing to consume their usual diet, in people with type 1 and type 2 diabetes. DESIGN A 12-mo randomized controlled trial was conducted. The primary outcome was mean CCA IMT, measured at baseline and 12 mo, with B-mode ultrasound. Participants in the intervention group received counseling from a dietitian at baseline and 1, 3, 6, and 9 mo, and compliance was measured with a food-frequency questionnaire at baseline, 3 mo, and 12 mo. The control group continued consuming their usual diet. RESULTS In total, 118 participants completed the study. Vegetable (46 g/d; 95% CI: 14, 77 g/d; P < 0.001) and fruit (179 g/d; 95% CI: 119, 239 g/d; P < 0.001) intakes were increased at 3 mo in the intervention group compared with the control group. This increase was not maintained at 12 mo, but intake increased overall in the cohort (fruit, 48 g/d; vegetables, 14 g/d). An increase in dairy consumption was not achieved, but yogurt intake was higher in the intervention group at 3 mo (38 g; 95% CI: 12, 65 g; P < 0.001); this was not maintained at 12 mo. At 12 mo, CCA IMT regressed (mean ± SD: -0.01 ± 0.04 mm; P < 0.001), with a greater effect in the treatment group (mean ± SD: -0.02 ± 0.04 mm compared with -0.004 ± 0.04 mm; P = 0.009). CONCLUSION Improving dietary quality in people with well-controlled type 1 and type 2 diabetes may slow CCA IMT progression. This trial was registered at https://www.anzctr.org.au as ACTRN12613000251729.
Collapse
Affiliation(s)
- Kristina S Petersen
- School of Pharmacy and Medical Sciences & Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Peter M Clifton
- School of Pharmacy and Medical Sciences & Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Natalie Blanch
- School of Pharmacy and Medical Sciences & Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| | - Jennifer B Keogh
- School of Pharmacy and Medical Sciences & Sansom Institute for Health Research, University of South Australia, Adelaide, Australia
| |
Collapse
|
44
|
Alvarez CA, Lingvay I, Vuylsteke V, Koffarnus RL, McGuire DK. Cardiovascular Risk in Diabetes Mellitus: Complication of the Disease or of Antihyperglycemic Medications. Clin Pharmacol Ther 2015; 98:145-61. [PMID: 25963811 DOI: 10.1002/cpt.143] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 05/06/2015] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease is the principal complication and the leading cause of death for patients with diabetes (DM). The efficacy of antihyperglycemic treatments on cardiovascular disease risk remains uncertain. Cardiovascular risk factors are affected by antihyperglycemic medications, as are many intermediate markers of cardiovascular disease. Here we summarize the evidence assessing the cardiovascular effects of antihyperglycemic medications with regard to risk factors, intermediate markers of disease, and clinical outcomes.
Collapse
Affiliation(s)
- C A Alvarez
- Texas Tech University Health Sciences Center, Dallas, Texas, University of Texas Southwestern, Dallas, Texas, USA
| | - I Lingvay
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - V Vuylsteke
- Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | - R L Koffarnus
- Texas Tech University Health Sciences Center, Dallas, Texas, USA
| | - D K McGuire
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
45
|
Cetinkalp S, Felekoglu C, Karadeniz M, Boyacıoglu H, Delen Y, Yildirim E, Yilmaz C. Comparison of the effects of intensive insulin treatment modalities on cardiovascular biomarkers in type 1 diabetes mellitus. Diabetes Metab Syndr 2015; 9:157-162. [PMID: 25952036 DOI: 10.1016/j.dsx.2015.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM To evaluate effects of intensive insulin treatment modalities on cardiovascular biomarkers in patients with type 1 diabetes mellitus (T1DM). MATERIALS AND METHODS A total of 25 patients with T1DM receiving intensive insulin therapy either in the form of continuous insulin pump (IP group; n=13) or as multiple daily injections (MDI group; n=12) and 13 controls (control group, n=13) were included. Data on demographics, anthropometrics, diabetes history, and laboratory findings including glycemic and lipid parameters, and cardiovascular biomarkers [C-reactive protein (mg/dL), homocysteine (μmol/L), fibrinogen (mg/dL), oxidized LDL (ng/dL), PAI-1 (ng/mL), MCP-1 (pg/mL) and VEGF (pg/mL)] were recorded in each group. Correlation of cardiovascular biomarkers to other parameters was also evaluated in T1DM patients. RESULTS Apart from significantly higher mean (SD) values for HbA1c [6.1 (0.3) vs. 5.6 (0.5)% (43 (3) vs. 38 (5) mmol/mol), p<0.05)] and HDL-cholesterol [71.5 (13.6) vs. 58.2 (10.8), p<0.01) in the IP than in the MDI group, no significance difference was noted between insulin treatment modalities as well as between patient and control groups in terms of demographic, anthropometric and laboratory parameters. Negative correlation of MCP-1 to treatment duration (r=-0.615, p=0.025), and HDL-c to CRP (r=-0.685, p=0.010) and VEGF (r=-0.678, p=0.011) was noted in IP group, whereas positive correlation of PAI-1 to diabetes age (r=0.805, p=0.002) and treatment duration was noted in MDI group. CONCLUSION Our findings in a cohort of T1DM patients with optimal glycemic control revealed that intensive insulin therapy was not associated with an increase in atherosclerotic markers in T1DM, regardless of whether continuous IP infusion or MDIs was administered.
Collapse
Affiliation(s)
- Sevki Cetinkalp
- Department of Endocrinology and Metabolic Diseases, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Canan Felekoglu
- Izmir Bozyaka Training and Research Hospital, Izmir, Turkey.
| | | | - Hayal Boyacıoglu
- Department of Statistics, Ege University Faculty of Science, Izmir, Turkey.
| | - Yasemin Delen
- Department of Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Eser Yildirim
- Department of Biochemistry, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Candeger Yilmaz
- Department of Endocrinology and Metabolic Diseases, Ege University Faculty of Medicine, Izmir, Turkey.
| |
Collapse
|
46
|
Bächle C, Lange K, Stahl-Pehe A, Castillo K, Scheuing N, Holl RW, Giani G, Rosenbauer J. Symptoms of Eating Disorders and Depression in Emerging Adults with Early-Onset, Long-Duration Type 1 Diabetes and Their Association with Metabolic Control. PLoS One 2015; 10:e0131027. [PMID: 26121155 PMCID: PMC4487688 DOI: 10.1371/journal.pone.0131027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 05/26/2015] [Indexed: 02/07/2023] Open
Abstract
Background This study analyzed the prevalence of and association between symptoms of eating disorders and depression in female and male emerging adults with early-onset, long-duration type 1 diabetes and investigated how these symptoms are associated with metabolic control. Methods In a nationwide population-based survey, 211 type 1 diabetes patients aged 18-21 years completed standardized questionnaires, including the SCOFF questionnaire for eating disorder symptoms and the Patient Health Questionnaire (PHQ-9) for symptoms of depression and severity of depressive symptoms (PHQ-9 score). Multiple linear and logistic regression models were used to analyze the association between eating disorder and depressive symptoms and their associations with HbA1c. Results A total of 30.2% of the women and 9.5% of the men were screening positive for eating disorders. The mean PHQ-9 score (standard deviation) was 5.3 (4.4) among women and 3.9 (3.6) among men. Screening positive for an eating disorder was associated with more severe depressive symptoms among women (βwomen 3.8, p<0.001). However, neither eating disorder symptoms nor severity of depressive symptoms were associated with HbA1c among women, while HbA1c increased with the severity of depressive symptoms among men (βmen 0.14, p=0.006). Conclusions Because of the high prevalence of eating disorder and depressive symptoms, their interrelationship, and their associations with metabolic control, particularly among men, regular mental health screening is recommended for young adults with type 1 diabetes.
Collapse
Affiliation(s)
- Christina Bächle
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- * E-mail:
| | - Karin Lange
- Hannover Medical School, Department of Medical Psychology, Hannover, Germany
| | - Anna Stahl-Pehe
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Katty Castillo
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Nicole Scheuing
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- University of Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany
| | - Reinhard W. Holl
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- University of Ulm, Institute of Epidemiology and Medical Biometry, ZIBMT, Ulm, Germany
| | - Guido Giani
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Joachim Rosenbauer
- German Diabetes Center, Institute for Biometrics and Epidemiology, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| |
Collapse
|
47
|
Caramori ML, Kim Y, Natarajan R, Moore JH, Rich SS, Mychaleckyj JC, Kuriyama R, Kirkpatrick D, Mauer M. Differential Response to High Glucose in Skin Fibroblasts of Monozygotic Twins Discordant for Type 1 Diabetes. J Clin Endocrinol Metab 2015; 100:E883-9. [PMID: 25901990 PMCID: PMC5393515 DOI: 10.1210/jc.2014-4467] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
CONTEXT Most epigenetic studies in diabetes compare normal cells in "high glucose" (HG) to cells in "normal glucose" (NG) and cells returned from HG to NG. Here we challenge this approach. OBJECTIVE The objective was to determine whether there were differences in gene expression in skin fibroblasts of monozygotic twins (MZT) discordant for type 1 diabetes (T1D). DESIGN Skin fibroblasts were grown in NG (5.5 mmol/L) and HG (25 mmol/L) for multiple passages. SETTING This study was conducted at the University of Minnesota. PATIENTS Patients were nine MZT pairs discordant for T1D. MAIN OUTCOME MEASURE(S) Gene expression was assessed by mRNA-Seq, using the Illumina HiSeq 2000 instrument. Pathway analysis tested directionally consistent group differences within the Kyoto Encyclopedia of Genes and Genomes pathways. RESULTS A total of 3308 genes were differentially expressed between NG and HG in T1D MZT vs 889 in non-T1D twins. DNA replication, proteasome, cell cycle, base excision repair, homologous recombination, pyrimidine metabolism, and spliceosome pathways had overrepresented genes with increased expression in T1D twins with P values ranging from 7.21 × 10(-10) to 1.39 × 10(-4). In a companion article, we demonstrate that these pathway changes are related to diabetic nephropathy risk. There were no pathways statistically significant differently expressed in nondiabetic twins in HG vs NG. CONCLUSIONS In vivo exposure to diabetes alters cells in a manner that markedly changes their in vitro responses to HG. These results highlight the importance of using cells directly derived from diabetic patients for studies examining the effects of HG in diabetes.
Collapse
Affiliation(s)
- M Luiza Caramori
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Youngki Kim
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Rama Natarajan
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Jason H Moore
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Stephen S Rich
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Josyf C Mychaleckyj
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Ryoko Kuriyama
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - David Kirkpatrick
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| | - Michael Mauer
- Departments of Medicine and Pediatrics (M.L.C., M.M.) and Pediatrics and Laboratory Medicine and Pathology (Y.K.), University of Minnesota, Minneapolis, Minnesota 55455; Department of Diabetes Complications, Obesity and Metabolism (R.N.), Beckman Research Institute, City of Hope, Duarte, California 91010; Department of Genetics (J.H.M.), Dartmouth College, Hanover, New Hampshire 03755; Departments of Public Health Sciences (S.S.R.) and Bioinformatics and Genetics (J.C.M.), University of Virginia, Charlottesville, Virginia 22908; and Department of Genetics, Cell Biology and Development (R.K., D.K.), University of Minnesota, Minneapolis, Minnesota 55455
| |
Collapse
|
48
|
Momeni A, Dyani MA, Ebrahimi E, Sedehi M, Naderi A. Association of retinopathy and intima media thickness of common carotid artery in type 2 diabetic patients. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2015; 20:393-6. [PMID: 26109997 PMCID: PMC4468457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Revised: 01/21/2015] [Accepted: 04/14/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND This study was carried out in order to evaluate the relationship between retinopathy and carotid intima-media thickness (CIMT). MATERIALS AND METHODS In a cross-sectional study, 154 diabetic patients who had a history of diabetic disease were evaluated in two equal groups of 77 patients with and without retinopathy, respectively. CIMT was evaluated in all of the patients. RESULTS Mean age of the patients was 59.65 ± 9.37 years. Mean CIMT of all patients was 0.84 ± 0.18. CIMT of patients with retinopathy was significantly greater than patients without retinopathy (P < 0.001). CIMT also correlated with age, duration of diabetes, systolic blood pressure, blood urea nitrogen, and serum creatinine. CONCLUSION CIMT may be used as a simple, available and noninvasive method for screening of macro and microvascular complication of diabetic patients.
Collapse
Affiliation(s)
- Ali Momeni
- Department of Nephrology, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Mohamad Ali Dyani
- Department of Radiology, Shahrekord University of Medical Sciences, Shahrekord, Iran,Address for correspondence: Dr. Mohamad Ali Dyani, Hajar Hospital, Shahrekord, Iran. E-mail:
| | - Elnaz Ebrahimi
- Department of Internal Medicine, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Morteza Sedehi
- Department of Epidemiology, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Afsaneh Naderi
- Department of Ophtalmology, Shahrekord University of Medical Sciences, Shahrekord, Iran
| |
Collapse
|
49
|
Sveen KA, Dahl-Jørgensen K, Stensaeth KH, Angel K, Seljeflot I, Sell DR, Monnier VM, Hanssen KF. Glucosepane and oxidative markers in skin collagen correlate with intima media thickness and arterial stiffness in long-term type 1 diabetes. J Diabetes Complications 2015; 29:407-12. [PMID: 25600701 DOI: 10.1016/j.jdiacomp.2014.12.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Revised: 12/20/2014] [Accepted: 12/20/2014] [Indexed: 01/21/2023]
Abstract
AIMS To study intima media thickness (cIMT) and arterial stiffness in type 1 diabetes of long duration, and their associations with the collagen cross-linker glucosepane and inflammatory and oxidative markers. METHODS Twenty-seven individuals with type 1 diabetes mellitus of 40 years duration from the Oslo Study cohort and 24 age-matched controls were included. cIMT measurements of the carotid artery were performed longitudinally. Pulse wave velocity (PWV), augmentation index (AIx) and augmentation pressure (AP) were assessed cross-sectionally. Glucosepane and the oxidative product methionine sulfoxide (MetSO) were determined in skin collagen by liquid chromatography-mass spectrometry. Circulating inflammatory markers were determined by ELISAs. RESULTS The diabetes patients had significantly increased cIMT and arterial stiffness compared to controls. Significant correlations were noted for skin glucosepane with cIMT (r=0.41) and PWV (r=0.44). Skin MetSO and monocyte chemoattractant protein-1 (MCP-1) correlated significantly with AIx and AP. After correcting for age and mean arterial pressure in multiple linear regression analysis, MetSO and MCP-1 were both independently associated with AIx and AP. CONCLUSIONS These results suggest more premature atherosclerosis and arterial pathology in individuals with diabetes compared to age-matched controls. They also suggest an association between the arterial pathology and markers of collagen crosslinking, oxidative damage and inflammation in type 1 diabetes patients of forty years disease duration.
Collapse
Affiliation(s)
- Kari Anne Sveen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine University of Oslo, Oslo, Norway.
| | - Knut Dahl-Jørgensen
- Department of Pediatrics, Oslo University Hospital, Ullevaal, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine University of Oslo, Oslo, Norway
| | - Knut Haakon Stensaeth
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Kristin Angel
- Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ingebjørg Seljeflot
- Department of Cardiology, Oslo University Hospital, Oslo, Norway; Center for Clinical Heart Research, Oslo University hospital, Ullevaal, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine University of Oslo, Oslo, Norway
| | - David R Sell
- Departments of Pathology and Biochemistry Case Western Reserve University, Cleveland, OH, USA
| | - Vincent M Monnier
- Departments of Pathology and Biochemistry Case Western Reserve University, Cleveland, OH, USA
| | - Kristian F Hanssen
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine University of Oslo, Oslo, Norway
| |
Collapse
|
50
|
Ornoy A, Reece EA, Pavlinkova G, Kappen C, Miller RK. Effect of maternal diabetes on the embryo, fetus, and children: congenital anomalies, genetic and epigenetic changes and developmental outcomes. ACTA ACUST UNITED AC 2015; 105:53-72. [PMID: 25783684 DOI: 10.1002/bdrc.21090] [Citation(s) in RCA: 169] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Pregestational and gestational diabetes mellitus (PGDM; GDM) are significant health concerns because they are associated with an increased rate of malformations and maternal health complications. METHODS We reviewed the data that help us to understand the effects of diabetes in pregnancy. RESULTS Diabetic embryopathy can affect any developing organ system, but cardiovascular and neural tube defects are among the most frequent anomalies. Other complications include preeclampsia, preterm delivery, fetal growth abnormalities, and perinatal mortality. Neurodevelopmental studies on offspring of mothers with diabetes demonstrated increased rate of Gross and Fine motor abnormalities, of Attention Deficit Hyperactivity Disorder, learning difficulties, and possibly also Autism Spectrum Disorder. The mechanisms underlying the effects of maternal hyperglycemia on the developing fetus may involve increased oxidative stress, hypoxia, apoptosis, and epigenetic changes. Evidence for epigenetic changes are the following: not all progeny are affected and not to the same extent; maternal diet may influence pregnancy outcomes; and maternal diabetes alters embryonic transcriptional profiles and increases the variation between transcriptomic profiles as a result of altered gene regulation. Research in animal models has revealed that maternal hyperglycemia is a teratogen, and has helped uncover potential therapeutic targets which, when blocked, can mitigate or ameliorate the negative effects of diabetes on the developing fetus. CONCLUSIONS Tight metabolic control, surveillance, and labor management remain the cornerstone of care for pregnant women with diabetes, but advances in the field indicate that new treatments to protect the mother and baby are not far from becoming clinical realities.
Collapse
Affiliation(s)
- Asher Ornoy
- Department of Medical Neurobiology, Laboratory of Teratology, Hebrew University Hadassah Medical School, Jerusalem, Israel
| | | | | | | | | |
Collapse
|