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Stone SI, Balasubramanyam A, Posey JE. Atypical Diabetes: What Have We Learned and What Does the Future Hold? Diabetes Care 2024; 47:770-781. [PMID: 38329838 PMCID: PMC11043229 DOI: 10.2337/dci23-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/21/2023] [Indexed: 02/10/2024]
Abstract
As our understanding of the pathophysiology of diabetes evolves, we increasingly recognize that many patients may have a form of diabetes that does not neatly fit with a diagnosis of either type 1 or type 2 diabetes. The discovery and description of these forms of "atypical diabetes" have led to major contributions to our collective understanding of the basic biology that drives insulin secretion, insulin resistance, and islet autoimmunity. These discoveries now pave the way to a better classification of diabetes based on distinct endotypes. In this review, we highlight the key biological and clinical insights that can be gained from studying known forms of atypical diabetes. Additionally, we provide a framework for identification of patients with atypical diabetes based on their clinical, metabolic, and molecular features. Helpful clinical and genetic resources for evaluating patients suspected of having atypical diabetes are provided. Therefore, appreciating the various endotypes associated with atypical diabetes will enhance diagnostic accuracy and facilitate targeted treatment decisions.
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Affiliation(s)
- Stephen I. Stone
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Jennifer E. Posey
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX
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Kubota-Mishra E, Huang X, Minard CG, Astudillo M, Refaey A, Montes G, Sisley S, Ram N, Winter WE, Naylor RN, Balasubramanyam A, Redondo MJ, Tosur M. High Prevalence of A-β+ Ketosis-Prone Diabetes in Children with Type 2 Diabetes and Diabetic Ketoacidosis at Diagnosis: Evidence from the Rare and Atypical Diabetes Network (RADIANT). Pediatr Diabetes 2024; 2024:5907924. [PMID: 38765897 PMCID: PMC11100136 DOI: 10.1155/2024/5907924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background A-β+ ketosis-prone diabetes (KPD) in adults is characterized by presentation with diabetic ketoacidosis (DKA), negative islet autoantibodies, and preserved β-cell function in persons with a phenotype of obesity-associated type 2 diabetes (T2D). The prevalence of KPD has not been evaluated in children. We investigated children with DKA at "T2D" onset and determined the prevalence and characteristics of pediatric A-β+ KPD within this cohort. Methods We reviewed the records of 716 children with T2D at a large academic hospital and compared clinical characteristics of those with and without DKA at onset. In the latter group, we identified patients with A-β+ KPD using criteria of the Rare and Atypical Diabetes Network (RADIANT) and defined its prevalence and characteristics. Results Mean age at diagnosis was 13.7 ± 2.4 years: 63% female; 59% Hispanic, 29% African American, 9% non-Hispanic White, and 3% other. Fifty-six (7.8%) presented with DKA at diagnosis and lacked islet autoantibodies. Children presenting with DKA were older and had lower C-peptide and higher glucose concentrations than those without DKA. Twenty-five children with DKA (45%) met RADIANT A-β+ KPD criteria. They were predominantly male (64%), African American or Hispanic (96%), with substantial C-peptide (1.3 ± 0.7 ng/mL) at presentation with DKA and excellent long-term glycemic control (HbA1c 6.6% ± 1.9% at follow-up (median 1.3 years postdiagnosis)). Conclusions In children with a clinical phenotype of T2D and DKA at diagnosis, approximately half meet criteria for A-β+ KPD. They manifest the key characteristics of obesity, preserved β-cell function, male predominance, and potential to discontinue insulin therapy, similar to adults with A-β+ KPD.
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Affiliation(s)
- Elizabeth Kubota-Mishra
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Xiaofan Huang
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Marcela Astudillo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | | | - Graciela Montes
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sisley
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - William E. Winter
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Rochelle N. Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Departments of Pediatric and Medicine, University of Chicago, Chicago, IL, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Maria J. Redondo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Mustafa Tosur
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - RADIANT Study Group
- The RADIANT Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, USA
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Osafehinti D, Mulukutla SN, Hampe CS, Gaba R, Ram N, Weedon MN, Oram RA, Balasubramanyam A. Type 1 Diabetes Genetic Risk Score Differentiates Subgroups of Ketosis-Prone Diabetes. Diabetes Care 2023; 46:1778-1782. [PMID: 37506364 PMCID: PMC10516251 DOI: 10.2337/dc23-0622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023]
Abstract
OBJECTIVE To determine whether genetic risk for type 1 diabetes (T1D) differentiates the four Aβ subgroups of ketosis-prone diabetes (KPD), where A+ and A- define the presence or absence of islet autoantibodies and β+ and β- define the presence or absence of β-cell function. RESEARCH DESIGN AND METHODS We compared T1D genetic risk scores (GRS) of patients with KPD across subgroups, race/ethnicity, β-cell function, and glycemia. RESULTS Among 426 patients with KPD (54% Hispanic, 31% African American, 11% White), rank order of GRS was A+β- > A+β+ = A-β- > A-β+. GRS of A+β- KPD was lower than that of a T1D cohort, and GRS of A-β+ KPD was higher than that of a type 2 diabetes cohort. GRS was lowest among African American patients, with a similar distribution across KPD subgroups. CONCLUSIONS T1D genetic risk delineates etiologic differences among KPD subgroups. Patients with A+β- KPD have the highest and those with A-β+ KPD the lowest GRS.
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Affiliation(s)
- Deborah Osafehinti
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | | | - Ruchi Gaba
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Michael N. Weedon
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, and The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Richard A. Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, and The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, U.K
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
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Balasubramanyam A, Redondo MJ, Craigen W, Dai H, Davis A, Desai D, Dussan M, Faruqi J, Gaba R, Gonzalez I, Jhangiani S, Kubota-Mishra E, Liu P, Murdock D, Posey J, Ram N, Sabo A, Sisley S, Tosur M, Venner E, Astudillo M, Cardenas A, Fang MA, Hattery E, Ideouzu A, Jimenez J, Kikani N, Montes G, O’Brien NG, Wong LJ, Goland R, Chung WK, Evans A, Gandica R, Leibel R, Mofford K, Pring J, Evans-Molina C, Anwar F, Monaco G, Neyman A, Saeed Z, Sims E, Spall M, Hernandez-Perez M, Mather K, Moors K, Udler MS, Florez JC, Calverley M, Chen V, Chu K, Cromer S, Deutsch A, Faciebene M, Greaux E, Koren D, Kreienkamp R, Larkin M, Marshall W, Ricevuto P, Sabean A, Thangthaeng N, Han C, Sherwood J, Billings LK, Banerji MA, Bally K, Brown N, Ji B, Soni L, Lee M, Abrams J, Thomas L, Abrams J, Skiwiersky S, Philipson LH, Greeley SAW, Bell G, Banogon S, Desai J, Ehrmann D, Letourneau-Freiberg LR, Naylor RN, Papciak E, Friedman Ross L, Sundaresan M, Bender C, Tian P, Rasouli N, Kashkouli MB, Baker C, Her A, King C, Pyreddy A, Singh V, Barklow J, Farhat N, Lorch R, Odean C, Schleis G, Underkofler C, Pollin TI, Bryan H, Maloney K, Miller R, Newton P, Nikita ME, Nwaba D, Silver K, Tiner J, Whitlatch H, Palmer K, Riley S, Streeten E, Oral EA, Broome D, Dill Gomes A, Foss de Freitas M, Gregg B, Grigoryan S, Imam S, Sonmez Ince M, Neidert A, Richison C, Akinci B, Hench R, Buse J, Armstrong C, Christensen C, Diner J, Fraser R, Fulghum K, Ghorbani T, Kass A, Klein K, Kirkman MS, Hirsch IB, Baran J, Dong X, Kahn SE, Khakpour D, Mandava P, Sameshima L, Kalerus T, Pihoker C, Loots B, Santarelli K, Pascual C, Niswender K, Edwards N, Gregory J, Powers A, Ramirez A, Scott J, Smith J, Urano F, Hughes J, Hurst S, McGill J, Stone S, May J, Krischer JP, Adusumalli R, Albritton B, Aquino A, Bransford P, Cadigan N, Gandolfo L, Garmeson J, Gomes J, Gowing R, Karges C, Kirk C, Muller S, Morissette J, Parikh HM, Perez-Laras F, Remedios CL, Ruiz P, Sulman N, Toth M, Wurmser L, Eberhard C, Fiske S, Hutchinson B, Nekkanti S, Wood R, Florez JC, Alkanaq A, Brandes M, Burtt N, Flannick J, Olorunfemi P, Udler MS, Caulkins L, Wasserfall C, Winter W, Pittman D, Akolkar B, Lee C, Carey DJ, Hood D, Marcovina SM, Newgard CB. The Rare and Atypical Diabetes Network (RADIANT) Study: Design and Early Results. Diabetes Care 2023; 46:1265-1270. [PMID: 37104866 PMCID: PMC10234756 DOI: 10.2337/dc22-2440] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/27/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE The Rare and Atypical Diabetes Network (RADIANT) will perform a study of individuals and, if deemed informative, a study of their family members with uncharacterized forms of diabetes. RESEARCH DESIGN AND METHODS The protocol includes genomic (whole-genome [WGS], RNA, and mitochondrial sequencing), phenotypic (vital signs, biometric measurements, questionnaires, and photography), metabolomics, and metabolic assessments. RESULTS Among 122 with WGS results of 878 enrolled individuals, a likely pathogenic variant in a known diabetes monogenic gene was found in 3 (2.5%), and six new monogenic variants have been identified in the SMAD5, PTPMT1, INS, NFKB1, IGF1R, and PAX6 genes. Frequent phenotypic clusters are lean type 2 diabetes, autoantibody-negative and insulin-deficient diabetes, lipodystrophic diabetes, and new forms of possible monogenic or oligogenic diabetes. CONCLUSIONS The analyses will lead to improved means of atypical diabetes identification. Genetic sequencing can identify new variants, and metabolomics and transcriptomics analysis can identify novel mechanisms and biomarkers for atypical disease.
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Parikh HM, Remedios CL, Hampe CS, Balasubramanyam A, Fisher-Hoch SP, Choi YJ, Patel S, McCormick JB, Redondo MJ, Krischer JP. Data Mining Framework for Discovering and Clustering Phenotypes of Atypical Diabetes. J Clin Endocrinol Metab 2023; 108:834-846. [PMID: 36314086 DOI: 10.1210/clinem/dgac632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/24/2022] [Indexed: 12/23/2022]
Abstract
CONTEXT Some individuals present with forms of diabetes that are "atypical" (AD), which do not conform to typical features of either type 1 diabetes (T1D) or type 2 diabetes (T2D). These forms of AD display a range of phenotypic characteristics that likely reflect different endotypes based on unique etiologies or pathogenic processes. OBJECTIVE To develop an analytical approach to identify and cluster phenotypes of AD. METHODS We developed Discover Atypical Diabetes (DiscoverAD), a data mining framework, to identify and cluster phenotypes of AD. DiscoverAD was trained against characteristics of manually classified patients with AD among 278 adults with diabetes within the Cameron County Hispanic Cohort (CCHC) (Study A). We then tested DiscoverAD in a separate population of 758 multiethnic children with T1D within the Texas Children's Hospital Registry for New-Onset Type 1 Diabetes (TCHRNO-1) (Study B). RESULTS We identified an AD frequency of 11.5% in the CCHC (Study A) and 5.3% in the pediatric TCHRNO-1 (Study B). Cluster analysis identified 4 distinct groups of AD in Study A: cluster 1, positive for the 65 kDa glutamate decarboxylase autoantibody (GAD65Ab), adult-onset, long disease duration, preserved beta-cell function, no insulin treatment; cluster 2, GAD65Ab negative, diagnosed at age ≤21 years; cluster 3, GAD65Ab negative, adult-onset, poor beta-cell function, lacking central obesity; cluster 4, diabetic ketoacidosis (DKA)-prone participants lacking a typical T1D phenotype. Applying DiscoverAD to the pediatric patients with T1D in Study B revealed 2 distinct groups of AD: cluster 1, autoantibody negative, poor beta-cell function, lower body mass index (BMI); cluster 2, autoantibody positive, higher BMI, higher incidence of DKA. CONCLUSION DiscoverAD can be adapted to different datasets to identify and define phenotypes of participants with AD based on available clinical variables.
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Affiliation(s)
- Hemang M Parikh
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Cassandra L Remedios
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
| | - Christiane S Hampe
- Department of Medicine, University of Washington, Seattle, WA 98195, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
| | - Susan P Fisher-Hoch
- The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, TX 78520, USA
| | - Ye Ji Choi
- The University of Texas Rio Grande Valley School of Medicine, Edinburg Campus, Edinburg, TX 78539, USA
| | - Sanjeet Patel
- The Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA
| | - Joseph B McCormick
- The University of Texas Health Science Center at Houston School of Public Health, Brownsville Regional Campus, Brownsville, TX 78520, USA
| | - Maria J Redondo
- Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA
| | - Jeffrey P Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA
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Kikani N, Balasubramanyam A. Remission in Ketosis-Prone Diabetes. Endocrinol Metab Clin North Am 2023; 52:165-174. [PMID: 36754492 DOI: 10.1016/j.ecl.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and biomarkers of autoimmune T1D. The A-β+ subgroup of KPD provides unique insight into the concept of "remission" since these patients have substantial preservation of beta-cell function permitting the discontinuation of insulin therapy, despite initial presentation with DKA. Measurements of C-peptide levels are essential to predict remission and guide potential insulin withdrawal. Further studies into predictors of remission and relapse can help us guide patients with A-β+ KPD toward remission and develop targeted treatments for this form of atypical diabetes.
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Affiliation(s)
- Nupur Kikani
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Unit 1461, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology, and Metabolism, Baylor College of Medicine, BCM 179A, One Baylor Plaza, Houston, TX 77030, USA.
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A patient with ketosis-prone type 2 diabetes showing nearly normalized glucose tolerance after recovery from severe diabetic ketoacidosis. Diabetol Int 2022; 14:109-113. [PMID: 36636160 PMCID: PMC9829925 DOI: 10.1007/s13340-022-00599-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 07/20/2022] [Indexed: 01/16/2023]
Abstract
Unprovoked A-β+ ketosis-prone type 2 diabetes (KPD) is characterized by the sudden onset of diabetic ketosis/ketoacidosis (DK/DKA) without precipitating factors, negative anti-islet autoantibodies ("A- "), and preservation of β-cell function ("β+ ") after recovery from DKA using insulin therapy. However, there have been few reports on glucose tolerance after recovery. We present a case of KPD with nearly normalized glucose tolerance after recovery from severe DKA. A 41-year-old obese woman first presented with unprovoked severe DKA, i.e., ketonuria, plasma glucose 570 mg/dL, pH 7.18, and HCO3 - 5.2 mmol/L, without anti-islet autoantibodies. She achieved insulin-free glycemic remission after recovery from DKA, leading to the diagnosis of KPD. Thereafter, 75 g oral glucose tolerance test showed impaired fasting glucose and time-in-range using intermittently scanned continuous glucose monitoring was 97% without medication. These findings suggest that, despite the initial severe DKA, some patients with KPD might achieve normalized glucose tolerance after recovery. The similar onset patterns of DKA necessitates appropriately distinguishing KPD from acute-onset type 1B (idiopathic) diabetes. Supplementary Information The online version contains supplementary material available at 10.1007/s13340-022-00599-6.
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Satomura A, Oikawa Y, Haisa A, Suzuki S, Nakanishi S, Katsuki T, Shimada A. Clinical Significance of Insulin Peptide-specific Interferon-γ-related Immune Responses in Ketosis-prone Type 2 Diabetes. J Clin Endocrinol Metab 2022; 107:e2124-e2132. [PMID: 34922394 DOI: 10.1210/clinem/dgab912] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Unprovoked A-β+ ketosis-prone type 2 diabetes (KPD) is characterized by the sudden onset of diabetic ketosis/ketoacidosis (DK/DKA) without precipitating factors, negative anti-islet autoantibodies ("A-"), and preservation of β-cell function ("β+") after recovery from DKA. Although this phenotype often appears with acute hyperglycemia and DK/DKA just like acute-onset type 1 diabetes (AT1D), the involvement of anti-islet immune responses remains unknown. OBJECTIVE We sought to clarify the immunological role of insulin-associated molecules in unprovoked A-β+ KPD. METHODS In this cross-sectional study, blood samples from 75 participants (42 with AT1D and 33 with KPD) were evaluated for interferon (IFN)-γ-secreting peripheral blood mononuclear cells (PBMCs) reactive to 4 insulin B-chain amino acid 9-23-related peptides (B:9-23rPep) using an enzyme-linked immunospot (ELISpot) assay. RESULTS Overall, 36.4% (12/33) of KPD participants showed positive IFN-γ ELISpot assay results; the positivity rate in KPD was similar to that in AT1D (38.1%; 16/42) and statistically significantly higher than the previously reported rate in type 2 diabetes (8%; 2/25; P < .0167). Moreover, B:9-23rPep-specific IFN-γ-producing PBMC frequency was negatively correlated with age and ad lib serum C-peptide levels in all KPD participants and positively correlated with glycated hemoglobin A1c level in KPD participants with positive IFN-γ ELISpot results. CONCLUSION These findings suggest the involvement of B:9-23rPep-specific IFN-γ-related immunoreactivity in the pathophysiology of some unprovoked A-β+ KPD. Moreover, increased immunoreactivity may reflect transiently decreased β-cell function and increased disease activity at the onset of DK/DKA, thereby playing a key role in DK/DKA development in this KPD phenotype.
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Affiliation(s)
- Atsushi Satomura
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Akifumi Haisa
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Seiya Suzuki
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Shunpei Nakanishi
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
| | - Takeshi Katsuki
- Department of Internal Medicine, Tokyo Saiseikai Central Hospital, Tokyo 108-0073, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, School of Medicine, Saitama Medical University, Saitama 350-0495, Japan
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Gaba R, Balasubramanyam A. Covid-19: A new cause of "provoked" A-β+ Ketosis-Prone Diabetes. J Diabetes Complications 2022; 36:108147. [PMID: 35153127 PMCID: PMC8820105 DOI: 10.1016/j.jdiacomp.2022.108147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/02/2022] [Indexed: 01/08/2023]
Affiliation(s)
- Ruchi Gaba
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, United States of America.
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, United States of America.
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Gupta RD, Atri A, Mondal S, Bhattacharjee A, Garai R, Hazra AK, Choudhury B, Dutta DS, Lodh M, Ganguly A. Characterizing progressive beta-cell recovery after new-onset DKA in COVID-19 provoked A-β+ KPD (ketosis-prone diabetes): A prospective study from Eastern India. J Diabetes Complications 2022; 36:108100. [PMID: 34916147 PMCID: PMC8656268 DOI: 10.1016/j.jdiacomp.2021.108100] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/25/2021] [Accepted: 11/27/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recent literature suggests a bi-directional relationship between COVID-19 infection and diabetes mellitus, with an increasing number of previously normoglycemic adults with COVID-19 being admitted with new-onset diabetic ketoacidosis (DKA). However, the possibility of COVID-19 being a potential trigger for A-β + ketosis-prone diabetes (KPD) in these patients needs elucidation. Our study aimed at analyzing such a cohort of patients and determining their natural course of β-cell recovery on serial follow-up. METHODS After initial screening, n = 42 previously non-diabetic patients with new-onset DKA and RT-PCR positive COVID-19, were included in our ten-month follow-up study. Of these, n = 22 were negative (suspected A-β + KPD) and n = 20 were positive (Type 1A DM) for autoantibodies (GAD/IA-2/ZnT8). Subsequently, n = 19 suspected KPD and n = 18 Type 1A DM patients were followed-up over ten months with serial assessments of clinical, biochemical and β-cell secretion. Amongst the former, n = 15 (79%) patients achieved insulin independence, while n = 4 (21%) continued to require insulin at ten-months follow-up. RESULTS On comparison, the suspected KPD patients showed significantly greater BMI, age, Hba1c, IL-6 and worse DKA parameters at presentation. Serial C-peptide estimations demonstrated significant β-cell recovery in KPD group, with complete recovery seen in the 15 patients who became insulin independent on follow-up. Younger age, lower BMI, initial severity of DKA and inflammation (IL-6 levels), along-with reduced 25-hydroxy-Vitamin-D levels were associated with poorer recovery of β-cell secretion at ten-month follow-up amongst the KPD patients, CONCLUSIONS: This is the first prospective study to demonstrate progressive recovery of β-cell secretion in new-onset A-β + KPD provoked by COVID-19 infection in Indian adults, with a distinctly different profile from Type 1A DM. Given their significant potential for β-cell recovery, meticulous follow-up involving C-peptide estimations can help guide treatment and avoid injudicious use of insulin.
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Affiliation(s)
- Riddhi Das Gupta
- Department of Endocrinology and Metabolism, HealthWorld Hospitals, Durgapur, India.
| | - Avica Atri
- Christian Medical College, Vellore, Tamil Nadu, India
| | - Sunetra Mondal
- Department of Endocrinology and Metabolism, HealthWorld Hospitals, Durgapur, India
| | | | - Ramprasad Garai
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Arindam Kumar Hazra
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Brojen Choudhury
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Dhriti Sundar Dutta
- Department of Critical Care Medicine, HealthWorld Hospitals, Durgapur, India
| | - Moushumi Lodh
- Department of Biochemistry, HealthWorld Hospitals, Durgapur, India
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Redondo MJ, Balasubramanyam A. Toward an Improved Classification of Type 2 Diabetes: Lessons From Research into the Heterogeneity of a Complex Disease. J Clin Endocrinol Metab 2021; 106:e4822-e4833. [PMID: 34291809 PMCID: PMC8787852 DOI: 10.1210/clinem/dgab545] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Accumulating evidence indicates that type 2 diabetes (T2D) is phenotypically heterogeneous. Defining and classifying variant forms of T2D are priorities to better understand its pathophysiology and usher clinical practice into an era of "precision diabetes." EVIDENCE ACQUISITION AND METHODS We reviewed literature related to heterogeneity of T2D over the past 5 decades and identified a range of phenotypic variants of T2D. Their descriptions expose inadequacies in current classification systems. We attempt to link phenotypically diverse forms to pathophysiology, explore investigative methods that have characterized "atypical" forms of T2D on an etiological basis, and review conceptual frameworks for an improved taxonomy. Finally, we propose future directions to achieve the goal of an etiological classification of T2D. EVIDENCE SYNTHESIS Differences among ethnic and racial groups were early observations of phenotypic heterogeneity. Investigations that uncover complex interactions of pathophysiologic pathways leading to T2D are supported by epidemiological and clinical differences between the sexes and between adult and youth-onset T2D. Approaches to an etiological classification are illustrated by investigations of atypical forms of T2D, such as monogenic diabetes and syndromes of ketosis-prone diabetes. Conceptual frameworks that accommodate heterogeneity in T2D include an overlap between known diabetes types, a "palette" model integrated with a "threshold hypothesis," and a spectrum model of atypical diabetes. CONCLUSION The heterogeneity of T2D demands an improved, etiological classification scheme. Excellent phenotypic descriptions of emerging syndromes in different populations, continued clinical and molecular investigations of atypical forms of diabetes, and useful conceptual models can be utilized to achieve this important goal.
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Affiliation(s)
- Maria J Redondo
- Section of Diabetes and Endocrinology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
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12
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Abstract
An etiologically based classification of diabetes is needed to account for the heterogeneity of type 1 and type 2 diabetes (T1D and T2D) and emerging forms of diabetes worldwide. It may be productive for both classification and clinical discovery to consider variant forms of diabetes as a spectrum. Maturity onset diabetes of youth and neonatal diabetes serve as models for etiologically defined, rare forms of diabetes in the spectrum. Ketosis-prone diabetes is a model for more complex forms, amenable to phenotypic dissection. Bioinformatic approaches such as clustering analyses of large datasets and multi-omics investigations of rare and atypical phenotypes are promising avenues to explore and define new subgroups of diabetes.
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Affiliation(s)
- Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA;
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13
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Sjöholm Å. Atypical diabetes: a diagnostic challenge. BMJ Open Diabetes Res Care 2020; 8:8/1/e001470. [PMID: 32771985 PMCID: PMC7418657 DOI: 10.1136/bmjdrc-2020-001470] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/17/2020] [Accepted: 06/27/2020] [Indexed: 02/03/2023] Open
Abstract
In medical school, we learned how to classify diabetes according to different clinical characteristics. However, at the dawn of the precision medicine era, it is clear that today's clinical reality does not always align well with textbook teachings. The terms juvenile versus elderly-onset diabetes, as well as insulin-dependent versus non-insulin-dependent diabetes, have become obsolete. Contrary to what is often taught severe ketoacidosis may occur in type 2 diabetes. Patients may also suffer from two or more forms of diabetes simultaneously or consecutively. Five authentic cases of diabetes with uncommon characteristics that pose diagnostic challenges are presented here.
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Affiliation(s)
- Åke Sjöholm
- Department of Internal Medicine, Region Gävleborg, Gavle, Sweden
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14
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McKeigue PM, Spiliopoulou A, McGurnaghan S, Colombo M, Blackbourn L, McDonald TJ, Onengut-Gomuscu S, Rich SS, A Palmer CN, McKnight JA, J Strachan MW, Patrick AW, Chalmers J, Lindsay RS, Petrie JR, Thekkepat S, Collier A, MacRury S, Colhoun HM. Persistent C-peptide secretion in Type 1 diabetes and its relationship to the genetic architecture of diabetes. BMC Med 2019; 17:165. [PMID: 31438962 PMCID: PMC6706940 DOI: 10.1186/s12916-019-1392-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 07/15/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The objective of this cross-sectional study was to explore the relationship of detectable C-peptide secretion in type 1 diabetes to clinical features and to the genetic architecture of diabetes. METHODS C-peptide was measured in an untimed serum sample in the SDRNT1BIO cohort of 6076 Scottish people with clinically diagnosed type 1 diabetes or latent autoimmune diabetes of adulthood. Risk scores at loci previously associated with type 1 and type 2 diabetes were calculated from publicly available summary statistics. RESULTS Prevalence of detectable C-peptide varied from 19% in those with onset before age 15 and duration greater than 15 years to 92% in those with onset after age 35 and duration less than 5 years. Twenty-nine percent of variance in C-peptide levels was accounted for by associations with male gender, late age at onset and short duration. The SNP heritability of residual C-peptide secretion adjusted for gender, age at onset and duration was estimated as 26%. Genotypic risk score for type 1 diabetes was inversely associated with detectable C-peptide secretion: the most strongly associated loci were the HLA and INS gene regions. A risk score for type 1 diabetes based on the HLA DR3 and DQ8-DR4 serotypes was strongly associated with early age at onset and inversely associated with C-peptide persistence. For C-peptide but not age at onset, there were strong associations with risk scores for type 1 and type 2 diabetes that were based on SNPs in the HLA region but not accounted for by HLA serotype. CONCLUSIONS Persistence of C-peptide secretion varies widely in people clinically diagnosed as type 1 diabetes. C-peptide persistence is influenced by variants in the HLA region that are different from those determining risk of early-onset type 1 diabetes. Known risk loci for diabetes account for only a small proportion of the genetic effects on C-peptide persistence.
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Affiliation(s)
- Paul M McKeigue
- Usher Institute of Population Health and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK.
| | - Athina Spiliopoulou
- Usher Institute of Population Health and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Stuart McGurnaghan
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Campus, Crewe Road, Edinburgh, UK
| | - Marco Colombo
- Usher Institute of Population Health and Informatics, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - Luke Blackbourn
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Campus, Crewe Road, Edinburgh, UK
| | | | | | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, USA
| | | | | | | | | | | | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | | | - Helen M Colhoun
- Institute of Genetics and Molecular Medicine, University of Edinburgh, Western General Hospital Campus, Crewe Road, Edinburgh, UK
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15
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BALASUBRAMANYAM ASHOK. SYNDROMES OF KETOSIS-PRONE DIABETES. TRANSACTIONS OF THE AMERICAN CLINICAL AND CLIMATOLOGICAL ASSOCIATION 2019; 130:145-155. [PMID: 31516178 PMCID: PMC6736014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Ketosis-prone diabetes (KPD) is a heterogeneous condition characterized by patients who present with diabetic ketoacidosis but lack the phenotype of autoimmune type 1 diabetes. Here I review progress in our understanding of KPD and its place in the expanding universe of "atypical diabetes." I focus on investigations of our collaborative research group at Baylor College of Medicine and the University of Washington using a longitudinally followed, heterogeneous, multiethnic cohort of KPD patients. We have identified clinically and pathophysiologically distinct KPD subgroups, separable by the presence or absence of islet autoimmunity and the presence or absence of beta cell functional reserve. The resulting "Aß" classification of KPD accurately predicts long-term glycemic control and insulin dependence. I describe key characteristics of the KPD subgroups, their natural histories, and our investigations into their immunologic, genetic, and metabolic etiologies. These studies serve as a paradigm for the investigation of atypical forms of diabetes.
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Affiliation(s)
- ASHOK BALASUBRAMANYAM
- Correspondence and reprint requests: Ashok Balasubramanyam, MD, Baylor College of Medicine,
BCM 171A, One Baylor Plaza, Houston, Texas 77479713-798-5691713-798-4585
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16
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Gaba R, Mehta P, Balasubramanyam A. Evaluation and management of ketosis-prone diabetes. Expert Rev Endocrinol Metab 2019; 14:43-48. [PMID: 30612498 DOI: 10.1080/17446651.2019.1561270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 12/17/2018] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Patients presenting with diabetic ketoacidosis (DKA) who lack the classic phenotype of autoimmune type 1 diabetes have become increasingly identified in recent decades. This has led to the recognition of heterogeneous syndromes of 'ketosis-prone diabetes' (KPD). Evaluation and optimal management of KPD differs from that of 'typical' type 1 or type 2 diabetes. Awareness of these differences and a systematic approach to diagnosis and treatment can improve glycemic control and prevent both acute and chronic complications of diabetes. AREAS COVERED This article reviews the Aß classification scheme ('A' for autoantibody status and 'ß' for beta cell functional reserve) which accurately delineates subgroups of KPD, and addresses the relevance of defining these subgroups for clinical outcomes and long-term insulin dependence. Subsequently, the detailed evaluation and management of KPD patients after their index DKA episode is described. EXPERT COMMENTARY Among patients presenting with DKA, it is important to diagnose specific subgroups of KPD and not assume that they represent exclusively patients with autoimmune type 1 diabetes. The Aß classification is an accurate aid to diagnosis, and permits optimal management of the subgroups (e.g., insulin treatment for the ß- subgroups; follow-up testing and a range of treatment options for the ß+ subgroups).
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Affiliation(s)
- Ruchi Gaba
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Paras Mehta
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
| | - Ashok Balasubramanyam
- a Division of Diabetes, Endocrinology and Metabolism , Baylor College of Medicine , Houston , TX , USA
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17
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Lontchi-Yimagou E, Boudou P, Nguewa JL, Noubiap JJ, Kamwa V, Djahmeni EN, Atogho-Tiedeu B, Azabji-Kenfack M, Etoa M, Lemdjo G, Dehayem MY, Mbanya JC, Gautier JF, Sobngwi E. Acute phase ketosis-prone atypical diabetes is associated with a pro-inflammatory profile: a case-control study in a sub-Saharan African population. J Diabetes Metab Disord 2018; 17:37-43. [PMID: 30288384 PMCID: PMC6154517 DOI: 10.1007/s40200-018-0336-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/01/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Eric Lontchi-Yimagou
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon
| | - Philippe Boudou
- 2Unit of Hormonal Biology, Department of Biochemistry, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Jean Louis Nguewa
- 3Inserm UMRS 1138, Cordeliers Research Centre, University Paris-6, 75006 Paris, France
| | - Jean Jacques Noubiap
- 4Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Vicky Kamwa
- University hospital of Birmingham, Birmingham, UK
| | | | - Babara Atogho-Tiedeu
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon
| | - Marcel Azabji-Kenfack
- 7Department of Physiological Sciences and Biochemistry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Martine Etoa
- National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Gaelle Lemdjo
- National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Jean Claude Mbanya
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon.,National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon.,8Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Jean-Francois Gautier
- 2Unit of Hormonal Biology, Department of Biochemistry, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 1 avenue Claude Vellefaux, 75010 Paris, France.,3Inserm UMRS 1138, Cordeliers Research Centre, University Paris-6, 75006 Paris, France
| | - Eugène Sobngwi
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon.,National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon.,8Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
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18
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Arts RJW, Joosten LAB, Netea MG. The Potential Role of Trained Immunity in Autoimmune and Autoinflammatory Disorders. Front Immunol 2018. [PMID: 29515591 PMCID: PMC5826224 DOI: 10.3389/fimmu.2018.00298] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
During induction of trained immunity, monocytes and macrophages undergo a functional and transcriptional reprogramming toward increased activation. Important rewiring of cellular metabolism of the myeloid cells takes place during induction of trained immunity, including a shift toward glycolysis induced through the mTOR pathway, as well as glutaminolysis and cholesterol synthesis. Subsequently, this leads to modulation of the function of epigenetic enzymes, resulting in important changes in chromatin architecture that enables increased gene transcription. However, in addition to the beneficial effects of trained immunity as a host defense mechanism, we hypothesize that trained immunity also plays a deleterious role in the induction and/or maintenance of autoimmune and autoinflammatory diseases if inappropriately activated.
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Affiliation(s)
- Rob J W Arts
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Medical Genetics, Iuliu Haţieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Mihai G Netea
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands.,Department for Genomics and Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany
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19
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Guarnotta V, Vigneri E, Pillitteri G, Ciresi A, Pizzolanti G, Giordano C. Higher cardiometabolic risk in idiopathic versus autoimmune type 1 diabetes: a retrospective analysis. Diabetol Metab Syndr 2018; 10:40. [PMID: 29760789 PMCID: PMC5944025 DOI: 10.1186/s13098-018-0341-6] [Citation(s) in RCA: 5] [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: 08/03/2017] [Accepted: 04/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Idiopathic type 1 diabetes mellitus (IDM) is characterized by an onset with insulinopenia and ketoacidosis with negative β-cell autoimmunity markers and lack of association with HLA. The aim of the study is to compare the clinical and metabolic parameters, the macro and microvascular complications, the adipose tissue dysfunction and the insulin secretion and sensitivity indexes in patients with IDM and autoimmune type 1 diabetes mellitus (ADM) at clinical onset. METHODS Thirty patients with IDM and 30 with ADM, matched for age and gender, were retrospectively analyzed. BMI, waist circumference, lipids, glycemia, HbA1c, insulin requirement, glutamic oxaloacetic and glutamic pyruvic transaminases (GOT and GPT), glucagon stimulated c-peptide (GSC-pep) test levels, M value during hyperinsulinemic euglycemic clamp and Visceral Adiposity Index (VAI) were obtained from our database. RESULTS Patients with IDM showed a significantly higher BMI (p 0.012), WC (p 0.07), VAI (p 0.004), LDL-cholesterol (p 0.027), GOT (p 0.005), GPT (p 0.001), M value (p 0.006) and GSC-pep peak (p 0.036), with concomitant lower HDL-cholesterol (p < 0.001), than patients with ADM. In addition, patients with IDM showed a more marked familial history for diabetes (p 0.005) and a higher percentage of hepatic steatosis (p 0.001), visceral obesity (p 0.032) and hypercholesterolemia (p 0.007) compared to patients with ADM. CONCLUSIONS Patients with IDM show many metabolic complications at onset, such as visceral obesity, hepatic steatosis and hypercholesterolemia and a higher cardiometabolic risk, than patients with ADM, similarly to patients with type 2 diabetes at onset.
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Affiliation(s)
- Valentina Guarnotta
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
| | - Enrica Vigneri
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
| | - Giuseppe Pillitteri
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
| | - Alessandro Ciresi
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
| | - Giuseppe Pizzolanti
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
| | - Carla Giordano
- Biomedical Department of Internal and Specialist Medicine (DIBIMIS), Section of Diabetes, Endocrinology and Metabolism, University of Palermo, Italy, Piazza Delle Cliniche 2, 90127 Palermo, Italy
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20
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Merino J, Florez JC. Precision medicine in diabetes: an opportunity for clinical translation. Ann N Y Acad Sci 2018; 1411:140-152. [PMID: 29377200 PMCID: PMC6686889 DOI: 10.1111/nyas.13588] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 11/27/2017] [Accepted: 12/04/2017] [Indexed: 12/12/2022]
Abstract
Metabolic disorders present a public health challenge of staggering proportions. In diabetes, there is an urgent need to better understand disease heterogeneity, clinical trajectories, and related comorbidities. A pressing and timely question is whether we are ready for precision medicine in diabetes. Some biological insights that have emerged during the last decade have already been used to direct clinical decision making, especially in monogenic forms of diabetes. However, much work is necessary to integrate high-dimensional explorations into complex disease architectures, less penetrant biological alterations, and broader phenotypes, such as type 2 diabetes. In addition, for precision medicine to take hold in diabetes, reproducibility, interpretability, and actionability remain key guiding objectives. In this review, we examine how mounting data sets generated during the last decade to understand biological variability are now inspiring new venues to clarify diabetes nosology and ultimately translate findings into more effective prevention and treatment strategies.
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Affiliation(s)
- Jordi Merino
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
| | - Jose C. Florez
- Diabetes Unit and Center for Genomic Medicine, Massachusetts General Hospital, Boston, Massachusetts
- Programs in Metabolism and Medical & Population Genetics, Broad Institute of MIT and Harvard, Cambridge, Massachusetts
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
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21
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Gupta RD, Ramachandran R, Gangadhara P, Anoop S, Singh SH, Satyaraddi A, Sathyakumar S, Asha HS, Thomas N. Clinical characteristics, beta-cell dysfunction and treatment outcomes in patients with A-β+ Ketosis-Prone Diabetes (KPD): The first identified cohort amongst Asian Indians. J Diabetes Complications 2017; 31:1401-1407. [PMID: 28668376 DOI: 10.1016/j.jdiacomp.2017.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Ketosis-prone diabetes (KPD), an atypical form of diabetes, has emerged as a heterogeneous syndrome in multiple ethnic groups. The objectives of this study were to look into the clinical characteristics of adult Asian Indian patients with recently diagnosed, antibody negative diabetes presenting with unprovoked ketoacidosis (A-β+ KPD) and to determine the natural course of recovery of beta-cell functions on serial follow-up over one year. RESEARCH DESIGN AND METHODS Newly diagnosed adult diabetes patients (n=11) with suspected KPD (A-β+) were prospectively studied over a period of 1-year with serial evaluations of clinical, biochemical and beta-cell secretion characteristics. These were compared with a control group (n=23) of KPD (A+β-) (classical Type 1A diabetes) with similar presentation. Beta-cell secretion was assessed by fasting and stimulated C-peptide values after a standard mixed meal challenge. Glycaemic control and treatment outcomes were also documented. RESULTS In comparison to the A+β- KPD controls, the A-β+ KPD patients had a significantly older age, higher BMI, stronger family history of type 2 diabetes, more severe ketoacidosis and higher fasting and stimulated C-peptide level at presentation. On serial follow-up, the patients with KPD achieved complete recovery of their beta-cell function with remission from insulin-dependence within 3-4months without further recurrences of DKA. CONCLUSIONS This is the first reported series of A-β+ KPD from India. The phenotype of Indian A-β+ KPD patients differs from their Western counterparts in that they are relatively younger and leaner, though the male preponderance and natural history of recovery of beta-cell dysfunction bears similarity.
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Affiliation(s)
- Riddhi Das Gupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
| | - Roshna Ramachandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Praveen Gangadhara
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Shajith Anoop
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Surjitkumar H Singh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
| | - Anil Satyaraddi
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Samantha Sathyakumar
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - H S Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
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Vellanki P, Umpierrez GE. DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES. Endocr Pract 2017; 23:971-978. [PMID: 28534682 DOI: 10.4158/ep161679.ra] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes. METHODS We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes. RESULTS In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy. CONCLUSION KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes. ABBREVIATIONS A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.
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23
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Use of a High-Density Protein Microarray to Identify Autoantibodies in Subjects with Type 2 Diabetes Mellitus and an HLA Background Associated with Reduced Insulin Secretion. PLoS One 2015; 10:e0143551. [PMID: 26606528 PMCID: PMC4659622 DOI: 10.1371/journal.pone.0143551] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 11/05/2015] [Indexed: 12/27/2022] Open
Abstract
New biomarkers for type 2 diabetes mellitus (T2DM) may aid diagnosis, drug development or clinical treatment. Evidence is increasing for the adaptive immune system’s role in T2DM and suggests the presence of unidentified autoantibodies. While high-density protein microarrays have emerged as a useful technology to identify possible novel autoantigens in autoimmune diseases, its application in T2DM has lagged. In Pima Indians, the HLA haplotype (HLA-DRB1*02) is protective against T2DM and, when studied when they have normal glucose tolerance, subjects with this HLA haplotype have higher insulin secretion compared to those without the protective haplotype. Possible autoantibody biomarkers were identified using microarrays containing 9480 proteins in plasma from Pima Indians with T2DM without the protective haplotype (n = 7) compared with those with normal glucose regulation (NGR) with the protective haplotype (n = 11). A subsequent validation phase involving 45 cases and 45 controls, matched by age, sex and specimen storage time, evaluated 77 proteins. Eleven autoantigens had higher antibody signals among T2DM subjects with the lower insulin-secretion HLA background compared with NGR subjects with the higher insulin-secretion HLA background (p<0.05, adjusted for multiple comparisons). PPARG2 and UBE2M had lowest p-values (adjusted p = 0.023) while PPARG2 and RGS17 had highest case-to-control antibody signal ratios (1.7). A multi-protein classifier involving the 11 autoantigens had sensitivity, specificity, and area under the receiver operating characteristics curve of 0.73, 0.80, and 0.83 (95% CI 0.74–0.91, p = 3.4x10-8), respectively. This study identified 11 novel autoantigens which were associated with T2DM and an HLA background associated with reduced insulin secretion. While further studies are needed to distinguish whether these antibodies are associated with insulin secretion via the HLA background, T2DM more broadly, or a combination of the two, this study may aid the search for autoantibody biomarkers by narrowing the list of protein targets.
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Gaba R, Gambhire D, Uy N, Gonzalez EV, Iyer D, Hampe CS, Ram N, Balasubramanyam A. Factors associated with early relapse to insulin dependence in unprovoked A-β+ ketosis-prone diabetes. J Diabetes Complications 2015; 29:918-22. [PMID: 26071380 PMCID: PMC4540630 DOI: 10.1016/j.jdiacomp.2015.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/13/2015] [Accepted: 04/20/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Unprovoked "A-β+" Ketosis-Prone Diabetes (KPD), a unique diabetic syndrome of adult-onset, obesity and proneness to ketoacidosis, is associated with rapid recovery of β cell function and insulin-independence. Whereas most patients experience prolonged remission, a subset relapses early to insulin dependence. We sought to define factors associated with early relapse. METHODS We utilized a prospective, longitudinal database to analyze 50 unprovoked A-β+ KPD patients with >2 measurements of β cell function and glycemia following baseline assessment. RESULTS 19 patients (38%) relapsed to insulin dependence <1 year after the index DKA episode, while 31 (62%) remained insulin-independent for >1 year (median 4.2 years). Younger age at baseline (OR=0.947, P=0.033), and lower HOMA2-%β (OR=0.982, P=0.001), lower HOMA2-IR (OR=0.582, P=0.046) and higher HbA1c at 1 year (OR=1.71, P=0.002) were associated with early relapse. A multivariate model with these variables and the interaction of HOMA2-%β and HbA1c at 1 year provided a good fit (P<0.05). CONCLUSIONS Relapse to insulin dependence in unprovoked A-β+ KPD patients is associated with younger age and, after 1 year, lack of robust increase in β cell functional reserve, and suboptimal glycemic control. Measurements of these parameters 1 year after the index DKA episode can be used to assess the need for insulin therapy.
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Affiliation(s)
- Ruchi Gaba
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | | | - Natalie Uy
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Erica V Gonzalez
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Dinakar Iyer
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | - Nalini Ram
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Ashok Balasubramanyam
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX.
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Tersey SA, Bolanis E, Holman TR, Maloney DJ, Nadler JL, Mirmira RG. Minireview: 12-Lipoxygenase and Islet β-Cell Dysfunction in Diabetes. Mol Endocrinol 2015; 29:791-800. [PMID: 25803446 DOI: 10.1210/me.2015-1041] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The insulin producing islet β-cells have increasingly gained attention for their role in the pathogeneses of virtually all forms of diabetes. Dysfunction, de-differentiation, and/or death of β-cells are pivotal features in the transition from normoglycemia to hyperglycemia in both animal models of metabolic disease and humans. In both type 1 and type 2 diabetes, inflammation appears to be a central cause of β-cell derangements, and molecular pathways that modulate inflammation or the inflammatory response are felt to be prime targets of future diabetes therapy. The lipoxygenases (LOs) represent a class of enzymes that oxygenate cellular polyunsaturated fatty acids to produce inflammatory lipid intermediates that directly and indirectly affect cellular function and survival. The enzyme 12-LO is expressed in all metabolically active tissues, including pancreatic islets, and has received increasing attention for its role in promoting cellular inflammation in the setting of diabetes. Genetic deletion models of 12-LO in mice reveal striking protection from metabolic disease and its complications and an emerging body of literature has implicated its role in human disease. This review focuses on the evidence supporting the proinflammatory role of 12-LO as it relates to islet β-cells, and the potential for 12-LO inhibition as a future avenue for the prevention and treatment of metabolic disease.
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Affiliation(s)
- Sarah A Tersey
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
| | - Esther Bolanis
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
| | - Theodore R Holman
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
| | - David J Maloney
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
| | - Jerry L Nadler
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
| | - Raghavendra G Mirmira
- Departments of Pediatrics and the Center for Diabetes and Metabolic Diseases (S.A.T., R.G.M.), Biochemistry and Molecular Biology (E.B., R.G.M.), Medicine (R.G.M.), and Cellular and Integrative Physiology (R.G.M.), Indiana University School of Medicine, Indianapolis, Indiana 46202; Department of Chemistry and Biochemistry (T.R.H.), University of California, Santa Cruz, Santa Cruz, California 95064; National Center for Advancing Translational Sciences (D.J.M.), National Institutes of Health, Rockville, Maryland 20850; and Department of Medicine and the Strelitz Diabetes Center (J.L.N.), Eastern Virginia Medical School, Norfolk, Virginia 23507
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Coleman NJ, Miernik J, Philipson L, Fogelfeld L. Lean versus obese diabetes mellitus patients in the United States minority population. J Diabetes Complications 2014; 28:500-5. [PMID: 24581791 DOI: 10.1016/j.jdiacomp.2013.11.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2013] [Revised: 11/19/2013] [Accepted: 11/20/2013] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To identify special characteristics in large group of lean diabetes minority patients in comparison to obese type 2 diabetes. METHODS 1784 Lean (BMI <25) diabetes patients were identified and compared with 8630 obese (BMI ≥30) patients. Patients with Type 1 Diabetes (N=523) were excluded. Patient data, including demographics, psychosocial factors, insulin use, and complications was analyzed. RESULTS In lean compared to obese, there was male predominance (62% vs 48%, p<0.001), higher prevalence of insulin use (49% vs 44%, p=0.001), lower TG/HDL (2.28 vs 3.4, p<0.001), and higher prevalence of alcoholism (5.7% vs 2.4%, p<0.001) and pancreatitis (3.6% vs 0.9%, p<0.001). In both groups, African Americans and Latinos were the prevalent ethnicities (38%, 34% vs. 53%,31%). When comparing patients within the lean group who were on insulin (49%) to those on oral medications, there were more males (65% vs. 59%, p<0.001), earlier age of onset (40±14 vs. 47±12, p<0.001), lower BMI (22.1±2 vs. 22.6±1.7, p<0.001) and lower TG/HDL (2.18 vs. 2.42, p=0.021). CONCLUSIONS A subset of diabetes patients in the United States minority population are lean and may have rapid beta cell failure. The etiology is not clear and acquired factors, genetics, and autoimmunity may be contributory.
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Affiliation(s)
- Nathaniel J Coleman
- Division of Endocrinology, John H. Stroger, Jr Hospital of Cook County and Rush University Medical Center
| | - Jadwiga Miernik
- Division of Endocrinology, John H. Stroger, Jr Hospital of Cook County and Rush University Medical Center
| | | | - Leon Fogelfeld
- Division of Endocrinology, John H. Stroger, Jr Hospital of Cook County and Rush University Medical Center.
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Oak S, Gaur LK, Radtke J, Patel R, Iyer D, Ram N, Gaba R, Balasubramanyam A, Hampe CS. Masked and overt autoantibodies specific to the DPD epitope of 65-kDa glutamate decarboxylase (GAD65-DPD) are associated with preserved β-cell functional reserve in ketosis-prone diabetes. J Clin Endocrinol Metab 2014; 99:E1040-4. [PMID: 24601691 PMCID: PMC4037721 DOI: 10.1210/jc.2013-4189] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Ketosis-prone diabetes (KPD), defined by presentation with diabetic ketoacidosis (DKA), comprises 4 subgroups based on the presence or absence of islet cell autoantibodies (A(-) or A(+)) and β-cell functional reserve (β(-) or β(+)). Among A(+) KPD, autoantibody epitope reactivity to 65-kDa glutamate decarboxylase (GAD65), defined by monoclonal GAD65Ab(DPD), was associated with greater β-cell functional reserve. In a majority of healthy individuals, GAD65Ab are present in the sera but are masked by anti-idiotypic antibodies; in contrast, overtly GAD65Ab-positive patients with autoimmune type 1 diabetes patients lack these anti-idiotypic antibodies. OBJECTIVE Our objective was to determine the presence of masked and overt GAD65Ab(DPD) in relation to β-cell function and genetic risk factors in KPD patients. DESIGN We investigated the associations of masked and overt GAD65Ab(DPD) with β-cell functional reserve, and their relationship with human leukocyte antigen (HLA) class II haplotypes linked to autoimmune diabetes susceptibility or resistance, in a large KPD cohort. PATIENTS Adult KPD patients (n = 384) were followed longitudinally in a research clinic. MAIN OUTCOME MEASURES β-Cell function, autoantibody status, GAD65Ab epitopes, and HLA class II haplotypes were evaluated. RESULTS Overall, KPD patients with β-cell functional reserve (β(+) subgroups) showed significantly higher frequency of masked GAD65Ab(DPD) than patients without β-cell functional reserve (β(-) subgroups): 112 of 144 (79%) compared with 59 of 100 (59%), respectively (P = .002). Masked or overt GAD65Ab(DPD) were also more frequent among autoantibody-positive patients with preserved β-cell functional reserve (A(+)β(+) KPD) than those lacking β-cell function (A(+)β(-) KPD): 77% compared with 55% (P = .01). The susceptibility HLA haplotypes DQA1*0301/DQB1*0302 and DQA1*0301/DQB1*0201 were associated with absence of overt or masked GAD65Ab(DPD) (odds Ratios 2.3 and 2.2, respectively). CONCLUSIONS Masked GAD65Ab(DPD) are strongly associated with preserved β-cell functional reserve among patients with KPD. Absence of GAD65Ab(DPD) reactivity is associated with 2 HLA class II susceptibility haplotypes for autoimmune type 1 diabetes.
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Affiliation(s)
- Shilpa Oak
- University of Washington (S.O., L.K.G., J.R., C.S.H.), Seattle, Washington 98109; and Diabetes Research Center (R.P., D.I., N.R., R.G., A.B.), Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Baylor College of Medicine, and Endocrine Service (N.R., R.G., A.B.), Ben Taub General Hospital, Houston, Texas 77030
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Lu H, Hu F, Zeng Y, Zou L, Luo S, Sun Y, Liu H, Sun L. Ketosis onset type 2 diabetes had better islet β-cell function and more serious insulin resistance. J Diabetes Res 2014; 2014:510643. [PMID: 24829925 PMCID: PMC4009153 DOI: 10.1155/2014/510643] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 03/13/2014] [Accepted: 03/16/2014] [Indexed: 12/16/2022] Open
Abstract
Diabetic ketosis had been identified as a characteristic of type 1 diabetes mellitus (T1DM), but now emerging evidence has identified that they were diagnosed as T2DM after long time follow up. This case control study was aimed at comparing the clinical characteristic, β-cell function, and insulin resistance of ketosis and nonketotic onset T2DM and providing evidence for treatment selection. 140 cases of newly diagnosed T2DM patients were divided into ketosis (62 cases) and nonketotic onset group (78 cases). After correction of hyperglycemia and ketosis with insulin therapy, plasma C-peptide concentrations were measured at 0, 0.5, 1, 2, and 3 hours after 75 g glucose oral administration. Area under the curve (AUC) of C-peptide was calculated. Homoeostasis model assessment was used to estimate basal β-cell function (HOMA-β) and insulin resistance (HOMA-IR). Our results showed that ketosis onset group had higher prevalence of nonalcoholic fatty liver disease (NAFLD) than nonketotic group (P = 0.04). Ketosis onset group had increased plasma C-peptide levels at 0 h, 0.5 h, and 3 h and higher AUC(0-0.5), AUC₀₋₁, AUC₀₋₃ (P < 0.05). Moreover, this group also had higher HOMA-β and HOMA-IR than nonketotic group (P < 0.05). From these data, we concluded that ketosis onset T2DM had better islet β-cell function and more serious insulin resistance than nonketotic onset T2DM.
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Affiliation(s)
- Hongyun Lu
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Fang Hu
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Yingjuan Zeng
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Lingling Zou
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Shunkui Luo
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Ying Sun
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Hong Liu
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
| | - Liao Sun
- Department of Endocrinology & Metabolism, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, Guangdong 519000, China
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