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Mujammami M, Nimer RM, Al Mogren M, Almalki R, Alabdaljabar MS, Benabdelkamel H, Abdel Rahman AM. Metabolomics Panel Associated with Cystic Fibrosis-Related Diabetes toward Biomarker Discovery. ACS OMEGA 2024; 9:32873-32880. [PMID: 39100315 PMCID: PMC11292812 DOI: 10.1021/acsomega.4c03626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 07/08/2024] [Accepted: 07/10/2024] [Indexed: 08/06/2024]
Abstract
The most prevalent comorbidity among cystic fibrosis (CF) patients is cystic fibrosis-related diabetes (CFRD). CFRD has been linked to one of the worse clinical outcomes and a higher mortality. Improved clinical results have been related to earlier diagnosis and treatment of CFRD. Therefore, the present study aimed to investigate the metabolome of human serum of patients with CFRD. This might aid in identifying novel biomarkers linked with the pathophysiology of CFRD and its diagnosis. The liquid chromatography-high-resolution mass spectrometry (LC-HRMS) metabolomics approach was utilized for serum samples from patients with CF (n = 36) and healthy controls (n = 36). Nine patients in the CF group had CFRD, and 27 were non-CFRD patients (nCFRD). A total of 2328 metabolites were significantly altered in CF compared with the healthy control. Among those, 799 significantly dysregulated metabolites were identified between CFRD and nCFRD. Arachidonic acid (AA), ascorbate, and aldarate metabolism were the most common metabolic pathways dysregulated in CF. l-Homocysteic acid (l-HCA) levels were significantly reduced in CF and CFRD compared to the control and nCFRD, respectively. In addition, gamma-glutamylglycine and l-5-hydroxytryptophan (5-HTP) had the highest discrimination between CFRD and nCFRD with AUC (0.716 and 0.683, respectively). These biomarkers might serve as diagnostic biomarkers and aid in understanding potential metabolic changes linked to CF and CFRD.
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Affiliation(s)
- Muhammad Mujammami
- Endocrinology
and Diabetes Unit, Department of Medicine, College of Medicine, King Saud University, Riyadh 12372, Saudi Arabia
- Diabetes
University Center, King Saud University Medical City, King Saud University, Riyadh 12372, Saudi Arabia
| | - Refat M. Nimer
- Department
of Medical Laboratory Sciences, Jordan University
of Science and Technology, Irbid 22110, Jordan
| | - Maha Al Mogren
- Metabolomics
Section, Department of Clinical Genomics, Center for Genomics Medicine, King Faisal Specialist Hospital and Research Centre
(KFSHRC), Riyadh 11211, Saudi Arabia
| | - Reem Almalki
- Metabolomics
Section, Department of Clinical Genomics, Center for Genomics Medicine, King Faisal Specialist Hospital and Research Centre
(KFSHRC), Riyadh 11211, Saudi Arabia
| | | | - Hicham Benabdelkamel
- Proteomics
Resource Unit, Obesity Research Center, College of Medicine, King Saud University, Riyadh 11362, Saudi Arabia
| | - Anas M. Abdel Rahman
- Metabolomics
Section, Department of Clinical Genomics, Center for Genomics Medicine, King Faisal Specialist Hospital and Research Centre
(KFSHRC), Riyadh 11211, Saudi Arabia
- Department
of Biochemistry and Molecular Medicine, College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
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Mastracci TL, Apte M, Amundadottir LT, Alvarsson A, Artandi S, Bellin MD, Bernal-Mizrachi E, Caicedo A, Campbell-Thompson M, Cruz-Monserrate Z, El Ouaamari A, Gaulton KJ, Geisz A, Goodarzi MO, Hara M, Hull-Meichle RL, Kleger A, Klein AP, Kopp JL, Kulkarni RN, Muzumdar MD, Naren AP, Oakes SA, Olesen SS, Phelps EA, Powers AC, Stabler CL, Tirkes T, Whitcomb DC, Yadav D, Yong J, Zaghloul NA, Pandol SJ, Sander M. Integrated Physiology of the Exocrine and Endocrine Compartments in Pancreatic Diseases: Workshop Proceedings. Diabetes 2023; 72:433-448. [PMID: 36940317 PMCID: PMC10033248 DOI: 10.2337/db22-0942] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/29/2022] [Indexed: 03/22/2023]
Abstract
The Integrated Physiology of the Exocrine and Endocrine Compartments in Pancreatic Diseases workshop was a 1.5-day scientific conference at the National Institutes of Health (Bethesda, MD) that engaged clinical and basic science investigators interested in diseases of the pancreas. This report provides a summary of the proceedings from the workshop. The goals of the workshop were to forge connections and identify gaps in knowledge that could guide future research directions. Presentations were segregated into six major theme areas, including 1) pancreas anatomy and physiology, 2) diabetes in the setting of exocrine disease, 3) metabolic influences on the exocrine pancreas, 4) genetic drivers of pancreatic diseases, 5) tools for integrated pancreatic analysis, and 6) implications of exocrine-endocrine cross talk. For each theme, multiple presentations were followed by panel discussions on specific topics relevant to each area of research; these are summarized here. Significantly, the discussions resulted in the identification of research gaps and opportunities for the field to address. In general, it was concluded that as a pancreas research community, we must more thoughtfully integrate our current knowledge of normal physiology as well as the disease mechanisms that underlie endocrine and exocrine disorders so that there is a better understanding of the interplay between these compartments.
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Affiliation(s)
- Teresa L. Mastracci
- Department of Biology, Indiana University–Purdue University Indianapolis, Indianapolis, IN
| | - Minoti Apte
- Faculty of Medicine and Health, University of New South Wales, Sydney, Australia
| | | | - Alexandra Alvarsson
- Diabetes, Obesity, and Metabolism Institute, Mount Sinai Hospital, New York, NY
| | - Steven Artandi
- Department of Internal Medicine, Stanford University, Stanford, CA
| | - Melena D. Bellin
- Departments of Pediatrics and Surgery, University of Minnesota Medical School, Minneapolis, MN
| | - Ernesto Bernal-Mizrachi
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Alejandro Caicedo
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Martha Campbell-Thompson
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Zobeida Cruz-Monserrate
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Kyle J. Gaulton
- Department of Pediatrics, University of California San Diego, La Jolla, CA
| | - Andrea Geisz
- Department of Molecular and Cell Biology, Boston University Henry M. Goldman School of Dental Medicine, Boston, MA
| | - Mark O. Goodarzi
- Division of Endocrinology, Diabetes, and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Manami Hara
- Department of Medicine, The University of Chicago, Chicago, IL
| | - Rebecca L. Hull-Meichle
- Department of Medicine, Division of Metabolism, Endocrinology, and Nutrition, University of Washington, Seattle, WA
| | - Alexander Kleger
- Institute of Molecular Oncology and Stem Cell Biology, Ulm University, Ulm, Germany
| | - Alison P. Klein
- Department of Pathology and Medicine, Johns Hopkins School of Medicine, Baltimore MD
| | - Janel L. Kopp
- Department of Cellular & Physiological Sciences, The University of British Columbia, Vancouver, Canada
| | | | - Mandar D. Muzumdar
- Departments of Genetics and Internal Medicine (Oncology), Yale University School of Medicine, New Haven, CT
| | | | - Scott A. Oakes
- Department of Pathology, The University of Chicago, Chicago, IL
| | - Søren S. Olesen
- Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Edward A. Phelps
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL
| | - Alvin C. Powers
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN
| | - Cherie L. Stabler
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL
| | - Temel Tirkes
- Department of Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN
| | | | - Dhiraj Yadav
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Jing Yong
- Degenerative Diseases Program, Sanford Burnham Prebys Medical Discovery Institute, La Jolla, CA
| | - Norann A. Zaghloul
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - Stephen J. Pandol
- Department of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Maike Sander
- Department of Pediatrics and Department of Cellular and Molecular Medicine, University of California San Diego, La Jolla, CA
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Auxological and Endocrinological Features in Children and Adolescents with Cystic Fibrosis. J Clin Med 2022; 11:jcm11144041. [PMID: 35887806 PMCID: PMC9323690 DOI: 10.3390/jcm11144041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 02/01/2023] Open
Abstract
Cystic fibrosis (CF) is a multisystem autosomal recessive disease caused by mutations that lead to deficient or dysfunctional CF transmembrane conductance regulator (CFTR) proteins. Patients typically present malnutrition resulting from the malabsorption of fundamental nutrients and recurring lung infections, with a progressive worsening of the respiratory function. For these reasons, the clinical management of CF requires a multidisciplinary team. From an endocrinological point of view, patients often present major complications, such as diabetes, bone disease, thyroid disorders, delayed growth and puberty, hypogonadism and infertility, which negatively affect their quality of life and, in some cases, significantly reduce life expectancy. These complications can arise as a direct result of CFTR dysfunction and/or as a consequence of a deterioration in the function of the organs affected. The objective of this review is to analyze all the possible endocrinological complications that can occur in patients with CF by evaluating the most recent papers in the literature.
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Iafusco F, Maione G, Rosanio FM, Mozzillo E, Franzese A, Tinto N. Cystic Fibrosis-Related Diabetes (CFRD): Overview of Associated Genetic Factors. Diagnostics (Basel) 2021; 11:diagnostics11030572. [PMID: 33810109 PMCID: PMC8005125 DOI: 10.3390/diagnostics11030572] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/19/2021] [Indexed: 12/21/2022] Open
Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disease in the Caucasian population and is caused by mutations in the CF transmembrane conductance regulator (CFTR) gene that encodes for a chloride/bicarbonate channel expressed on the membrane of epithelial cells of the airways and of the intestine, as well as in cells with exocrine and endocrine functions. A common nonpulmonary complication of CF is cystic fibrosis-related diabetes (CFRD), a distinct form of diabetes due to insulin insufficiency or malfunction secondary to destruction/derangement of pancreatic betacells, as well as to other factors that affect their function. The prevalence of CFRD increases with age, and 40–50% of CF adults develop the disease. Several proposed hypotheses on how CFRD develops have emerged, including exocrine-driven fibrosis and destruction of the entire pancreas, as well as contrasting theories on the direct or indirect impact of CFTR mutation on islet function. Among contributors to the development of CFRD, in addition to CFTR genotype, there are other genetic factors related and not related to type 2 diabetes. This review presents an overview of the current understanding on genetic factors associated with glucose metabolism abnormalities in CF.
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Affiliation(s)
- Fernanda Iafusco
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
| | - Giovanna Maione
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
| | - Francesco Maria Rosanio
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Enza Mozzillo
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Adriana Franzese
- Regional Center of Pediatric Diabetology, Department of Translational Medical Sciences, Section of Pediatrics, University of Naples “Federico II”, 80131 Naples, Italy; (F.M.R.); (E.M.); (A.F.)
| | - Nadia Tinto
- Department of Molecular Medicine and Medical Biotechnology, University of Naples “Federico II”, 80131 Naples, Italy; (F.I.); (G.M.)
- CEINGE Advanced Biotechnology, 80131 Naples, Italy
- Correspondence:
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Coderre L, Debieche L, Plourde J, Rabasa-Lhoret R, Lesage S. The Potential Causes of Cystic Fibrosis-Related Diabetes. Front Endocrinol (Lausanne) 2021; 12:702823. [PMID: 34394004 PMCID: PMC8361832 DOI: 10.3389/fendo.2021.702823] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/06/2021] [Indexed: 12/16/2022] Open
Abstract
Cystic fibrosis (CF) is a genetic disease caused by mutations in the cystic fibrosis transmembrane conductance regulator gene (CFTR). Cystic fibrosis-related diabetes (CFRD) is the most common comorbidity, affecting more than 50% of adult CF patients. Despite this high prevalence, the etiology of CFRD remains incompletely understood. Studies in young CF children show pancreatic islet disorganization, abnormal glucose tolerance, and delayed first-phase insulin secretion suggesting that islet dysfunction is an early feature of CF. Since insulin-producing pancreatic β-cells express very low levels of CFTR, CFRD likely results from β-cell extrinsic factors. In the vicinity of β-cells, CFTR is expressed in both the exocrine pancreas and the immune system. In the exocrine pancreas, CFTR mutations lead to the obstruction of the pancreatic ductal canal, inflammation, and immune cell infiltration, ultimately causing the destruction of the exocrine pancreas and remodeling of islets. Both inflammation and ductal cells have a direct effect on insulin secretion and could participate in CFRD development. CFTR mutations are also associated with inflammatory responses and excessive cytokine production by various immune cells, which infiltrate the pancreas and exert a negative impact on insulin secretion, causing dysregulation of glucose homeostasis in CF adults. In addition, the function of macrophages in shaping pancreatic islet development may be impaired by CFTR mutations, further contributing to the pancreatic islet structural defects as well as impaired first-phase insulin secretion observed in very young children. This review discusses the different factors that may contribute to CFRD.
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Affiliation(s)
- Lise Coderre
- Immunology-Oncology Section, Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada
| | - Lyna Debieche
- Immunology-Oncology Section, Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada
- Département de médecine, Université de Montréal, Montréal, QC, Canada
| | - Joëlle Plourde
- Immunology-Oncology Section, Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada
- Département de médecine, Université de Montréal, Montréal, QC, Canada
| | - Rémi Rabasa-Lhoret
- Division of Cardiovascular and Metabolic Diseases, Institut de recherche clinique de Montréal, Montréal, QC, Canada
- Département de nutrition, Université de Montréal, Montréal, QC, Canada
- Cystic Fibrosis Clinic, Centre Hospitalier de l’Université de Montréal (CHUM), Montréal, QC, Canada
| | - Sylvie Lesage
- Immunology-Oncology Section, Maisonneuve-Rosemont Hospital Research Center, Montréal, QC, Canada
- Département de microbiologie, infectiologie et immunologie, Université de Montréal, Montréal, QC, Canada
- *Correspondence: Sylvie Lesage,
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Acute hyperosmolar hyperglycaemic state in cystic fibrosis-related diabetes caused by glucocorticoid and itraconazole interaction. J Cyst Fibros 2020; 20:330-332. [PMID: 32928702 DOI: 10.1016/j.jcf.2020.08.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 07/12/2020] [Accepted: 08/29/2020] [Indexed: 11/23/2022]
Abstract
Hyperosmolar hyperglycaemic state (HHS) has not previously been reported in cystic fibrosis-related diabetes (CFRD). We report the case of a 15-year old boy with stable CFRD who developed acute HHS after treatment with glucocorticoids and itraconazole for presumed allergic broncho-pulmonary aspergillosis (ABPA). This case highlights the dangerous and preventable combination of high glucose intake, glucocorticoids and itraconazole inhibition of CYP3A4 (with resultant glucocorticoid accumulation) that can result in a state of life- threatening HHS in an adolescent with previously stable CFRD.
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Kawasaki E, Oikawa Y, Okada A, Kanatsuna N, Kawamura T, Kikuchi T, Terasaki J, Miura J, Itoh Y, Hanafusa T. Different interaction of onset age and duration of type 1 diabetes on the dynamics of autoantibodies to insulinoma-associated antigen-2 and zinc transporter 8. J Diabetes Investig 2020; 12:510-515. [PMID: 32696593 PMCID: PMC8015838 DOI: 10.1111/jdi.13370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/22/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022] Open
Abstract
Aims/Introduction This study aimed to investigate the dynamics associated with autoantibodies to insulinoma‐associated antigen‐2 (IA‐2A) and zinc transporter 8 (ZnT8A) relating to the onset age and disease duration in patients with type 1 diabetes. Methods Using bridging‐type enzyme‐linked immunosorbent assay, IA‐2A, ZnT8A and glutamic acid decarboxylase autoantibodies were evaluated in 269 patients with type 1 diabetes (median onset age 18.2 years, range 0.8–86 years; median diabetes duration 7 years, range 0–58 years). We then compared the prevalence of these autoantibodies among the different age groups, along with the duration of diabetes using the Cochran–Armitage trend test and multivariate logistic regression analysis. Results The prevalence of IA‐2A, ZnT8A and glutamic acid decarboxylase autoantibodies in patients with duration of ≤3 years was 41.1, 36.7 and 72.2%, respectively, with 80.0% expressing one or more of these autoantibodies. This prevalence declined according to the disease duration (P < 0.005). Both IA‐2A and ZnT8A were more frequently observed in younger patients, whereas glutamic acid decarboxylase autoantibodies was more common in older patients. Multivariate logistic regression analysis showed that there was a significant interaction between the onset age and duration of diabetes in patients diagnosed when aged ≤10 years regarding all anti‐islet autoantibodies (P < 0.05). However, for patients diagnosed in the middle tertile (aged 11–30 years), the interaction was significant only for ZnT8A, and for those with late‐onset diabetes (aged ≥31 years) only for IA‐2A. Conclusions The current study showed that the rate of disappearance of anti‐islet autoantibodies is faster in patients aged ≤10 years, and that even though both proteins are localized in the insulin granule membrane, humoral autoimmunity to IA‐2 and ZnT8 differs according to the age of onset.
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Affiliation(s)
| | - Yoichi Oikawa
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo, Japan.,Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama, Japan
| | | | - Norio Kanatsuna
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki, Japan
| | - Tomoyuki Kawamura
- Department of Pediatrics, Osaka City University Graduate School of Medicine, Osaka, Japan
| | | | - Jungo Terasaki
- Department of Internal Medicine (I), Osaka Medical College, Takatsuki, Japan
| | - Junnosuke Miura
- Diabetes Center, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Lam ATN, Aksit MA, Vecchio-Pagan B, Shelton CA, Osorio DL, Anzmann AF, Goff LA, Whitcomb DC, Blackman SM, Cutting GR. Increased expression of anion transporter SLC26A9 delays diabetes onset in cystic fibrosis. J Clin Invest 2020; 130:272-286. [PMID: 31581148 DOI: 10.1172/jci129833] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/25/2019] [Indexed: 12/16/2022] Open
Abstract
Diabetes is a common complication of cystic fibrosis (CF) that affects approximately 20% of adolescents and 40%-50% of adults with CF. The age at onset of CF-related diabetes (CFRD) (marked by clinical diagnosis and treatment initiation) is an important measure of the disease process. DNA variants associated with age at onset of CFRD reside in and near SLC26A9. Deep sequencing of the SLC26A9 gene in 762 individuals with CF revealed that 2 common DNA haplotypes formed by the risk variants account for the association with diabetes. Single-cell RNA sequencing (scRNA-Seq) indicated that SLC26A9 is predominantly expressed in pancreatic ductal cells and frequently coexpressed with CF transmembrane conductance regulator (CFTR) along with transcription factors that have binding sites 5' of SLC26A9. These findings were replicated upon reanalysis of scRNA-Seq data from 4 independent studies. DNA fragments derived from the 5' region of SLC26A9-bearing variants from the low-risk haplotype generated 12%-20% higher levels of expression in PANC-1 and CFPAC-1 cells compared with the high- risk haplotype. Taken together, our findings indicate that an increase in SLC26A9 expression in ductal cells of the pancreas delays the age at onset of diabetes, suggesting a CFTR-agnostic treatment for a major complication of CF.
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Affiliation(s)
- Anh-Thu N Lam
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melis A Aksit
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Briana Vecchio-Pagan
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Applied Physics Laboratory, Johns Hopkins University, Laurel, Maryland, USA
| | - Celeste A Shelton
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Ariel Precision Medicine, Pittsburgh, Pennsylvania, USA
| | - Derek L Osorio
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Arianna F Anzmann
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Loyal A Goff
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | - Scott M Blackman
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Garry R Cutting
- McKusick-Nathans Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Aksit MA, Pace RG, Vecchio-Pagán B, Ling H, Rommens JM, Boelle PY, Guillot L, Raraigh KS, Pugh E, Zhang P, Strug LJ, Drumm ML, Knowles MR, Cutting GR, Corvol H, Blackman SM. Genetic Modifiers of Cystic Fibrosis-Related Diabetes Have Extensive Overlap With Type 2 Diabetes and Related Traits. J Clin Endocrinol Metab 2020; 105:5599821. [PMID: 31697830 PMCID: PMC7236628 DOI: 10.1210/clinem/dgz102] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/02/2019] [Indexed: 02/08/2023]
Abstract
CONTEXT Individuals with cystic fibrosis (CF) develop a distinct form of diabetes characterized by β-cell dysfunction and islet amyloid accumulation similar to type 2 diabetes (T2D), but generally have normal insulin sensitivity. CF-related diabetes (CFRD) risk is determined by both CFTR, the gene responsible for CF, and other genetic variants. OBJECTIVE To identify genetic modifiers of CFRD and determine the genetic overlap with other types of diabetes. DESIGN AND PATIENTS A genome-wide association study was conducted for CFRD onset on 5740 individuals with CF. Weighted polygenic risk scores (PRSs) for type 1 diabetes (T1D), T2D, and diabetes endophenotypes were tested for association with CFRD. RESULTS Genome-wide significance was obtained for variants at a novel locus (PTMA) and 2 known CFRD genetic modifiers (TCF7L2 and SLC26A9). PTMA and SLC26A9 variants were CF-specific; TCF7L2 variants also associated with T2D. CFRD was strongly associated with PRSs for T2D, insulin secretion, postchallenge glucose concentration, and fasting plasma glucose, and less strongly with T1D PRSs. CFRD was inconsistently associated with PRSs for insulin sensitivity and was not associated with a PRS for islet autoimmunity. A CFRD PRS comprising variants selected from these PRSs (with a false discovery rate < 0.1) and the genome-wide significant variants was associated with CFRD in a replication population. CONCLUSIONS CFRD and T2D have more etiologic and mechanistic overlap than previously known, aligning along pathways involving β-cell function rather than insulin sensitivity. Two CFRD risk loci are unrelated to T2D and may affect multiple aspects of CF. An 18-variant PRS stratifies risk of CFRD in an independent population.
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Affiliation(s)
- Melis A Aksit
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rhonda G Pace
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | | | - Hua Ling
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Johanna M Rommens
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Pierre-Yves Boelle
- Sorbonne Université, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique, iPLESP, AP-HP, Hôpital Saint-Antoine, Paris, France
| | - Loic Guillot
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Karen S Raraigh
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elizabeth Pugh
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Peng Zhang
- Center for Inherited Disease Research, Johns Hopkins University, Baltimore, Maryland
| | - Lisa J Strug
- The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | | | - Michael R Knowles
- Marsico Lung Institute/UNC CF Research Center, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Garry R Cutting
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Harriet Corvol
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, Paris, France
| | - Scott M Blackman
- McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Correspondence and Reprint Requests: Scott M. Blackman, McKusick-Nathans Institute of the Department of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205. E-mail:
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Granados A, Chan CL, Ode KL, Moheet A, Moran A, Holl R. Cystic fibrosis related diabetes: Pathophysiology, screening and diagnosis. J Cyst Fibros 2019; 18 Suppl 2:S3-S9. [DOI: 10.1016/j.jcf.2019.08.016] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 08/14/2019] [Accepted: 08/15/2019] [Indexed: 12/12/2022]
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Moran A, Pillay K, Becker D, Granados A, Hameed S, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2018: Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2018; 19 Suppl 27:64-74. [PMID: 30094886 DOI: 10.1111/pedi.12732] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 07/13/2018] [Indexed: 11/29/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Dorothy Becker
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Andrea Granados
- Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Shihab Hameed
- Department of Endocrinology, Sydney Children's Hospital, Randwick, NSW, Australia.,School of Women's and Children's Health, University of New South Wales, Kensington, NSW, Australia
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
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12
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Kim GJ, Merjaneh L. Pediatric Case Series of Cystic Fibrosis, Diabetes, and Islet Cell Autoimmunity. Clin Diabetes 2018; 36:331-333. [PMID: 30364027 PMCID: PMC6187956 DOI: 10.2337/cd18-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Grace J Kim
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, WA
| | - Lina Merjaneh
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, WA
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13
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Cory M, Moin ASM, Moran A, Rizza RA, Butler PC, Dhawan S, Butler AE. An Increase in Chromogranin A-Positive, Hormone-Negative Endocrine Cells in Pancreas in Cystic Fibrosis. J Endocr Soc 2018; 2:1058-1066. [PMID: 30202828 PMCID: PMC6125715 DOI: 10.1210/js.2018-00143] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/08/2018] [Indexed: 01/09/2023] Open
Abstract
We sought to establish whether an increase in chromogranin A-positive, hormone-negative (CPHN) endocrine cells occurs in the pancreas of patients with cystic fibrosis (CF), as potential evidence of neogenesis. Pancreata were obtained at autopsy from nondiabetic patients with CF (n = 12) and age-matched nondiabetic control subject (CS) individuals without CF (n = 12). In addition, pancreas from three diabetic patients with CF was obtained. Pancreas sections were stained for chromogranin A, insulin, and a cocktail of glucagon, somatostatin, pancreatic polypeptide, and ghrelin and evaluated for the frequency of CPHN cells. There was a higher frequency of CPHN cells in islets of the patients with CF compared with the CS group. Moreover, CPHN cells occurring as single cells or clusters scattered in the exocrine pancreas were also more frequent in patients with CF. The increased frequency of CPHN cells in pancreas of patients with CF may indicate an attempt at endocrine cell regeneration.
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Affiliation(s)
- Megan Cory
- Larry L. Hillblom Islet Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Abu Saleh Md Moin
- Larry L. Hillblom Islet Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Robert A Rizza
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Peter C Butler
- Larry L. Hillblom Islet Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Sangeeta Dhawan
- Diabetes and Metabolism Research Institute, City of Hope, Duarte, California
| | - Alexandra E Butler
- Larry L. Hillblom Islet Research Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
- Life Sciences and Research Division, Anti-Doping Laboratory, Doha, Qatar
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14
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Abstract
Cystic fibrosis (CF) is the most common autosomal recessive disorder in Caucasian populations. Individuals with CF have seen significant increases in life expectancy in the last 60 years. As a result, previously rare complications are now coming to light. The most common of these is cystic fibrosis-related diabetes (CFRD), which affects 40-50% of CF adults. CFRD significantly impacts the pulmonary function and longevity of CF patients, yet a lack of consensus on the best methods to diagnose and treat CFRD remains. We begin by reviewing our understanding of the pathogenesis of CFRD, as emerging evidence shows the cystic fibrosis transmembrane conductance regulator (CFTR) also has important roles in the release of insulin and glucagon and in the protection of β cells from oxidative stress. We then discuss how current recommended methods of CFRD diagnosis are not appropriate, as continuous glucose monitoring becomes more effective, practical, and cost-effective. Finally, we evaluate emerging treatments which have narrowed the mortality gap within the CF patient group. In the future, pharmacological potentiators and correctors directly targeting CFTR show huge promise for both CFRD and the wider CF patient groups.
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Affiliation(s)
- Kayani Kayani
- Faculty of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Raihan Mohammed
- Faculty of Medicine, University of Cambridge, Cambridge, United Kingdom
- *Correspondence: Raihan Mohammed,
| | - Hasan Mohiaddin
- Faculty of Medicine, Imperial College London, London, United Kingdom
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15
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Bogdani M, Blackman SM, Ridaura C, Bellocq JP, Powers AC, Aguilar-Bryan L. Structural abnormalities in islets from very young children with cystic fibrosis may contribute to cystic fibrosis-related diabetes. Sci Rep 2017; 7:17231. [PMID: 29222447 PMCID: PMC5722914 DOI: 10.1038/s41598-017-17404-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/22/2017] [Indexed: 01/18/2023] Open
Abstract
Cystic fibrosis (CF)-related diabetes (CFRD) is thought to result from beta-cell injury due in part to pancreas exocrine damage and lipofibrosis. CFRD pancreata exhibit reduced islet density and altered cellular composition. To investigate a possible etiology, we tested the hypothesis that such changes are present in CF pancreata before the development of lipofibrosis. We evaluated pancreas and islet morphology in tissues from very young CF children (<4 years of age), and adult patients with CF and CFRD. The relative number of beta-cells in young CF tissues was reduced by 50% or more when compared to age-matched controls. Furthermore, young CF tissues displayed significantly smaller insulin-positive areas, lower proportion of beta-cells positive for the proliferation marker Ki67 or the ductal marker CK19 vs. control subjects, and islet inflammatory cell infiltrates, independently of the severity of the exocrine lesion and in the absence of amyloid deposits. CFRD pancreata exhibited greater islet injury with further reduction in islet density, decreased relative beta-cell number, and presence of amyloid deposits. Together, these results strongly suggest that an early deficiency in beta-cell number in infants with CF may contribute to the development of glucose intolerance in the CF pediatric population, and to CFRD, later in life.
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Affiliation(s)
| | - Scott M Blackman
- Division of Pediatric Endocrinology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cecilia Ridaura
- Department of Pathology, Instituto Nacional de Pediatría, Mexico City, Mexico
| | | | - Alvin C Powers
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, and Department of Molecular Physiology and Biophysics, Vanderbilt University School of Medicine, and VA Tennessee Valley Healthcare System, Nashville, TN, USA
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16
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Konrad K, Kapellen T, Lilienthal E, Prinz N, Bauer M, Thon A, Rietschel E, Wiemann D, Holl RW. Does β-Cell Autoimmunity Play a Role in Cystic Fibrosis-Related Diabetes? Analysis Based on the German/Austrian Diabetes Patienten Verlaufsdokumentation Registry. Diabetes Care 2016; 39:1338-44. [PMID: 27271187 DOI: 10.2337/dc16-0020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 05/03/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Research on β-cell autoimmunity in cystic fibrosis (CF)-related diabetes (CFRD) is still rare. We aimed to analyze the frequency of β-cell autoimmunity and the influence on age at diabetes onset, insulin requirement, type of insulin therapy, and hypoglycemic or ketoacidotic events in patients with CFRD compared with antibody-negative patients with CFRD in the Diabetes Patienten Verlaufsdokumentation (DPV) registry. RESEARCH DESIGN AND METHODS We analyzed data of 837 patients with CFRD in the German/Austrian DPV database by multivariable mixed-regression modeling. RESULTS In our cohort, 8.5% of patients with CFRD (n = 72) were found to be β-cell antibody positive. There was a female preponderance in this patient group: 65.3 vs. 57.6%. Diabetes onset (median [interquartile range]) was earlier (14.00 [10.15-15.90] vs. 16.10 [13.50-21.20] years; P < 0.005), and insulin dose/kg body weight was higher (0.95 [0.61-1.15] vs. 0.67 [0.33-1.04] IU/kg; P < 0.05). There were also differences in the type of insulin treatment. Insulin pump therapy was used significantly more often in patients with CFRD with β-cell autoimmunity (18.2 vs. 6.4%; P < 0.05). The differences for multiple daily injections (ICT) and conventional therapy (CT) were not significant (ICT: 67.7 vs. 79.0%; CT: 15.2 vs. 14.6). Oral antidiabetic agents were rarely used in both groups. Rate of severe hypoglycemia with coma and rate of ketoacidosis were higher in antibody-positive patients (hypoglycemia with coma: 8.0 vs. 1.4, P < 0.05; ketoacidosis: 9.3 vs. 0.9, P < 0.05). CONCLUSIONS Presence of β-cell autoantibodies in our cohort of patients with CFRD (8.5%) appeared to be greater than in the general population and was associated with female sex, earlier onset of diabetes, and higher insulin requirement. Insulin pump therapy was used significantly more often in patients with β-cell antibodies. Severe hypoglycemia and ketoacidosis were significantly more frequent in CFRD with β-cell autoimmunity compared with β-cell antibody-negative patients with CFRD.
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Affiliation(s)
- Katja Konrad
- Department of Pediatric and Adolescent Medicine, University of Cologne, Cologne, Germany Department of Pediatric and Adolescent Medicine, Elisabeth-Hospital Essen, Essen, Germany
| | - Thomas Kapellen
- Department of Pediatrics, University of Leipzig, Leipzig, Germany
| | | | - Nicole Prinz
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Maria Bauer
- Department of Pediatric and Adolescent Medicine, University of Linz, Linz, Austria
| | - Angelika Thon
- Department of Pediatrics, Hannover Medical School, Hannover, Germany
| | - Ernst Rietschel
- Department of Pediatric and Adolescent Medicine, University of Cologne, Cologne, Germany
| | - Dagobert Wiemann
- Department of Pediatrics, University of Magdeburg, Magdeburg, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany German Center for Diabetes Research, München-Neuherberg, Germany
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17
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Moran A, Pillay K, Becker DJ, Acerini CL. ISPAD Clinical Practice Consensus Guidelines 2014. Management of cystic fibrosis-related diabetes in children and adolescents. Pediatr Diabetes 2014; 15 Suppl 20:65-76. [PMID: 25182308 DOI: 10.1111/pedi.12178] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2014] [Accepted: 06/11/2014] [Indexed: 12/17/2022] Open
Affiliation(s)
- Antoinette Moran
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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18
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Abstract
Improved life expectancy in cystic fibrosis (CF) has led to an expanding population of adults with CF, now representing almost 50 % of the total CF population. This creates new challenges from long-term complications such as diabetes mellitus (DM), a condition that is present in 40 %-50 % of adults with CF. Cystic fibrosis-related diabetes (CFRD) results from a primary defect of insulin deficiency and although sharing features with type 1 (DM1) and type 2 diabetes (DM2), it is a clinically distinct condition. Progression to diabetes is associated with poorer CF clinical outcomes and increased mortality. CFRD is not associated with an increased risk of cardiovascular disease and the prevalence of microvascular complications is lower than DM1 or DM2. Rather, the primary goal of insulin therapy is the preservation of lung function and optimization of nutritional status. There is increasing evidence that appropriate screening and early intervention with insulin can reverse weight loss and improve pulmonary function. This approach may include targeting postprandial hyperglycemia not detected by standard diagnostic tests such as the oral glucose tolerance test. Further clinical research is required to guide when and how much to intervene in patients who are already dealing with the burden of one chronic illness.
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Affiliation(s)
- Donal O'Shea
- Department of Endocrinology, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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19
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Middleton PG, Wagenaar M, Matson AG, Craig ME, Holmes-Walker DJ, Katz T, Hameed S. Australian standards of care for cystic fibrosis-related diabetes. Respirology 2013; 19:185-192. [DOI: 10.1111/resp.12227] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 10/08/2013] [Accepted: 11/12/2013] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | - Maria E. Craig
- Sydney Children's Hospital Network (Westmead); Sydney New South Wales Australia
| | | | - Tamarah Katz
- Sydney Children's Hospital Network; Sydney New South Wales Australia
| | - Shihab Hameed
- Sydney Children's Hospital Network; Sydney New South Wales Australia
- School of Women's and Children's Health; Faculty of Medicine; University of New South Wales; Sydney New South Wales Australia
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20
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Kelly A, Moran A. Update on cystic fibrosis-related diabetes. J Cyst Fibros 2013; 12:318-31. [PMID: 23562217 DOI: 10.1016/j.jcf.2013.02.008] [Citation(s) in RCA: 142] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 02/27/2013] [Accepted: 02/28/2013] [Indexed: 11/28/2022]
Abstract
Diabetes mellitus has emerged as a common comorbidity in cystic fibrosis and is considered a clinical entity (cystic fibrosis-related diabetes, CFRD) distinct from that of type 1 diabetes (T1DM) and type 2 diabetes (T2DM). The relevance of this diagnosis extends not only from its imposition of additional medical burden but its association with worse health outcomes in individuals with CF. This paper will review the 2010 U.S. and other international guidelines for screening and treating CFRD. It will highlight newer data regarding early glucose and insulin secretion defects, mechanisms linking CFRD to worse outcomes, and recent advances in T2DM that may provide insights for CFRD; insulin secretion will be reviewed as background for these recent developments.
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Affiliation(s)
- Andrea Kelly
- Division of Endocrinology & Diabetes, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA 19104, USA.
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21
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Bizzarri C, Giannone G, Benevento D, Montemitro E, Alghisi F, Cappa M, Lucidi V. ZnT8 antibodies in patients with cystic fibrosis: an expression of secondary beta-cell damage? J Cyst Fibros 2013; 12:803-5. [PMID: 23535193 DOI: 10.1016/j.jcf.2013.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 12/23/2012] [Accepted: 03/04/2013] [Indexed: 01/10/2023]
Abstract
Cystic Fibrosis-Related Diabetes (CFRD) is caused by a severe insulin deficiency with associated different degrees of insulin resistance. Data concerning the potential impact of autoimmunity are conflicting. Ninety subjects with cystic fibrosis (CF) were tested for glucose tolerance and autoantibodies against insulin (IAA), glutamic acid decarboxylase (GADA), protein tyrosine phosphatase (IA2) and zinc transporter 8 (Znt8A). Eighty-three subjects showed a normal glucose tolerance (92.2%), 6 subjects (6.6%) impaired glucose tolerance and 1 subject (1.1%) newly diagnosed CFRD. Four subjects were found positive for both IAA and GADA (4.4%), one subject (1.1%) for both IA2 and GADA, and one subject (1.1%) for isolated GADA. Three subjects (3.3%) showed isolated ZnT8A positivity. ZnT8A positivity in CF patients is uncommon and not associated with other autoantibodies. ZnT8A may not represent a specific indicator of a primary autoimmune beta-cell destruction, but possibly the expression of a secondary damage of the pancreatic islets with autoantigen release.
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Affiliation(s)
- Carla Bizzarri
- Unit of Endocrinology and Diabetes, Bambino Gesù Children's Hospital, Rome, Italy.
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