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Hampe CS, Shojaie A, Brooks-Worrell B, Dibay S, Utzschneider K, Kahn SE, Larkin ME, Johnson ML, Younes N, Rasouli N, Desouza C, Cohen RM, Park JY, Florez HJ, Valencia WM, Palmer JP, Balasubramanyam A. GAD65Abs Are Not Associated With Beta-Cell Dysfunction in Patients With T2D in the GRADE Study. J Endocr Soc 2024; 8:bvad179. [PMID: 38333889 PMCID: PMC10853002 DOI: 10.1210/jendso/bvad179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Indexed: 02/10/2024] Open
Abstract
Context Autoantibodies directed against the 65-kilodalton isoform of glutamic acid decarboxylase (GAD65Abs) are markers of autoimmune type 1 diabetes (T1D) but are also present in patients with Latent Autoimmune Diabetes of Adults and autoimmune neuromuscular diseases, and also in healthy individuals. Phenotypic differences between these conditions are reflected in epitope-specific GAD65Abs and anti-idiotypic antibodies (anti-Id) against GAD65Abs. We previously reported that 7.8% of T2D patients in the GRADE study have GAD65Abs but found that GAD65Ab positivity was not correlated with beta-cell function, glycated hemoglobin (HbA1c), or fasting glucose levels. Context In this study, we aimed to better characterize islet autoantibodies in this T2D cohort. This is an ancillary study to NCT01794143. Methods We stringently defined GAD65Ab positivity with a competition assay, analyzed GAD65Ab-specific epitopes, and measured GAD65Ab-specific anti-Id in serum. Results Competition assays confirmed that 5.9% of the patients were GAD65Ab positive, but beta-cell function was not associated with GAD65Ab positivity, GAD65Ab epitope specificity or GAD65Ab-specific anti-Id. GAD65-related autoantibody responses in GRADE T2D patients resemble profiles in healthy individuals (low GAD65Ab titers, presence of a single autoantibody, lack of a distinct epitope pattern, and presence of anti-Id to diabetes-associated GAD65Ab). In this T2D cohort, GAD65Ab positivity is likely unrelated to the pathogenesis of beta-cell dysfunction. Conclusion Evidence for islet autoimmunity in the pathophysiology of T2D beta-cell dysfunction is growing, but T1D-associated autoantibodies may not accurately reflect the nature of their autoimmune process.
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Affiliation(s)
| | - Ali Shojaie
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
| | - Barbara Brooks-Worrell
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Sepideh Dibay
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
| | - Kristina Utzschneider
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Steven E Kahn
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Mary E Larkin
- Massachusetts General Hospital Diabetes Center, Harvard Medical School, Boston, MA 02114, USA
| | - Mary L Johnson
- International Diabetes Center, Minneapolis, MN 55416, USA
| | - Naji Younes
- The Biostatistics Center, Department of Biostatistics and Bioinformatics, Milken Institute School of Public Health, The George Washington University, Rockville, MD 20852, USA
| | - Neda Rasouli
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Cyrus Desouza
- Division of Diabetes, Endocrinology and Metabolism, University of Nebraska and Omaha VA Medical Center, Omaha, NE 68198, USA
| | - Robert M Cohen
- Division of Endocrinology, Diabetes and Metabolism, University of Cincinnati and Cincinnati VA Medical Center, Cincinnati, OH 45221, USA
| | | | - Hermes J Florez
- Department of Medicine, University of Miami, Miami, FL 33135, USA
- Division of Endocrinology, Diabetes and Metabolic Diseases, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Willy Marcos Valencia
- Division of Endocrinology, Diabetes and Metabolic Diseases, Medical University of South Carolina, Charleston, SC 29425, USA
- Geriatric Research, Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125, USA
- Robert Stempel Department of Public Health, College of Health and Urban Affairs, Florida International University, Miami, FL 33181, USA
| | - Jerry P Palmer
- Department of Biostatistics, Department of Medicine, University of Washington, Seattle, WA 98185, USA
- Department of Medicine, VA Puget Sound Health Care System, Seattle, WA 98108, USA
| | - Ashok Balasubramanyam
- Department of Medicine: Endocrinology, Diabetes and Metabolism, Baylor College of Medicine, Houston, TX 77030, USA
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Tam AA, Ozdemir D, Bestepe N, Dellal FD, Bilginer MC, Faki S, Bicer C, Ersoy R, Cakir B. Low rate of latent autoimmune diabetes in adults (LADA) in patients followed for type 2 diabetes: A single center's experience in Turkey. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2021; 64:584-590. [PMID: 34033299 PMCID: PMC10118961 DOI: 10.20945/2359-3997000000268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Objective In this study, we aimed to determine the frequency of and the clinical and metabolic features of patients with latent autoimmune diabetes in adults (LADA) at a single center in Turkey. Methods Patients over 30 years of age diagnosed with type 2 diabetes who did not require insulin for a minimum of 6 months following diagnosis were included. Data from 324 patients (163 women; 161 men), with a mean age of 54.97 ± 7.53 years, were analyzed in the study. Levels of antibodies to glutamate decarboxylase (anti-GAD) were measured in all patients, and LADA was diagnosed in patients testing positive for anti-GAD antibodies. Results Anti-GAD positivity was identified in 5 patients (1.5%). Family history of diabetes, body mass index (BMI), age, sex distribution, insulin resistance, serum triglycerides, high-density lipoprotein, and low-density lipoprotein were similar in the LADA and type 2 diabetes patients. Median HbA1c was significantly higher (10.8% vs. 7.38%, p = 0.002) and fasting C-peptide was lower (0.75 ng/mL vs. 2.82 ng/mL, p = 0.009) in patients with LADA compared to in those with type 2 diabetes. Among the 5 patients with LADA, 4 were positive for antithyroid peroxidase antibodies. The median disease duration was relatively shorter among patients with LADA (4 years vs. 7 years, p = 0.105). Conclusion We observed a LADA frequency of 1.5% among Turkish patients followed for type 2 diabetes. The presence of obesity and metabolic syndrome did not exclude LADA, and patients with LADA had worse glycemic control than patients with type 2 diabetes did.
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Affiliation(s)
- Abbas Ali Tam
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey,
| | - Didem Ozdemir
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Nagihan Bestepe
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Fatma Dilek Dellal
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Muhammet Cuneyt Bilginer
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Sevgul Faki
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Cemile Bicer
- Department of Biochemistry, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Reyhan Ersoy
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
| | - Bekir Cakir
- Department of Endocrinology and Metabolism, Yildirim Beyazit University Faculty of Medicine, Ankara, Turkey
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Koufakis T, Vas P, Kotsa K. Treating latent autoimmune diabetes in adults in the era of cardiovascular outcomes trials: Old dog should learn new tricks. Diabet Med 2021; 38:e14496. [PMID: 33306839 DOI: 10.1111/dme.14496] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/16/2020] [Accepted: 12/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Latent autoimmune diabetes in adults (LADA) is characterised by pathophysiological and clinical heterogeneity. Hence, the optimal treatment strategy for this type of diabetes remains a clinical challenge. AIM To discuss the potential of a modern therapeutic approach for LADA in the context of the novel findings of cardiovascular outcomes trials and stress the controversies surrounding LADA and the barriers in the effective management of people with this type of diabetes. METHODS We performed a literature search in major biomedical databases in order to retrieve relevant literature. The results of key studies, along with the authors' clinical experience and perspective, are summarised and discussed in this narrative, mini review article. RESULTS Insulin remains the primary treatment choice in individuals with low C-peptide levels. Although cardiovascular outcomes trials have mainly recruited participants with type 2 diabetes, recent data suggest that the cardiorenal protective properties of the new therapies are even present in people without diabetes and thus, the extrapolation of their results on LADA individuals sounds reasonable. Therefore, sodium-glucose co-transporter 2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists should be considered for the management of people with preserved insulin production being at high cardiovascular risk. The risk of diabetic ketoacidosis with SGLT2is requires increased vigilance by treating physicians. CONCLUSIONS Individualisation, preservation of beta-cell mass and function and cardiorenal protection are the new challenges in LADA therapy.
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Affiliation(s)
- Theocharis Koufakis
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Prashanth Vas
- King's College NHS Foundation Trust, London, UK
- King's Health Partners' Institute of Diabetes, Endocrinology and Obesity, London, UK
- Department of Diabetes, School of Life Course Sciences, King's College London, London, UK
| | - Kalliopi Kotsa
- Division of Endocrinology and Metabolism and Diabetes Centre, First Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Liu B, Xiang Y, Liu Z, Zhou Z. Past, present and future of latent autoimmune diabetes in adults. Diabetes Metab Res Rev 2020; 36:e3205. [PMID: 31318117 DOI: 10.1002/dmrr.3205] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 06/14/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
Latent autoimmune diabetes in adults (LADA) is the most common form of autoimmune diabetes diagnosed in adults. Similar to type 1 diabetes, the prevalence of LADA is impacted by ethnicity and geography. LADA is characterized by β cell loss due to autoimmunity and insulin resistance and has highly heterogeneous clinical features, autoimmunity, and genetics in a glutamic acid decarboxylase antibody (GADA) titre-dependent manner, suggesting LADA is part of a continuum spectrum between type 1 and type 2 diabetes. Although LADA is the most frequent form of autoimmune diabetes diagnosed in adults, clinical trials involving LADA are scarce. Here we review the recent advancements in LADA epidemiology, clinical features, pathogenesis, and interventions. We also highlight the environmental factors that are thought to play an important role in addition to genetics in the pathogenesis of LADA. In the future, high-throughput molecular profiles might shed light on the nature of LADA among the wide spectrum of diabetes and offer new opportunities to identify novel LADA-specific biomarkers.
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Affiliation(s)
- Bingwen Liu
- Department of Metabolism & Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, China
| | - Yufei Xiang
- Department of Metabolism & Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, China
| | - Zhenqi Liu
- Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | - Zhiguang Zhou
- Department of Metabolism & Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, China
- Key Laboratory of Diabetes Immunology, Ministry of Education, National Clinical Research Center for Metabolic Diseases, Central South University, Changsha, China
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Bisciglia A, Pasceri V, Irini D, Varveri A, Speciale G. Risk Factors for Ischemic Heart Disease. Rev Recent Clin Trials 2019; 14:86-94. [PMID: 30919783 DOI: 10.2174/1574887114666190328125153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Revised: 11/11/2017] [Accepted: 05/12/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several risk factors have been empirically linked to an increased risk of cardiovascular disease. Some of them are therapeutically amenable to modification; while others are not. Modifiable risk factors include physical inactivity, tobacco use, diet, "bad fats" in the blood, hypertension, and being overweight; while non-modifiable risk factors include the patient's family history, the presence versus absence of diabetes mellitus, and demographic characteristics like age, gender, ethnicity, and socio-economic status. METHODS In this article, we review those risk factors that are both clinically important and amenable to change. CONCLUSION To prevent cardiovascular disease, it is important to minimize modifiable risk factors, like LDL cholesterol.
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Affiliation(s)
- Andrea Bisciglia
- San Filippo Neri Hospital, Via Giovanni Martinotti, 20, 00135 Rome, Italy
| | - Vincenzo Pasceri
- San Filippo Neri Hospital, Via Giovanni Martinotti, 20, 00135 Rome, Italy
| | - Diego Irini
- San Filippo Neri Hospital, Via Giovanni Martinotti, 20, 00135 Rome, Italy
| | - Antonio Varveri
- San Filippo Neri Hospital, Via Giovanni Martinotti, 20, 00135 Rome, Italy
| | - Giulio Speciale
- San Filippo Neri Hospital, Via Giovanni Martinotti, 20, 00135 Rome, Italy
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Hope SV, Knight BA, Shields BM, Hill AV, Choudhary P, Strain WD, McDonald TJ, Jones AG. Random non-fasting C-peptide testing can identify patients with insulin-treated type 2 diabetes at high risk of hypoglycaemia. Diabetologia 2018; 61:66-74. [PMID: 28983693 PMCID: PMC6002965 DOI: 10.1007/s00125-017-4449-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 07/27/2017] [Indexed: 12/20/2022]
Abstract
AIMS/HYPOTHESIS The aim of this study was to determine whether random non-fasting C-peptide (rCP) measurement can be used to assess hypoglycaemia risk in insulin-treated type 2 diabetes. METHODS We compared continuous glucose monitoring-assessed SD of blood glucose and hypoglycaemia duration in 17 patients with insulin-treated type 2 diabetes and severe insulin deficiency (rCP < 200 pmol/l) and 17 matched insulin-treated control patients with type 2 diabetes but who had preserved endogenous insulin (rCP > 600 pmol/l). We then assessed the relationship between rCP and questionnaire-based measures of hypoglycaemia in 256 patients with insulin-treated type 2 diabetes and a comparison group of 209 individuals with type 1 diabetes. RESULTS Continuous glucose monitoring (CGM)-assessed glucose variability and hypoglycaemia was greater in individuals with rCP < 200 pmol/l despite similar mean glucose. In those with low vs high C-peptide, SD of glucose was 4.2 (95% CI 3.7, 4.6) vs 3.0 (2.6, 3.4) mmol/l (p < 0.001). In the low-C-peptide vs high-C-peptide group, the proportion of individuals experiencing sustained hypoglycaemia ≤ 4 mmol/l was 94% vs 41% (p < 0.001), the mean rate of hypoglycaemia was 5.5 (4.4, 6.7) vs 2.1 (1.4, 2.9) episodes per person per week (p = 0.004) and the mean duration was 630 (619, 643) vs 223 (216, 230) min per person per week (p = 0.01). Hypoglycaemia ≤ 3 mmol/l was infrequent in individuals with preserved C-peptide (1.8 [1.2, 2.6] episodes per person per week vs 0.4 [0.1, 0.8] episodes per person per week for low vs high C-peptide, p = 0.04) and only occurred at night. In a population-based cohort with insulin-treated type 2 diabetes, self-reported hypoglycaemia was twice as frequent in those with rCP < 200 pmol/l (OR 2.0, p < 0.001) and the rate of episodes resulting in loss of consciousness or seizure was five times higher (OR 5.0, p = 0.001). The relationship between self-reported hypoglycaemia and C-peptide was similar in individuals with type 1 and type 2 diabetes. CONCLUSIONS/INTERPRETATION Low rCP is associated with increased glucose variability and hypoglycaemia in patients with insulin-treated type 2 diabetes and represents a practical, stable and inexpensive biomarker for assessment of hypoglycaemia risk.
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Affiliation(s)
- Suzy V Hope
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
- Diabetes and Vascular Medicine, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Exeter, UK.
| | - Bridget A Knight
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Beverley M Shields
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Anita V Hill
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | | | - W David Strain
- Diabetes and Vascular Medicine, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Timothy J McDonald
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Angus G Jones
- NIHR Exeter Clinical Research Facility, University of Exeter Medical School and Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK.
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Chow LS, Chen H, Miller ME, Marcovina SM, Seaquist ER. Biomarkers associated with severe hypoglycaemia and death in ACCORD. Diabet Med 2016; 33:1076-83. [PMID: 26261902 PMCID: PMC4751070 DOI: 10.1111/dme.12883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 02/03/2023]
Abstract
AIMS AND HYPOTHESIS In patients with Type 2 diabetes, intensive glycaemic control is associated with hypoglycaemia and possibly increased mortality. However, no blood biomarkers exist to predict these outcomes. Using participants from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, we hypothesized that insulin deficiency and islet autoantibodies in patients with clinically diagnosed Type 2 diabetes would be associated with severe hypoglycaemia and death. METHODS A nested case-control study design was used. A case (n = 86) was a participant who died with at least one episode of severe hypoglycaemia, defined as hypoglycaemia requiring assistance, at any point during ACCORD follow-up. A control (n = 344) was a participant who did not die and did not have severe hypoglycaemia during follow-up. Each case was matched to four controls (glycaemic intervention arm, race, age and BMI). Baseline insulin deficiency (fasting C-peptide ≤ 0.15 nmol/l) and islet autoantibodies [glutamic acid decarboxylase (GAD), tyrosine phosphatase-related islet antigen 2 (IA2), insulin (IAA) and zinc transporter (ZnT8)] were measured. Conditional logistic regression with and without adjustment for age, BMI and diabetes duration was used. RESULTS Death during ACCORD in those who experienced at least one episode of severe hypoglycaemia was associated with insulin deficiency [OR 4.8 (2.1, 11.1): P < 0.0001], GAD antibodies [OR 2.3 (1.1, 5.1): P = 0.04], the presence of IAA or baseline insulin use [OR 6.1 (3.5,10.7): P < 0.0001], which remained significant after adjusting for age, BMI, and diabetes duration. There was no significant association with IA2 or ZnT8 antibodies. CONCLUSIONS In patients with Type 2 diabetes, C-peptide or GAD antibodies may serve as blood biomarkers predicting higher odds of subsequent severe hypoglycaemia and death. (Clinical Trial Registry No: NCT00000620, www.clinicaltrials.gov for original ACCORD study).
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Affiliation(s)
- L S Chow
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - H Chen
- Department of Biostatistical Sciences, Wake Forest School of Medicine, NC, USA
| | - M E Miller
- Department of Biostatistical Sciences, Wake Forest School of Medicine, NC, USA
| | - S M Marcovina
- Department of Medicine, University of Washington, WA, USA
| | - E R Seaquist
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Numata S, Katakami H, Inoue S, Sawada H, Hashida S. Development of a novel ultrasensitive enzyme immunoassay for human glutamic acid decarboxylase 65 antibody. Ann Clin Biochem 2015; 53:495-503. [DOI: 10.1177/0004563215609639] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/09/2015] [Indexed: 11/15/2022]
Abstract
Background We developed a novel, ultrasensitive enzyme immunoassay (immune complex transfer enzyme immunoassay) for determination of glutamic acid decarboxylase autoantibody concentrations in serum samples from patients with type 2 diabetes. Methods We developed an immune complex transfer enzyme immunoassay for glutamic acid decarboxylase autoantibody and measured glutamic acid decarboxylase autoantibody from 22 patients with type 1 diabetes, 29 patients with type 2 diabetes, and 32 healthy controls. Results A conventional ELISA kit identified 10 patients with type 1 diabetes and one patient with type 2 diabetes as glutamic acid decarboxylase autoantibody positive, whereas 15 patients with type 1 diabetes and six patients with type 2 diabetes were identified as glutamic acid decarboxylase autoantibody positive using immune complex transfer enzyme immunoassay. Conclusions Immune complex transfer enzyme immunoassay is a highly sensitive and specific assay for glutamic acid decarboxylase autoantibody and might be clinically useful for diabetic onset prediction and early diagnosis.
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Affiliation(s)
- Satoshi Numata
- Department of Nutrition, University of Kochi, Kochi, Japan
| | - Hideki Katakami
- Clinical Research Science, Department of Medicine, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Shinobu Inoue
- National Hospital Organization Miyazaki Higashi Hospital, Miyazaki, Japan
| | - Hirotake Sawada
- Division of Pediatrics, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Seiichi Hashida
- Institute for Health Sciences, Tokushima Bunri University, Tokushima, Japan
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Chow LS, Chen H, Miller ME, Marcovina SM, Seaquist ER. Biomarkers related to severe hypoglycaemia and lack of good glycaemic control in ACCORD. Diabetologia 2015; 58:1160-6. [PMID: 25652389 PMCID: PMC4416999 DOI: 10.1007/s00125-015-3512-0] [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: 11/19/2014] [Accepted: 01/09/2015] [Indexed: 01/18/2023]
Abstract
AIMS/HYPOTHESIS In patients with diabetes, intensive glycaemic control reduces microvascular complications. However, severe hypoglycaemia frequently complicates intensive glycaemic control. Blood biomarkers that predict successful intensification of glycaemic control in patients with type 2 diabetes without the development of severe hypoglycaemia would advance patient care. In patients who received intensive treatment for type 2 diabetes from the Action to Control Cardiovascular Risk in Diabetes (ACCORD) study, we hypothesised that insulin deficiency and islet autoantibodies would be associated with severe hypoglycaemia and failure to achieve near-normal glycaemia (HbA1c <6.0% [42 mmol/mol]). METHODS A nested case-control design was used. Cases (n = 326) were defined as participants having severe hypoglycaemia and failure to achieve an HbA1c level of <6.0% (42 mmol/mol) prior to the ACCORD transition or death. Controls (n = 1,075) were those who achieved an HbA1c level of <6.0% (42 mmol/mol) prior to the ACCORD transition or death without severe hypoglycaemia. Each case was matched (for race, age and BMI) by up to four controls. Baseline insulin deficiency (fasting C-peptide ≤0.15 nmol/l) and islet autoantibodies (glutamic acid decarboxylase [GAD], tyrosine phosphatase-related islet antigen 2 [IA2], insulin [IAA] and zinc transporter 8 [ZnT8]) were measured. Conditional logistic regression with and without adjustment for age, BMI and diabetes duration was used on the full cohort and after removal of patients who died and their respective controls. RESULTS Severe hypoglycaemia accompanied by an inability to achieve an HbA1c level of <6.0% (42 mmol/mol) was associated with insulin deficiency (adjusted OR 23.2 [95% CI 9.0, 59.5], p < 0.0001), the presence of IAA autoantibodies or baseline insulin use (adjusted OR 3.8 [95% CI 2.7, 5.3], p < 0.0001), GAD autoantibodies (OR 3.9 [95% CI 2.5, 6.0], p < 0.0001), IA2 autoantibodies (OR 16.7 [95% CI 3.9, 71.6], p = 0.0001) and ZnT8 autoantibodies (adjusted OR 3.9 [95% CI 1.2, 12.4], p = 0.02). CONCLUSIONS C-peptide and islet autoantibodies may serve as biomarkers to predict the risk of severe hypoglycaemia during intensification of type 2 diabetes treatment. TRIAL REGISTRATION ClinicalTrials.gov NCT00000620 (original ACCORD study).
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Affiliation(s)
- Lisa S Chow
- Department of Medicine, University of Minnesota, 420 Delaware St SE, MMC 101, Minneapolis, MN, 55455, USA,
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Abstract
This article highlights the difficulties in creating a definitive classification of diabetes mellitus in the absence of a complete understanding of the pathogenesis of the major forms. This brief review shows the evolving nature of the classification of diabetes mellitus. No classification scheme is ideal, and all have some overlap and inconsistencies. The only diabetes in which it is possible to accurately diagnose by DNA sequencing, monogenic diabetes, remains undiagnosed in more than 90% of the individuals who have diabetes caused by one of the known gene mutations. The point of classification, or taxonomy, of disease, should be to give insight into both pathogenesis and treatment. It remains a source of frustration that all schemes of diabetes mellitus continue to fall short of this goal.
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Affiliation(s)
- Celeste C Thomas
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA.
| | - Louis H Philipson
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA; Department of Pediatrics, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 900 East 57th Street, Chicago, IL 60637, USA
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11
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Brooks-Worrell BM, Boyko EJ, Palmer JP. Impact of islet autoimmunity on the progressive β-cell functional decline in type 2 diabetes. Diabetes Care 2014; 37:3286-93. [PMID: 25239783 PMCID: PMC4237971 DOI: 10.2337/dc14-0961] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Cross-sectional studies have suggested that islet autoimmunity may be more prevalent in type 2 diabetes (T2D) than previously appreciated and may contribute to the progressive decline in β-cell function. In this study, we longitudinally evaluated the effect of islet autoimmune development on the progressive β-cell dysfunction in T2D patients. RESEARCH DESIGN AND METHODS Twenty-three T2D patients negative for islet autoantibodies (GAD antibody and insulinoma-associated protein 2) and islet-specific T cells were evaluated prospectively for up to 36 months. We investigated the percentage of patients who developed islet autoantibodies (Ab+) and/or islet-reactive T cells (T+) and the effect of the islet autoimmunity on fasting and glucagon-stimulated C-peptide responses. We defined positive islet autoimmunity as Ab+ and/or T+ for at least two study visits. RESULTS Of the 23 patients, 6 (26%) remained negative for islet autoimmunity (Ab-T-), 14 (61%) developed Ab+ and/or T+, and 3 (13%) were unclassifiable because they developed islet autoimmunity at only one study visit. Islet Ab+ was observed to be less stable than islet-specific T-cell responses. Development of islet autoimmunity was significantly associated with a more rapid decline in fasting (P < 0.0001) and glucagon-stimulated (P < 0.05) C-peptide responses. CONCLUSIONS These pilot data suggest that the development of islet autoimmunity in T2D is associated with a significantly more rapid β-cell functional decline.
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Affiliation(s)
- Barbara M Brooks-Worrell
- VA Puget Sound Health Care System, Seattle, WA, and Department of Medicine, University of Washington, Seattle, WA
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, and Department of Medicine, University of Washington, Seattle, WA
| | - Jerry P Palmer
- VA Puget Sound Health Care System, Seattle, WA, and Department of Medicine, University of Washington, Seattle, WA
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Pipi E, Marketou M, Tsirogianni A. Distinct clinical and laboratory characteristics of latent autoimmune diabetes in adults in relation to type 1 and type 2 diabetes mellitus. World J Diabetes 2014; 5:505-510. [PMID: 25126396 PMCID: PMC4127585 DOI: 10.4239/wjd.v5.i4.505] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 03/14/2014] [Accepted: 06/18/2014] [Indexed: 02/05/2023] Open
Abstract
Ever since its first appearance among the multiple forms of diabetes, latent autoimmune diabetes in adults (LADA), has been the focus of endless discussions concerning mainly its existence as a special type of diabetes. In this mini-review, through browsing important peer-reviewed publications, (original articles and reviews), we will attempt to refresh our knowledge regarding LADA hoping to enhance our understanding of this controversial diabetes entity. A unique combination of immunological, clinical and metabolic characteristics has been identified in this group of patients, namely persistent islet cell antibodies, high frequency of thyroid and gastric autoimmunity, DR3 and DR4 human leukocyte antigen haplotypes, progressive loss of beta cells, adult disease onset, normal weight, defective glycaemic control, and without tendency to ketoacidosis. Although anthropomorphic measurements are useful as a first line screening, the detection of C-peptide levels and the presence of glutamic acid decarboxylase (GAD) autoantibodies is undoubtedly the sine qua non condition for a confirmatory LADA diagnosis. In point of fact, GAD autoantibodies are far from being solely a biomarker and the specific role of these autoantibodies in disease pathogenesis is still to be thoroughly studied. Nevertheless, the lack of diagnostic criteria and guidelines still puzzle the physicians, who struggle between early diagnosis and correct timing for insulin treatment.
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13
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Guía de práctica clínica de la ESC sobre diabetes, prediabetes y enfermedad cardiovascular, en colaboración con la European Association for the Study of Diabetes. Rev Esp Cardiol 2014. [DOI: 10.1016/j.recesp.2013.10.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Szepietowska B, Głębocka A, Puch U, Górska M, Szelachowska M. Latent autoimmune diabetes in adults in a population-based cohort of Polish patients with newly diagnosed diabetes mellitus. Arch Med Sci 2012; 8:491-5. [PMID: 22852005 PMCID: PMC3400915 DOI: 10.5114/aoms.2012.29405] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 01/12/2011] [Accepted: 02/24/2011] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Latent autoimmune diabetes in adults (LADA) is a slowly developing form of autoimmune diabetes characterized by the presence of type 1 diabetes-associated autoantibody. The aim of this study was to determine the incidence and characteristics of LADA in a population-based cohort of Polish patients with newly-diagnosed diabetes. MATERIAL AND METHODS The study cohort was taken from the resident population of the city Białystok, Poland, during the period 1 January to 31 December 2003, aged 20-64 years. During this period we identified 231 cases of diabetes. We measured glutamic acid decarboxylase (GADA) and insulin antibody (IAA), insulin, C peptide and glycated hemoglobin (HbA(1c)). Diagnosis of LADA was made according to Immunology Diabetes Society and Action LADA criteria. RESULTS The incidence of LADA was 10 per year per 100 000 people. The proportion of patients with LADA was 8.9% among newly diagnosed cases with diabetes. Patients with LADA were younger at diagnosis (48.5 ±9.4 years vs. 54.8 ±10.6 years, p < 0.01), had lower body mass index (26.9 ±9.3 kg/m(2) vs. 29.5 ±5.2 kg/m(2), p < 0.05), C peptide (126 ±127 pmol/l vs. 446 ±592 pmol/l, p < 0.001), and were less insulin resistant (HOMA IR 0.94 ±0.85 vs. 3.6±4.4, p < 0.001) compared to patients with type 2 diabetes. Glycated hemoglobin and fasting glucose were similar in patients with LADA and type 2 diabetes. CONCLUSIONS In addition to GAD, anti-insulin antibodies are useful for diagnosing autoimmune diabetes in adults. Patients with LADA have similar glucose control parameters (HbA(1c)) compared to patients with type 2 diabetes, although they are usually younger and have a lower body mass index. Patients with LADA make up a significant proportion of newly diagnosed people with diabetes mellitus in a Polish population.
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Affiliation(s)
- Barbara Szepietowska
- Department of Endocrinology, Diabetology and Internal Medicine, Medical University of Bialystok, Poland
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15
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Thunander M, Törn C, Petersson C, Ossiansson B, Fornander J, Landin-Olsson M. Levels of C-peptide, body mass index and age, and their usefulness in classification of diabetes in relation to autoimmunity, in adults with newly diagnosed diabetes in Kronoberg, Sweden. Eur J Endocrinol 2012; 166:1021-9. [PMID: 22436402 PMCID: PMC3361790 DOI: 10.1530/eje-11-0797] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2011] [Accepted: 03/21/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVE C-peptide is a main outcome measure in treatment trials of diabetes. C-peptide also has a role in the classification of diabetes, which is often difficult in adults and this is also increasingly recognised in adolescents and elders. AIM We aimed to describe the levels of C-peptide in relation to age and body mass index (BMI) in a large population-based cohort of adults with newly diagnosed diabetes and compare the capabilities of C-peptide, age and BMI to discriminate between autoimmune and non-autoimmune diabetes. SUBJECTS AND METHODS Blood samples from 1180 patients were analysed regarding islet cell antibody, glutamic acid decarboxylase antibody and fasting C-peptide (FCP). Receiver operating characteristics (ROC) curves were analysed to check the ability of age, BMI and C-peptide to discriminate between autoantibody-positive (Ab(+)) and -negative (Ab(-)) diabetes. RESULTS Mean FCP was 0.73±0.5 (range 0.13-1.80) nmol/l in the Ab(+) and 1.42±0.9 (range 0.13-8.30) nmol/l in the Ab(-). FCP was 0.02 nmol/l higher per year increase in age at diagnosis of diabetes. Mean BMI was 26.0±4.8 (range 18.0-39.0) kg/m(2) in the Ab(+) and 28.9±5.3 (range 15.5-62.6) kg/m(2) in the Ab(-). FCP increased with age also within each BMI group. The highest area under the curve (AUC) in the ROC analysis was found for C-peptide, followed by age and BMI (0.78, 0.68 and 0.66 respectively). CONCLUSIONS At diagnosis of diabetes, C-peptide was superior to age and BMI in discriminating between autoimmune and non-autoimmune diabetes. C-peptide increased significantly with BMI and age, latter also within each BMI group. Most of the adults had normal or high levels of C-peptide at presentation of diabetes among the autoimmune patients.
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Affiliation(s)
- Maria Thunander
- Department of Internal Medicine, Central Hospital, Växjö, Kronoberg, Sweden.
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16
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Hwangbo Y, Kim JT, Kim EK, Khang AR, Oh TJ, Jang HC, Park KS, Kim SY, Lee HK, Cho YM. Prevalence and clinical characteristics of recently diagnosed type 2 diabetes patients with positive anti-glutamic Acid decarboxylase antibody. Diabetes Metab J 2012; 36:136-43. [PMID: 22540050 PMCID: PMC3335895 DOI: 10.4093/dmj.2012.36.2.136] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 10/21/2011] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Latent autoimmune diabetes in adults (LADA) refers to a specific type of diabetes characterized by adult onset, presence of islet auto-antibodies, insulin independence at the time of diagnosis, and rapid decline in β-cell function. The prevalence of LADA among patients with type 2 diabetes varies from 2% to 20% according to the study population. Since most studies on the prevalence of LADA performed in Korea were conducted in patients who had been tested for anti-glutamic acid decarboxylase antibody (GADAb), a selection bias could not be excluded. In this study, we examined the prevalence and clinical characteristics of LADA among adult patients recently diagnosed with type 2 diabetes. METHODS We included 462 patients who were diagnosed with type 2 diabetes within 5 years from the time this study was performed. We measured GADAb, fasting insulin level, fasting C-peptide level, fasting plasma glucose level, HbA1c, and serum lipid profiles and collected data on clinical characteristics. RESULTS The prevalence of LADA was 4.3% (20/462) among adult patients with newly diagnosed type 2 diabetes. Compared with the GADAb-negative patients, the GADAb-positive patients had lower fasting C-peptide levels (1.2±0.8 ng/mL vs. 2.0±1.2 ng/mL, P=0.004). Other metabolic features were not significantly different between the two groups. CONCLUSION The prevalence of LADA is 4.3% among Korean adult patients with recently diagnosed type 2 diabetes. The Korean LADA patients exhibited decreased insulin secretory capacity as reflected by lower C-peptide levels.
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Affiliation(s)
- Yul Hwangbo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Taek Kim
- Department of Internal Medicine, Eulji General Hospital, Seoul, Korea
| | - Eun Ky Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Ah Reum Khang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hak Chul Jang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Soo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Seong Yeon Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hong Kyu Lee
- Department of Internal Medicine, Eulji General Hospital, Seoul, Korea
| | - Young Min Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Riddle MC, Yuen KCJ. Reevaluating goals of insulin therapy: perspectives from large clinical trials. Endocrinol Metab Clin North Am 2012; 41:41-56. [PMID: 22575406 DOI: 10.1016/j.ecl.2012.03.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Recent large clinical trials have shown that intensive glycemic control can reduce microvascular complications, but appropriate and safe glycemic goals to improve macrovascular outcomes in patients with type 2 diabetes remain poorly defined. This article surveys recent epidemiologic studies and interventional trials, examines the current understanding of the natural history of type 2 diabetes, and proposes new goals and tactics for optimizing insulin therapy.
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Affiliation(s)
- Matthew C Riddle
- Division of Endocrinology, Diabetes and Clinical Nutrition, Department of Medicine, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mailcode L345, Portland, OR 97239, USA.
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Ekholm E, Gottsäter A, Dahlin LB, Sundkvist G. No signs of progressive beta cell damage during 20 years of prospective follow-up of autoantibody-negative diabetes. Acta Diabetol 2012; 49:57-62. [PMID: 21416148 DOI: 10.1007/s00592-011-0273-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2010] [Accepted: 03/02/2011] [Indexed: 01/23/2023]
Abstract
Both type 1 and type 2 diabetes are considered to be associated with different degrees of progressive beta cell damage. However, few long-term studies have been made. Our aim was to study the clinical course of 20 years of diabetes disease, including diabetes progression, comorbidity, and mortality in a prospectively studied cohort of consecutively diagnosed diabetic patients. Among all 233 patients diagnosed with diabetes during 1985-1987 in Malmö, Sweden, 50 of 118 surviving patients were followed-up after 20 years. The age at diagnose was 42.3 ± 23.1 and 57.5 ± 13.6 years for antibody-positive and antibody-negative patients, respectively. HbA1c and plasma lipids were analyzed with regard to metabolic control. Islet antibody-negative patients at diagnosis had highly preserved C-peptide levels after 20 years in contrast to antibody-positive patients (antibody negative: C-peptide 0 years 0.78 ± 0.47 and 20 years 0.70 ± 0.46 (nmol/l), P = 0.51 and antibody positive: C-peptide 0 years 0.33 ± 0.35 and 20 years 0.10 ± 0.18; P < 0.001. Islet antibodies but not age, BMI, or C-peptide at diagnosis were predictors of C-peptide levels at 20 years when analyzed by logistic regression (P < 0.05). HbA1c did not differ between the groups after 20 years. The 20-year mortality was higher among antibody-negative patients, dependent on the higher age at diagnosis in this group (number of deaths: antibody positive: 18 of 56 vs. antibody negative: 109 of 188, P < 0.001). Of the deceased, 79% had died from diseases or complications that may be associated with diabetes. We found no progressive beta cell damage in autoantibody-negative diabetes at a 20-year follow-up of the clinical course of diabetes.
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Affiliation(s)
- E Ekholm
- Department of Clinical Sciences/Diabetes and Endocrinology, Skåne University Hospital, Lund University, Malmö, Sweden.
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Irving RR, Wright-Pascoe R, Mills JL, Choo-Kang EG, Mclaughlin WA, Mullings AA, McGrowder D. Mosaic pancreas or type 3 diabetes: how do we define it? Int J Diabetes Dev Ctries 2011. [DOI: 10.1007/s13410-011-0028-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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20
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Pham MN, Hawa MI, Pfleger C, Roden M, Schernthaner G, Pozzilli P, Buzzetti R, Scherbaum WA, Seissler J, Kolb H, Hunter S, Leslie RDG, Schloot NC. Pro- and anti-inflammatory cytokines in latent autoimmune diabetes in adults, type 1 and type 2 diabetes patients: Action LADA 4. Diabetologia 2011; 54:1630-8. [PMID: 21347621 DOI: 10.1007/s00125-011-2088-6] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 01/24/2011] [Indexed: 12/16/2022]
Abstract
AIMS/HYPOTHESIS Systemic pro- and anti-inflammatory cytokines are associated with both type 1 and type 2 diabetes, while their role in latent autoimmune diabetes in adults (LADA) is unclear. Therefore, we compared cytokine concentrations in patients with LADA, type 1 or type 2 diabetes and healthy individuals to test the hypothesis that differences of cytokine concentrations between all groups are attributable to diabetes type and BMI. METHODS The pro-inflammatory cytokines IL-6 and TNF-α, and the anti-inflammatory cytokines IL-1 receptor antagonist (IL-1RA) and IL-10 were measured in 90 participants with type 1 diabetes, 61 with LADA, 465 with type 2 diabetes and 41 control participants using multiple regression models adjusted for BMI, sex, age, blood pressure and diabetes duration. RESULTS Patients with type 2 diabetes had higher concentrations of systemic IL-1RA, IL-6 and TNF-α cytokines than patients with either LADA or type 1 diabetes (p < 0.0001 for all differences). Cytokine concentrations in controls were lower than those in all diabetes types (p < 0.04). Increased BMI was positively associated with higher systemic cytokine concentrations in all diabetes types (p < 0.0001). Despite the association of cytokines with anthropometric data, differences between diabetes forms persisted also after adjusting analysis for the confounders BMI, age, sex, disease duration and blood pressure (p < 0.04). CONCLUSIONS/INTERPRETATION Although body mass associates positively with pro- and anti-inflammatory cytokine levels, patients with type 2 diabetes have higher cytokine levels independent of the prevailing BMI. LADA and type 1 diabetes could not be distinguished by systemic cytokines.
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Affiliation(s)
- M N Pham
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich-Heine University Duesseldorf, Auf'm Hennekamp 65, 40225 Duesseldorf, Germany.
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Abstract
BACKGROUND Diabetes mellitus has been historically divided into type 1 and type 2 diabetes, with type 1 being an autoimmune disease and type 2 being primarily a metabolic disease. CONTENT The current diabetes classification scheme needs to be reevaluated because of the accumulating evidence of immune system involvement in the pathophysiology of type 2 diabetes. SUMMARY There are similarities and differences between type 1 and type 2 diabetes with regard to pathogenesis, pathophysiology, and genetics. We propose a resolution to the dilemma of the current classification scheme.
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Maioli M, Pes GM, Delitala G, Puddu L, Falorni A, Tolu F, Lampis R, Orrù V, Secchi G, Cicalò AM, Floris R, Madau GF, Pilosu RM, Whalen M, Cucca F. Number of autoantibodies and HLA genotype, more than high titers of glutamic acid decarboxylase autoantibodies, predict insulin dependence in latent autoimmune diabetes of adults. Eur J Endocrinol 2010; 163:541-9. [PMID: 20603341 DOI: 10.1530/eje-10-0427] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE In latent autoimmune diabetes of adults (LADA), the progression into insulin-dependent diabetes is usually faster than in type 2 diabetes (T2D) but the factors influencing this progression are not completely known. In this study, we searched for sensitive markers associated with early development of insulin dependence. DESIGN The screening of 5568 T2D patients for glutamic acid decarboxylase autoantibodies (GAD65Ab) identified 276 LADA patients (M=131; F=145) and in 251 of them, tyrosine phosphatase-2 (IA-2Ab) and thyroperoxidase autoantibodies (TPOAbs), some clinical features and genotype variation of the main type 1 diabetes (T1D) disease susceptibility loci (HLA-DRB1 and HLA-DQB1) were analyzed. RESULTS Four years after the diagnosis of diabetes, high GAD65Ab titer was not significantly associated with faster progression toward insulin deficiency (P=0.104). Patients with GAD65Ab and TPOAb or IA-2Ab or triple positivity for both islet and TPOAbs (GAD65Ab/IA-2Ab/TPOAb) showed a significantly faster disease progression (P=0.002). Among 104 TPOAb-positive LADA patients, 10 received replacement therapy (l-thyroxine), 43 showed high TSH levels (62.7% developed insulin dependence), and 3 had hyperthyroidism treated with methimazole. Multivariate analysis revealed a significant effect on disease progression only for TPOAb (P=0.022), female gender (P=0.036), low body mass index (BMI; P=0.001), and T1D high/intermediate risk HLA-DRB1/DQB1 genotypes grouped (P=0.020). CONCLUSIONS High GAD65Ab titers per se are not a major risk factor for disease progression in LADA, while the number of positive autoantibodies and HLA DRB1-DQB1 genotypes at high risk for T1D are significant predictors. Moreover, clinical characteristics such as low BMI and female gender are more likely to identify patients who will require insulin therapy within 4 years of diagnosis.
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Affiliation(s)
- M Maioli
- Department of Internal Medicine, University of Sassari, Sassari, Italy.
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Grant SFA, Hakonarson H, Schwartz S. Can the genetics of type 1 and type 2 diabetes shed light on the genetics of latent autoimmune diabetes in adults? Endocr Rev 2010; 31:183-93. [PMID: 20007922 DOI: 10.1210/er.2009-0029] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The pathophysiology of latent autoimmune diabetes in adults (LADA) is considered less understood than its much better characterized counterparts of type 1 and type 2 diabetes (T1D and T2D), where its clinical presentation exhibits some features of each of these two main diseases, earning it a reputation as being "type 1.5 diabetes". The etiology of LADA remains unknown, but a genetic component has been implicated from recent reports of T1D and T2D genes playing a role in its pathogenesis. One way to shed much needed light on the classification of LADA is to determine the discrete genetic factors conferring risk to the pathogenesis of this specific phenotype and to determine to what extent LADA shares genetic similarities with T1D and T2D. For instance, no conclusive support for a role of the T1D-associated INS gene has been reported in T2D; conversely, but similarly, no evidence has been found for the role of the T2D-associated genes IDE/HHEX, SLC30A8, CDKAL1, CDKN2A/B, IGF2BP2, FTO, and TCF7L2 in T1D. However, and somewhat at odds with current thinking, TCF7L2, the most strongly associated gene with T2D to date, is strongly associated with LADA, a disorder considered by the World Health Organization to be a slowly progressing form of T1D. In this review, we address recent advances in the genetics of T1D and T2D and how such discoveries have in turn shed some light on the genetics of LADA as being potentially at the "genetic intersection" of these two major diseases.
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Affiliation(s)
- Struan F A Grant
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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Clinical and metabolic characteristics of patients with latent autoimmune diabetes in adults (LADA): Absence of rapid beta-cell loss in patients with tight metabolic control. DIABETES & METABOLISM 2010; 36:64-70. [DOI: 10.1016/j.diabet.2009.07.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 07/26/2009] [Accepted: 07/29/2009] [Indexed: 11/30/2022]
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Abstract
CONTEXT Autoantibodies that are reactive to islet antigens are present at the time of diagnosis in most patients with type 1 diabetes. Additionally, approximately 10% of phenotypic type 2 diabetic patients are positive for at least one of the islet autoantibodies, and this group is often referred to as "latent autoimmune diabetes in adults (LADA)." These patients share many genetic and immunological similarities with type 1 diabetes, suggesting that LADA, like type 1 diabetes, is an autoimmune disease. However, there are differences in autoantibody clustering, T cell reactivity, and genetic susceptibility and protection between type 1 diabetes and LADA, implying important differences in the underlying disease processes. EVIDENCE ACQUISITION AND SYNTHESIS In this clinical review, we will summarize the current understanding of LADA based on the MEDLINE search of all peer-reviewed publications (original articles and reviews) on this topic between 1974 and 2009. CONCLUSIONS In LADA, diabetes occurs earlier in the beta-cell-destructive process because of the greater insulin resistance. Complexities arise also because of variable definitions of LADA and type 1 diabetes in adults. As immunomodulatory therapies that slow or halt the type 1 diabetes disease process are discovered, testing these therapies in LADA will be essential.
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Affiliation(s)
- Ramachandra G Naik
- Charles River Clinical Services Northwest, Tacoma, Washington 98418, USA
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Thunander M, Petersson C, Jonzon K, Fornander J, Ossiansson B, Torn C, Edvardsson S, Landin-Olsson M. Incidence of type 1 and type 2 diabetes in adults and children in Kronoberg, Sweden. Diabetes Res Clin Pract 2008; 82:247-55. [PMID: 18804305 DOI: 10.1016/j.diabres.2008.07.022] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2008] [Revised: 07/10/2008] [Accepted: 07/14/2008] [Indexed: 12/19/2022]
Abstract
All newly diagnosed diabetes in Kronoberg during 3 years was registered, with blood samples from 1630/1666 (97.8%) adults. Those positive for GADab and/or ICA and/or C-peptide<0.25nmol/L (0.7%) were classified as type 1 diabetes, the remaining as type 2. Incidence of type 1 in 0-19-year-olds was 37.8(36.1-39.6, 95%CI) and in 20-100 year-olds 27.1(25.6-27.4) per 100 000 and year, it was bimodal with equal peaks in 0-9 year-olds and in 50-80-year-olds. Adults had type 2 incidence 378 (375-380), children 3.1 (2.6-3.6). Among adults 6.9% had type 1 and 93.1% type 2. Among antibodypositive adults (n=101), GADab were present in 90%, ICA in 71%, both GADab and ICA in 61%. Ophthalmology contact as second source was confirmed for 98%. There were no gender differences in type 1 in any age group, small ones in pediatric subgroups. In type 2 men predominated in ages above 40 years. Incidences of type 1 diabetes in both children and adults were very high and as high above age 50 years as in children. Incidence of type 2 was the highest reported from Sweden, to which new diagnostic criteria, a high degree of case-finding, and many elders, may have contributed, but results may also reflect a true increase in incidence of both types of diabetes.
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Affiliation(s)
- M Thunander
- Department of Internal Medicine, Central Hospital, S- 351 85 Vaxjo, Sweden.
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Leslie RDG, Kolb H, Schloot NC, Buzzetti R, Mauricio D, De Leiva A, Yderstraede K, Sarti C, Thivolet C, Hadden D, Hunter S, Schernthaner G, Scherbaum W, Williams R, Pozzilli P. Diabetes classification: grey zones, sound and smoke: Action LADA 1. Diabetes Metab Res Rev 2008; 24:511-9. [PMID: 18615859 DOI: 10.1002/dmrr.877] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diseases gain identity from clinical phenotype as well as genetic and environmental aetiology. The definition of type 1 diabetes is clinically exclusive, comprising patients who are considered insulin dependent at diagnosis, whilst the definition of type 2 diabetes is inclusive, only excluding those who are initially insulin dependent. Ketosis-prone diabetes (KPD) and latent autoimmune diabetes in adults (LADA) are each exclusive forms of diabetes which are, at least initially, clinically distinct from type 2 diabetes and type 1 diabetes, and each have a different natural history from these major types of diabetes.KPD can be diagnosed unequivocally as diabetes presenting with the categorical clinical feature, ketoacidosis. In contrast, LADA can be diagnosed by the co-occurrence of three traits, not one of which is categorical or exclusive to the condition: adult-onset non-insulin-requiring diabetes, an islet autoantibody such as glutamic acid decarboxylase autoantibodies (GADA) or cytoplasmic islet cell autoantibodies (ICA), and no need for insulin treatment for several months post-diagnosis. But while some would split diabetes into distinct subtypes, there is a strong case that these subtypes form a continuum of varying severity of immune and metabolic dysfunction modified by genetic and non-genetic factors. This article discusses the nature of disease classification in general, and KPD and LADA in particular, emphasizing the potential value and pitfalls in classifying diabetes and suggesting a need for more research in this area.
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Affiliation(s)
- R D G Leslie
- Institute of Cell and Molecular Science, University of London, London, UK.
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O'Gorman DJ, Yousif O, Dixon G, McQuaid S, Murphy E, Rahman Y, Gasparro D, Pacini G, Newsholme P, Nolan JJ. In vivo and in vitro studies of GAD-antibody positive subjects with Type 2 diabetes: A distinct sub-phenotype. Diabetes Res Clin Pract 2008; 80:365-70. [PMID: 18405999 DOI: 10.1016/j.diabres.2007.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2007] [Accepted: 12/08/2007] [Indexed: 11/24/2022]
Abstract
The purpose of this study was to determine if immune mechanisms in GAD positive patients' contribute to the pathogenesis of a specific sub-type of Type 2 diabetes. GAD positive (n=8) and GAD negative (n=8) subjects diagnosed with Type 2 diabetes were matched for age, gender, body mass index, duration of diabetes and glycaemic control. All subjects underwent an insulin-modified frequently sampled intravenous glucose tolerance test to measure insulin sensitivity and insulin secretory function with minimal model analysis. In addition, BRIN-BD11 clonal beta-cells were supplemented with patients' sera to determine basal and alanine-stimulated insulin secretion and terminal complement complex (TCC) formation. Both groups were severely insulin resistant (0.56+/-0.17 vs. 0.99+/-0.3310(-4)min(-1)/(microUml(-1)) for GADneg and GADpos, respectively) but the GAD negative subjects had a higher basal (87+/-11 vs. 58+/-14pmoll(-1), p<0.05) and glucose-stimulated insulin secretion (DeltaAUCins 0.96+/-0.12 vs. 0.60+/-0.12pmol/(l(-1)min), p<0.05). In vivo measures of insulin secretion were negatively correlated with TCC formation, independent of antibody status. In conclusion, GAD positive subjects initially diagnosed with Type 2 diabetes are unable to compensate for insulin resistance due to more pronounced beta-cell impairment. TCC formation may be partly responsible for the insulin secretory dysfunction associated with this specific sub-type of Type 2 diabetes.
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Affiliation(s)
- Donal J O'Gorman
- Metabolic Research Unit, Department of Endocrinology, St. James's Hospital, Trinity College Dublin, Dublin 8, Ireland
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Murao S, Kondo S, Ohashi J, Fujii Y, Shimizu I, Fujiyama M, Ohno K, Takada Y, Nakai K, Yamane Y, Osawa H, Makino H. Anti-thyroid peroxidase antibody, IA-2 antibody, and fasting C-peptide levels predict beta cell failure in patients with latent autoimmune diabetes in adults (LADA)--a 5-year follow-up of the Ehime study. Diabetes Res Clin Pract 2008; 80:114-21. [PMID: 18342387 DOI: 10.1016/j.diabres.2008.01.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2007] [Accepted: 11/21/2007] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To clarify the natural course and factors involved in beta cell failure in Japanese latent autoimmune diabetes in adults (LADA) patients. RESEARCH DESIGN AND METHODS Insulin secretion in 57 LADA patients identified from among 4980 adult-onset diabetic patients in a hospital-based Ehime study were examined over a 5-year period. Postprandial serum C-peptide levels below 0.33 nmol/l were defined as beta cell failure. The involvement of clinical and immunological factors in the progression to beta cell failure were evaluated. RESULTS Forty-two of the fifty-seven LADA patients completed the 5-year follow-up. Eleven (26.2%) required insulin treatment and five (11.9%) progressed to beta cell failure. A Cox regression analysis revealed that positive anti-thyroid peroxidase antibody (TPOAb) and insulinoma-associated protein 2 (IA-2Ab) were associated with the need for insulin treatment (p<0.05 and p<0.01, respectively). Positive TPOAb, anti-thyroglobulin antibody (TGAb), IA-2 antibody (p<0.01 for each), and lower serum fasting C-peptide levels (p<0.05) were contributors to the progression to beta cell failure. Involvement of type 1 diabetes susceptible HLA class II genes was not evident. CONCLUSIONS Japanese LADA patients are a heterogeneous population. In addition to IA-2 antibody, presence of TPOAb and fasting C-peptide level could indicate an oncoming deterioration of beta cell function.
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van Deutekom AW, Heine RJ, Simsek S. The islet autoantibody titres: their clinical relevance in latent autoimmune diabetes in adults (LADA) and the classification of diabetes mellitus. Diabet Med 2008; 25:117-25. [PMID: 18028440 DOI: 10.1111/j.1464-5491.2007.02316.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Latent autoimmune diabetes in the adult (LADA) is a slowly progressive form of autoimmune diabetes, characterized by diabetes-associated autoantibody positivity. A recent hypothesis proposes that LADA consists of a heterogeneous population, wherein several subgroups can be identified based on their autoimmune status. A systematic review of the literature was carried out to appraise whether the clinical characteristics of LADA patients correlate with the titre and numbers of diabetes-associated autoantibodies. We found that the simultaneous presence of multiple autoantibodies and/or a high-titre anti-glutamic acid decarboxylase (GAD)--compared with single and low-titre autoantibody--is associated with an early age of onset, low fasting C-peptide values as a marker of reduced pancreatic B-cell function, a high predictive value for future insulin requirement, the presence of other autoimmune disorders, a low prevalence of markers of the metabolic syndrome including high body mass index, hypertension and dyslipidaemia, and a high prevalence of the genotype known to increase the risk of Type 1 diabetes. We propose a more continuous classification of diabetes mellitus, based on the finding that the clinical characteristics gradually change from classic Type 1 diabetes to LADA and finally to Type 2 diabetes. Future studies should focus on determining optimal cut-off points of anti-GAD for differentiating clinically relevant diabetes mellitus subgroups.
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Affiliation(s)
- A W van Deutekom
- Department of Endocrinology/Diabetes Center, VU University Medical Center, Amsterdam, The Netherlands
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Jensen RA, Gilliam LK, Törn C, Landin-Olsson M, Karlsson FA, Palmer JP, Kockum I, Akesson K, Lernmark B, Lynch K, Breslow N, Lernmark A. Multiple factors affect the loss of measurable C-peptide over 6 years in newly diagnosed 15- to 35-year-old diabetic subjects. J Diabetes Complications 2007; 21:205-13. [PMID: 17616349 DOI: 10.1016/j.jdiacomp.2006.01.004] [Citation(s) in RCA: 17] [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: 09/09/2005] [Accepted: 01/10/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study is to identify risk factors for the loss of measurable plasma C-peptide in newly diagnosed 15- to 35-year-old diabetic subjects. METHODS This Swedish study included 778 subjects. C-peptide levels were obtained each year for 6 years after diagnosis. Loss of measurable C-peptide was defined as a level at or below the lower detection limit of the local assay (0.13 nmol/l). In addition to C-peptide, other baseline covariates included gender, age, body mass index, HLA genotype, and autoantibody levels. RESULTS Compared with autoantibody-negative subjects, autoantibody-positive subjects had lower median baseline C-peptide (0.27 vs. 0.50, P<.001), their levels declined over the study period, and the risk of losing measurable C-peptide was significantly higher when more than one autoantibody was present [odds ratio (OR), 4.0; 95% confidence interval (CI), 2.13-7.54]. Among autoantibody-positive individuals, the presence of GAD65Ab (OR, 1.8; 95% CI, 1.24-2.51) and islet cell antibodies (OR, 1.6; 95% CI, 1.19-2.18) conferred a higher risk for loss of measurable C-peptide as did female gender (OR, 1.6; 95% CI, 1.17-2.11) and time after diagnosis (OR, 1.5 for each additional year postdiagnosis; 95% CI, 1.41-1.57). Higher baseline C-peptide levels were protective (OR, 0.5 for each additional log(e) nanomoles per liter; 95% CI, 0.36-0.58). CONCLUSIONS This study identified autoantibody status, gender, and baseline C-peptide levels as factors that will be useful for predicting the disease course of 15- to 35-year-old diabetic individuals.
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Affiliation(s)
- Richard A Jensen
- Department of Biostatistics, University of Washington, Seattle, WA, USA.
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Guías de práctica clínica sobre diabetes, prediabetes y enfermedades cardiovasculares: versión resumida. Rev Esp Cardiol 2007. [DOI: 10.1016/s0300-8932(07)75070-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Dales R, Chen Y, Lin M, Karsh J. The association between allergy and diabetes in the Canadian population: implications for the Th1-Th2 hypothesis. Eur J Epidemiol 2006; 20:713-7. [PMID: 16151885 DOI: 10.1007/s10654-005-7920-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2005] [Indexed: 12/22/2022]
Abstract
T-lymphocytes may preferentially differentiate towards a Th1 subtype, which is thought to be involved in the autoimmune aspects of diabetes, or a Th2 subtype, which is thought to mediate allergic disease. The activation of one subtype is thought to inhibit the other. To determine if diabetes is less common among those with allergic disease, consistent with the postulated TH1/Th2 paradigm, we used data from the 2000-2001 Canadian Community Health Survey of those at least 12 years of age from 125,159 households. Diabetes requiring insulin was reported in 1% whether or not allergies were reported. The crude odds ratio between diabetes and allergies for the entire population was 1.06 (95% confidence interval (CI): 0.90, 1.24). Adjusted for household size, number of bedrooms, immigrant status, income adequacy, educational level, smoking status, alcohol drinking status, regular exercise, and age, there was a positive association between allergy and diabetes with an odds ratio of 1.25 (95% CI: 1.06, 1.49). These results do not provide evidence for the existence of the Th1/Th2 paradigm as a determinant of disease patterns in the general population.
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Affiliation(s)
- Robert Dales
- Department of Medicine, Ottawa Health Research Institute, Canada.
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Stenström G, Gottsäter A, Bakhtadze E, Berger B, Sundkvist G. Latent autoimmune diabetes in adults: definition, prevalence, beta-cell function, and treatment. Diabetes 2005; 54 Suppl 2:S68-72. [PMID: 16306343 DOI: 10.2337/diabetes.54.suppl_2.s68] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Latent autoimmune diabetes in adults (LADA) is a disorder in which, despite the presence of islet antibodies at diagnosis of diabetes, the progression of autoimmune beta-cell failure is slow. LADA patients are therefore not insulin requiring, at least during the first 6 months after diagnosis of diabetes. Among patients with phenotypic type 2 diabetes, LADA occurs in 10% of individuals older than 35 years and in 25% below that age. Prospective studies of beta-cell function show that LADA patients with multiple islet antibodies develop beta-cell failure within 5 years, whereas those with only GAD antibodies (GADAs) or only islet cell antibodies (ICAs) mostly develop beta-cell failure after 5 years. Even though it may take up to 12 years until beta-cell failure occurs in some patients, impairments in the beta-cell response to intravenous glucose and glucagon can be detected at diagnosis of diabetes. Consequently, LADA is not a latent disease; therefore, autoimmune diabetes in adults with slowly progressive beta-cell failure might be a more adequate concept. In agreement with proved impaired beta-cell function at diagnosis of diabetes, insulin is the treatment of choice.
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Fourlanos S, Dotta F, Greenbaum CJ, Palmer JP, Rolandsson O, Colman PG, Harrison LC. Latent autoimmune diabetes in adults (LADA) should be less latent. Diabetologia 2005; 48:2206-12. [PMID: 16193284 DOI: 10.1007/s00125-005-1960-7] [Citation(s) in RCA: 221] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Accepted: 05/11/2005] [Indexed: 12/15/2022]
Abstract
'Latent autoimmune diabetes in adults' (LADA) is the term coined to describe adults who have a slowly progressive form of autoimmune or type 1 diabetes that can be treated initially without insulin injections. The diagnosis of LADA is currently based on three clinical criteria: (1) adult age at onset of diabetes; (2) the presence of circulating islet autoantibodies, which distinguishes LADA from type 2 diabetes; and (3) insulin independence at diagnosis, which distinguishes LADA from classic type 1 diabetes. The prevalence of LADA in adults presenting with non-insulin-requiring diabetes is approximately 10%. Recognition of LADA expands the concept and prevalence of autoimmune diabetes, but LADA remains poorly understood at both a clinical and research level. In this perspective, we review the nomenclature, diagnostic criteria, genetics, pathology and therapy of LADA, to arrive at recommendations that might advance knowledge and management of this form of diabetes.
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Affiliation(s)
- S Fourlanos
- Autoimmunity and Transplantation Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
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Affiliation(s)
- P Narendran
- Clinical Science at North Bristol, University of Bristol, Southmead Hospital, Bristol, UK.
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Vauhkonen I, Niskanen L, Knip M, Mykkänen LM, Haffner S, Uusitupa M, Laakso M. Subtle hyperproinsulinaemia characterises the defective insulin secretory capacity in offspring of glutamic acid decarboxylase antibody-positive patients with latent autoimmune diabetes mellitus in adults. Eur J Endocrinol 2005; 153:265-73. [PMID: 16061833 DOI: 10.1530/eje.1.01972] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE We set out to assess whether hyperproinsulinaemia is an early finding in latent autoimmune diabetes in adults (LADA). RESEARCH DESIGN AND METHODS We measured plasma proinsulin and C-peptide responses during a 2-h oral glucose tolerance test (OGTT) and in the hyperglycaemic clamp in 21 normoglycaemic offspring of LADA patients testing positive for glutamic acid decarboxylase antibodies (GADA) or islet cell antibodies (ICA), and in 17 healthy control subjects without a family history of diabetes. RESULTS The study groups had comparable areas under the curves of blood glucose, plasma proinsulin, C-peptide and proinsulin/C-peptide in the OGTT. However, the offspring of LADA patients had higher proinsulin/C-peptide in the hyperglycaemic clamp (P < 0.01 versus the control group). The offspring of GADA-positive LADA patients (n = 9) had higher proinsulin and proinsulin/C-peptide than did the control group in the OGTT (P < 0.05 for both comparisons) and in the hyperglycaemic clamp (P < 0.001 and P < 0.05 respectively). They also had higher proinsulin than the offspring of ICA-positive LADA patients (n = 12) (P < 0.001) in the hyperglycaemic clamp. The offspring of ICA-positive LADA patients did not clearly show hyperproinsulinaemia during the tests, but they had lower maximal glucose-stimulated insulin secretory capacity than the control group (P < 0.05) and the offspring of GADA-positive LADA patients (P < 0.05) in the hyperglycaemic clamp. CONCLUSIONS These results suggested that insulin secretion in the offspring of GADA-positive LADA patients is characterised by subtle defects in the processing of insulin precursors. Furthermore, various proinsulin responses among the offspring of LADA patients with different autoimmune markers provided further evidence that LADA is a heterogeneous disorder.
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Affiliation(s)
- Ilkka Vauhkonen
- Department of Medicine, Kuopio University Hospital, Finland.
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Yang L, Zhou ZG, Huang G, Ouyang LL, Li X, Yan X. Six-year follow-up of pancreatic β cell function in adults with latent autoimmune diabetes. World J Gastroenterol 2005; 11:2900-5. [PMID: 15902725 PMCID: PMC4305656 DOI: 10.3748/wjg.v11.i19.2900] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the characteristics of the progression of islet β cell function in Chinese latent autoimmune diabetes in adult (LADA) patients with glutamic acid decarboxylase antibody (GAD-Ab) positivity, and to explore the prognostic factors for β cell function.
METHODS: Forty-five LADA patients with GAD-Ab positivity screened from phenotypic type 2 diabetic (T2DM) patients and 45 T2DM patients without GAD-Ab matched as controls were followed-up every 6 mo. Sixteen patients in LADA1 and T2DM1 groups respectively have been followed-up for 6 years, while 29 patients in LADA2 and T2DM2 groups respectively for only 1.5 years. GAD-Ab was determined by radioligand assay, and C-peptides (CP) by radioimmune assay.
RESULTS: The percentage of patients whose fasting CP (FCP) decreased more than 50% compared with the baseline reached to 25.0% at 1.5th year in LADA1 group, and FCP level decreased (395.8±71.5 vs 572.8±72.3 pmol/L, P<0.05) at 2.5th year and continuously went down to the end of follow-up. No significant changes of the above parameters were found in T2DM1 group. The average decreased percentages of FCP per year in LADA and T2DM patients were 15.8% (4.0-91.0%) and 5.2% (-3.5 to 35.5%, P = 0.000) respectively. The index of GAD-Ab was negatively correlated with the FCP in LADA patients (rs = -0.483, P = 0.000). The decreased percentage of FCP per year in LADA patients were correlated with GAD-Ab index, body mass index (BMI) and age at onset (rs = 0.408, -0.301 and -0.523 respectively, P<0.05). Moreover, GAD-Ab was the only risk factor for predicting β cell failure in LADA patients (B = 1.455, EXP (B) = 4.283, P = 0.023).
CONCLUSION: The decreasing rate of islet β cell function in LADA, being highly heterogeneous, is three times that of T2DM patients. The titer of GAD-Ab is an important predictor for the progression of islet β cell function, and age at onset and BMI could also act as the predictors.
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Affiliation(s)
- Lin Yang
- Institute of Metabolism and Endocrinology, the Second Xiangya Hospital, Central South University, Changsha 410011, Hunan Province, China
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Gottsäter A, Kangro M, Sundkvist G. Early parasympathetic neuropathy associated with elevated fasting plasma C-peptide concentrations and late parasympathetic neuropathy with hyperglycaemia and other microvascular complications. Diabet Med 2004; 21:1304-9. [PMID: 15569133 DOI: 10.1111/j.1464-5491.2004.01340.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS To examine the relationship between parasympathetic neuropathy, hyperinsulinaemia, glycaemic control (HbA(1c)), and future diabetic complications. METHODS We assessed parasympathetic nerve function [expiration/inspiration (E/I) ratio], glomerular filtration rate (GFR), glycaemic control (HbA(1c)), fasting plasma (f-p-) C-peptide in 82 Type 2 diabetic patients (age 61 +/- 1 years) 5 and 12-15 years after diagnosis. Diabetic retinopathy was assessed 15 years after diagnosis. RESULTS High HbA(1c) values in the first study were associated with retinopathy (with 8.6 +/- 2.0 vs. without retinopathy 6.2 +/- 1.9%; P < 0.0001) and disturbed parasympathetic nerve function (low E/I ratio; r(s) = -0.41; P = 0.0061) in the second study, as well as with deteriorations in GFR between the first and second study (r(s) = 0.62; P < 0.0001). Patients with parasympathetic neuropathy in the first study had significantly higher f-p-C-peptide concentrations than those without 3 years (1.20 +/- 0.43 vs. 0.86 +/- 0.40 nmol/l; P = 0.0015) and 5 years (1.20 +/- 0.44 vs. 0.82 +/- 0.33 nmol/l; P < 0.0001), but not 15 years after diagnosis. CONCLUSION High HbA(1c) values 5 years after diagnosis of Type 2 diabetes were associated with retinopathy, disturbed parasympathetic nerve function, and deterioration in GFR 7-10 years later. Parasympathetic neuropathy 5 years after diagnosis was associated with high C-peptide concentrations. Parasympathetic nerve function has to be considered when beta-cell function is evaluated. Hyperglycaemia is an important factor for the development of complications in Type 2 diabetes.
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Affiliation(s)
- A Gottsäter
- Department of Vascular Diseases, University of Lund, University Hospital MAS, Malmo, Sweden.
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Affiliation(s)
- H K Chiu
- Department of Medicine, Division of Metabolism, Endocrinology and Nutrition, University of Washington, VA Puget Sound Health Care System, Seattle, WA, USA.
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Palmer JP, Fleming GA, Greenbaum CJ, Herold KC, Jansa LD, Kolb H, Lachin JM, Polonsky KS, Pozzilli P, Skyler JS, Steffes MW. C-peptide is the appropriate outcome measure for type 1 diabetes clinical trials to preserve beta-cell function: report of an ADA workshop, 21-22 October 2001. Diabetes 2004; 53:250-64. [PMID: 14693724 DOI: 10.2337/diabetes.53.1.250] [Citation(s) in RCA: 365] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The underlying cause of type 1 diabetes, loss of beta-cell function, has become the therapeutic target for a number of interventions in patients with type 1 diabetes. Even though insulin therapies continue to improve, it remains difficult to achieve normal glycemic control in type 1 diabetes, especially long term. The associated risks of hypoglycemia and end-organ diabetic complications remain. Retention of beta-cell function in patients with type 1 diabetes is known to result in improved glycemic control and reduced hypoglycemia, retinopathy, and nephropathy. To facilitate the development of therapies aimed at altering the type 1 diabetes disease process, an American Diabetes Association workshop was convened to identify appropriate efficacy outcome measures in type 1 diabetes clinical trials. The following consensus emerged: While measurements of immune responses to islet cells are important in elucidating pathogenesis, none of these measures have directly correlated with the decline in endogenous insulin secretion. HbA(1c) is a highly valuable clinical measure of glycemic control, but it is an insensitive measure of beta-cell function, particularly with the currently accepted standard of near-normal glycemic control. Rates of severe hypoglycemia and diabetic complications ultimately will be improved by therapies that are effective at preserving beta-cell function but as primary outcomes require inordinately large and protracted trials. Endogenous insulin secretion is assessed best by measurement of C-peptide, which is cosecreted with insulin in a one-to-one molar ratio but unlike insulin experiences little first pass clearance by the liver. Measurement of C-peptide under standardized conditions provides a sensitive, well accepted, and clinically validated assessment of beta-cell function. C-peptide measurement is the most suitable primary outcome for clinical trials of therapies aimed at preserving or improving endogenous insulin secretion in type 1 diabetes patients. Available data demonstrate that even relatively modest treatment effects on C-peptide will result in clinically meaningful benefits. The development of therapies for addressing this important unmet clinical need will be facilitated by trials that are carefully designed with beta-cell function as determined by C-peptide measurement as the primary efficacy outcome.
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Affiliation(s)
- Jerry P Palmer
- Department of Medicine, University of Washington,and DVA Puget Sound Health Care System, Seattle, Washington 98108, USA.
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Avilés-Santa L, Maclaren N, Raskin P. Immune-mediated disease and secondary failure to oral therapy in type 2 diabetes mellitus. J Diabetes Complications 2004; 18:10-7. [PMID: 15019594 DOI: 10.1016/s1056-8727(02)00253-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2002] [Accepted: 11/01/2002] [Indexed: 11/16/2022]
Abstract
PURPOSE To determine the proportion of adults with type 2 diabetes, who developed secondary failure to oral medications that had immune-mediated diabetes (IMD). SUBJECTS AND METHODS One hundred and eight subjects who failed to oral therapy were screened for autoantibodies (ICA, IAA, IA-2A, and GADA(65)) and HLA DR/DQ markers of IMD. RESULTS Mean age was 49 years and mean body mass index (BMI) was 31.5 kg/m(2); 21.3% were non-Hispanic White (NHW), 32.3% Latin American (LA), and 43.2% African American (AA). Fourteen percent had one or more autoantibodies [Ab(+)]: five NHW, three LA, and seven AA. Ab(+) patients were younger (P=.03) and had lower body weight (P=.05) than Ab(-) patients. HLA markers of susceptibility for IMD were identified in 64% Ab(+) and in 43% Ab(-) (chi(2), P=.46). CONCLUSIONS These results suggest that secondary failure to oral therapy can be due to continuing IMD in obese, type 2 diabetic individuals of varying ethnic backgrounds than those who have been traditionally associated with autoimmune type 1 diabetes. Screening for markers for IMD at diagnosis could be a useful way to predict those likely to develop secondary failure to oral therapy and may assist in the selection of medical therapy.
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Affiliation(s)
- Larissa Avilés-Santa
- Department of Internal Medicine, The University of Texas Southwestern Medical Center at Dallas, Parkland Health and Hospital System 5323 Harry Hines Boulevard G5.238, Dallas, TX 75390-8858, USA.
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Affiliation(s)
- Ramachandra G Naik
- Consultant Endocrinologist, Bombay Hospital and Medical Research Center, 12 New Marine Lines, Mumbai, India 400 020
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Palmer JP, Hirsch IB. What's in a name: latent autoimmune diabetes of adults, type 1.5, adult-onset, and type 1 diabetes. Diabetes Care 2003; 26:536-8. [PMID: 12547896 DOI: 10.2337/diacare.26.2.536] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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Borg H, Gottsäter A, Fernlund P, Sundkvist G. A 12-year prospective study of the relationship between islet antibodies and beta-cell function at and after the diagnosis in patients with adult-onset diabetes. Diabetes 2002; 51:1754-62. [PMID: 12031962 DOI: 10.2337/diabetes.51.6.1754] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
To clarify the relationships between islet antibodies (islet cell antibody [ICA], GAD antibody [GADA], and IA-2 antibody [IA-2A]) versus the progression of beta-cell dysfunction, we have followed a group of diabetic patients from their diagnosis at 21-73 years of age. Patients with ICA had high levels of GADA and/or IA-2A at diagnosis and a more severe beta-cell dysfunction 5 years after diagnosis than those with only GADA in low concentrations. The aim of the current 12-year follow-up study was to examine the further progression of beta-cell dysfunction in relation to islet antibodies at and after diagnosis. Among 107 patients, complete beta-cell failure 12 years after diagnosis was restricted to those with islet antibodies at diagnosis (16 of 21 [77%] with multiple antibodies and 4 of 5 [80%] with only GADA). In contrast, among antibody-negative patients, fasting P-C-peptide levels were unchanged. Most GADA-positive patients (22 of 27 [81%]) remained GADA positive after 12 years. Associated with decreasing fasting P-C-peptide levels (0.85 nmol/l [0.84] at diagnosis vs. 0.51 nmol/l [0.21] 12 years after diagnosis, P < 0.05), ICA developed after diagnosis in 6 of 105 originally antibody negative mostly overweight patients. In conclusion, multiple islet antibodies or GADA alone at diagnosis of diabetes predict future complete beta-cell failure. After diagnosis, GADA persisted in most patients, whereas ICA development in patients who were antibody negative at diagnosis indicated decreasing beta-cell function.
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Affiliation(s)
- Henrik Borg
- Department of Endocrinology, Lund University, Malmö University Hospital, Malmö, Sweden.
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Soriguer-Escofet F, Esteva I, Rojo-Martinez G, Ruiz de Adana S, Catalá M, Merelo MJ, Aguilar M, Tinahones F, García-Almeida JM, Gómez-Zumaquero JM, Cuesta-Muñoz AL, Ortego J, Freire JM. Prevalence of latent autoimmune diabetes of adults (LADA) in Southern Spain. Diabetes Res Clin Pract 2002; 56:213-20. [PMID: 11947969 DOI: 10.1016/s0168-8227(02)00002-5] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To study the prevalence of diabetes mellitus and islet autoantibodies in an adult population from Southern Spain. RESEARCH AND METHODS A cross-sectional study in Southern Spain of 1226 people, age 18-65 years. Clinical data were obtained and a blood sample taken to measure autoantibodies (glutamic acid decarboxylase antibodies (GADAb), tyrosine phosphatase antibodies (IA2Ab), and insulin antibodies (IAA)). An oral glucose tolerance test (OGTT) was also given to 982 of the subjects. RESULTS The overall prevalence of diabetes mellitus according to the WHO 1979 criteria was 10.9% and according to the ADA 1997 criteria it was 14.7% (8.8% were unaware of their diabetes). The prevalence of impaired fasting glucose (IFG) was 12.4% and of impaired glucose tolerance (IGT) 11.5%. The prevalence of GADAb+ in the general population was 0.9% and in the diabetic population 3.7%. There were no significant differences between groups in the prevalence of IA2Ab or IAA (both were 0.8% in the general population). Of the three autoantibodies studied, only GADAb were significantly different in the diabetic population (P=0.0006). CONCLUSIONS The prevalence of Type 2 diabetes and LADA are high in the south of Spain.
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Affiliation(s)
- Federico Soriguer-Escofet
- Endocrinology and Nutrition Service, Hospital Civil, Carlos Haya Hospital Complex, Malaga 29018, Spain.
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Falorni A, Calcinaro F. Autoantibody profile and epitope mapping in latent autoimmune diabetes in adults. Ann N Y Acad Sci 2002; 958:99-106. [PMID: 12021088 DOI: 10.1111/j.1749-6632.2002.tb02951.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The presence of islet cell autoantibodies in adult diabetic subjects who do not require insulin treatment for at least six months after the initial clinical diagnosis identifies the so-called latent autoimmune diabetes in the adult (LADA). Glutamic acid decarboxylase autoantibodies (GAD65Ab) are the best immune marker to identify LADA patients, while other islet autoantibodies, such as IA-2 autoantibodies, have a very low diagnostic sensitivity. Islet cell antibodies, as detected by indirect immunofluorescence, may improve the diagnostic specificity of the immune analysis when detected in GAD65Ab-positive patients. Although the majority of LADA patients progresses towards insulin dependency within a few years after the diagnosis, this form of diabetes is heterogeneous. The presence of high titers of GAD65Ab and/or GAD65Ab directed towards COOH-terminal epitopes of the autoantigen (GAD65-CAb) identifies a subgroup of LADA patients with clinical characteristics similar to those of typical type 1 diabetes and at very high risk of progression toward insulin dependency. On the other hand, low titers of GAD65Ab, or the exclusive presence of GAD65Ab directed to middle epitopes of the autoantigen, characterizes LADA patients with clinical characteristics almost indistinguishable from those of GAD65Ab-negative type 2 diabetic patients. LADA subjects, especially in the presence of high titers of GAD65Ab and/or GAD65-CAb, have an increased risk for other organ-specific autoimmune diseases such as thyroid autoimmune diseases or autoimmune Addison's. LADA should be considered a major component of the autoimmune polyendocrine syndromes, and screening for other autoimmune diseases should be performed in all LADA patients.
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Affiliation(s)
- Alberto Falorni
- Department of Internal Medicine, Section of Internal Medicine and Endocrine & Metabolic Sciences, University of Perugia, Perugia, Italy
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Vague P, Nguyen L. Rationale and methods for the estimation of insulin secretion in a given patient: from research to clinical practice. Diabetes 2002; 51 Suppl 1:S240-4. [PMID: 11815486 DOI: 10.2337/diabetes.51.2007.s240] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Although the plasma insulin assay is now 40 years old, it is not widely used in clinical practice. However, simple methods (such as the various indexes relating fasting insulin to fasting glucose), the increase in plasma insulin at the 30th minute of an oral glucose tolerance test, and the increase in insulin or C-peptide after stimulation by glucagon are relatively reliable compared with more sophisticated approaches to assess beta-cell sensitivity to glucose, kinetics of insulin secretion, residual insulin secretion, or insulin sensitivity. But these measures are of no decisive help in distinguishing between the various forms of impaired fasting glucose or non-insulin-dependent diabetes, such as type 2 diabetes, slow type 1 diabetes, the various forms of maturity-onset diabetes of the young, or the mitochondrial genome defects. No data are available to show that the measurement of plasma insulin may be of help to adapt the treatment of a diabetic patient, except for the need of insulin therapy. There are some suggestions that fasting plasma insulin and, more precisely, the homeostasis model assessment indexes may help to predict the progression toward diabetes or the progressive deterioration of beta-cell function in diabetic patients.
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Affiliation(s)
- Philippe Vague
- Department of Nutrition, Endocrinology, and Metabolic Diseases, CHU Timone, Marseille, France.
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