Type 1 Diabetes Mellitus in the SARS-CoV-2 Pandemic: Oxidative Stress as a Major Pathophysiological Mechanism Linked to Adverse Clinical Outcomes

Risk of Type 1 Diabetes Mellitus in SARS-CoV-2 Patients

Recent studies have found that a link between people with type 1 diabetes mellitus (T1DM) are at higher risk of morbidity as well as mortality from COVID-19 infection, indicating a need for vaccination. T1DM appears to impair innate and adaptive immunity. The overabundance of pro-inflammatory cytokines produced in COVID-19 illness that is severe and potentially fatal is known as a "cytokine storm." Numerous cohorts have revealed chronic inflammation as a key risk factor for unfavorable COVID-19 outcomes. TNF-α, interleukin (IL)-1a, IL-1, IL-2, IL-6, and other cytokines were found in higher concentrations in patients with T1DM. Even more importantly, oxidative stress contributes significantly to the severity and course of COVID- 19's significant role in the progression and severity of COVID-19 diseases. Severe glucose excursions, a defining characteristic of type 1 diabetes, are widely recognized for their potent role as mediating agents of oxidative stress via several routes, such as heightened production of advanced glycation end products (AGEs) and activation of protein kinase C (PKC). Furthermore, persistent endothelial dysfunction and hypercoagulation found in T1DM may impair microcirculation and endothelium, which could result in the development of various organ failure and acute breathing syndrome.

COVID-19 infection and inactivated vaccination: Impacts on clinical and immunological profiles in Chinese children with type 1 diabetes

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has been linked to an increased incidence of diabetes and diabetic ketoacidosis (DKA). However, the relationship between COVID-19 infection and progression to type 1 diabetes (T1D) in children has not been well defined.

AIM

To evaluate the influence of COVID-19 infection and inactivated vaccine administration on the progression of T1D among Chinese children.

METHODS

A total of 197 newly diagnosed patients with T1D were retrospectively enrolled from Children's Hospital of Fudan University between September 2020 and December 2023. The patients were divided into three groups based on their history of COVID-19 infection and vaccination: the infection group, the vaccination-only group, and the non-infection/non-vaccination group. Comprehensive clinical assessments and detailed immunological evaluations were performed to delineate the characteristics and immune responses of these groups.

RESULTS

The incidence of DKA was significantly higher in the COVID-19 infection group (70.2%) compared to the non-infection/non-vaccination group (62.5%) and vacscination-only group (45.6%; P = 0.015). Prior COVID-19 infection was correlated with increased DKA risk (OR: 1.981, 95%CI: 1.026-3.825, P = 0.042), while vaccination was associated with a reduced risk (OR: 0.558, 95%CI: 0.312-0.998, P = 0.049). COVID-19 infection mildly altered immune profiles, with modest differences in autoantibody positivity, lymphocyte distribution, and immunoglobulin levels. Notably, HLA-DR3 positive children with a history of COVID-19 infection had an earlier T1D onset and lower fasting C-peptide levels than the HLA-DR3 negative children with a history of infection (both P < 0.05).

CONCLUSION

COVID-19 infection predisposes children to severe T1D, characterized by enhanced DKA risk. Inactivated vaccination significantly lowers DKA incidence at T1D onset. These findings are valuable for guiding future vaccination and T1D risk surveillance strategies in epidemic scenarios in the general pediatric population.

The published trend of studies on COVID-19 and diabetes: bibliometric analysis

Background

Since the COVID-19 pandemic outbreak, diabetes mellitus (DM) has been at the core of the confirmed risk factors for fatal or critical care unit-treated COVID-19 and COVID-19 related complications. Although relevant studies on DM have developed rapidly during the COVID-19 pandemic. However, the aforementioned research results have not been systematically quantified by means of bibliometric analysis.

Purpose

The purpose of this study is to provide a comprehensive analysis of the current status and trends of publications related to DM research during the COVID19 epidemic.

Methods

A bibliometric analysis was performed using the Web of Science database. In this study, we used citespace, R software and R-Bibliometrix to analyze keywords, most-cited authors, most-cited countries, most-cited global documents, and co-occurrence and co-citation networks.

Results

A total of 1688 publications was included in this study. Investigators from the United States contributed the most publications. The United States, China and Europe have the most collaboration with the other countries/regions. A total of 3355 institutions made contributions to this study. Of the top 10 institutions with the most publications, N8 Research Partnership showed the most centrality. Among the top 10 journals, Diabetes Research and Clinical Practice published the most articles. Among authors included, Khunti Kamlesh is rated first with 27 papers and has the highest centrality. The most frequently co-cited article is entitled "Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study". The most popular keywords included diabetes, mortality, diabetes, outcome, occurrences, risk, and type 1 diabetes.

Conclusion

This bibliometric study provides an overall picture of DM research and research trends during the COVID-19 pandemic and provides a basis for researchers to develop their next research strategies.

Diabetic Ketoacidosis After COVID-19 Vaccine in Patients with Type 1 Diabetes Mellitus

Background

The coronavirus disease 2019 (COVID-19) vaccine is one of the few vaccines that obtained emergency authorization to combat the fatal pandemic. Despite the fact that some available literature addressed its short-term side effects, there are still limitations on its effects on type 1 diabetes mellitus (T1DM).

Objectives

The aim of the present study was to assess the association between COVID-19 vaccination and diabetic ketoacidosis (DKA) among individuals with T1DM. Additionally, the study aimed to determine the effects of the vaccine on glucose control, variability, and risk of hypoglycemia.

Methods

This retrospective study was conducted at King Fahad Specialist Hospital (KFSH) in Qassim Region, Saudi Arabia. Diabetic ketoacidosis cases admitted to the hospital within February 2020 and August 2022 were included in the study based on specific inclusion criteria. Finally, a total of 49 patients were included in statistical analyses.

Results

Out of the 62 patients admitted to the hospital, 49 met the diagnostic criteria for DKA and agreed to participate in the study. The majority of the remaining patients (n = 13) refused to participate, and only a few of them lacked complete documentation. Of the 49 patients who were included in the study, 46 cases had a history of T1DM; nevertheless, 3 patients were newly diagnosed with T1DM. Additionally, among these participants, 16 (32.7%), 19 (38.8%), and 14 (28.6%) patients had mild, moderate, and severe DKA, respectively. There were 27 male (55.1%) and 22 female (44.9%) patients. About 91% of the patients were vaccinated against COVID-19, 30.6% of whom were vaccinated within 29 days of being diagnosed with DKA. The pH and bicarbonate levels were observed to be significantly high among those who were diagnosed with DKA within 29 days of vaccination, with p-values of 0.031 and 0.037, respectively. Similarly, pH and random blood sugar (RBS) were observed to be significantly higher among the vaccinated patients than in the non-vaccinated subjects (P = 0.044 and P = 0.032, respectively).

Conclusions

The study findings revealed that some of the DKA indicators were evident among the vaccinated patients. However, larger-scale and multi-center studies are recommended in order to have more conclusive evidence and generalize the findings.

Pediatric Diabetes and Diabetic Ketoacidosis After COVID-19: Challenges Faced and Lessons Learnt

The coronavirus disease (COVID-19) pandemic affected the management and follow-up of several chronic ailments, including pediatric type 1 diabetes mellitus (T1DM). Restricted access to healthcare and fear of contracting the virus during medical facility visits resulted in poor compliance, irregular follow-up visits, treatment, and delayed diagnosis of complications in pediatric diabetes such as diabetic ketoacidosis (DKA). As such, the incidence of complicated DKA in resource-limited settings is high due to delayed presentation, poor compliance with therapy, and associated comorbidities such as malnutrition and sepsis. The pandemic had only added to the woes. The increased surge in DKA, in the face of limited resources, prompted clinicians to find alternative solutions to manage these children effectively. In this narrative review, we discuss the key challenges faced globally while caring for children with T1DM and DKA during the COVID-19 pandemic, and the lessons learned thereof.

COVID-19 vaccination and diabetic ketoacidosis

An efficient coronavirus disease 2019 (COVID-19) vaccine is urgently required to fight the pandemic due to its high transmission rate and quick dissemination. There have been numerous reports on the side effects of the COVID-19 immu-nization, with a focus on its negative effects. Clinical endocrinology is extremely interested in the endocrine issue that arises after receiving the COVID-19 vaccine. As was already mentioned, after receiving the COVID-19 vaccine, many clinical problems could occur. Additionally, there are some compelling reports on diabetes. After receiving the COVID-19 vaccine, a patient experienced hyperosmolar hyperglycemia state, a case of newly-onset type 2 diabetes. There has also been information on a potential connection between the COVID-19 vaccine and diabetic ketoacidosis. Common symptoms include thirst, polydipsia, polyuria, palpitations, a lack of appetite, and weariness. In extremely rare clinical circumstances, a COVID-19 vaccine recipient may develop diabetes complications such as hyperglycemia and ketoacidosis. In these circumstances, routine clinical care has a successful track record. It is advised to give vaccine recipients who are vulnerable to problems, such as those with type 1 diabetes as an underlying illness, extra attention.

Mild Hyperglycaemia in Hospitalised Children with Moderate COVID-19 Infection

Background and Objectives: COVID-19 infection may influence many physiological processes, including glucose metabolism. Acute hyperglycaemia has been related to a worse prognosis in patients with severe COVID-19 infection. The aim of our study was to find out if moderate COVID-19 infection is associated with hyperglycaemia. Materials and Methods: A total of 235 children were enrolled in the study between October 2021 and October 2022, 112 with confirmed COVID-19 infection and 123 with other RNA viral infection. In all patients, types of symptoms, glycaemia at the time of admission, and basic anthropometric and biochemical parameters were recorded. Results: Average glycaemia was significantly higher in COVID-19 patients compared to other viral infections (5.7 ± 1.12 vs. 5.31 ± 1.4 mmol/L, p = 0.011). This difference was more obvious in subgroups with gastrointestinal manifestations (5.6 ± 1.11 vs. 4.81 ± 1.38 mmol/L, p = 0.0006) and with fever (5.76±1.22 vs. 5.11±1.37 mmol/L, p = 0.002), while no significant difference was found in subgroups with mainly respiratory symptoms. The risk of hyperglycaemia (>5.6 mmol/L) was higher in COVID-19 patients compared to other viral infections (OR = 1.86, 95%CI = 1.10-3.14, p = 0.02). The risk of hyperglycaemia was significantly higher in COVID-19 compared to other viral infections in the subgroups of patients with fever (OR = 3.59, 95% CI 1.755-7.345, p = 0.0005) and with gastrointestinal manifestations (OR = 2.48, 95% CI 1.058-5.791, p = 0.036). Conclusion: According to our results, mild hyperglycaemia was significantly more common in children with moderate COVID-19 infection compared to other RNA virus respiratory and gastrointestinal infections, especially when accompanied by fever or gastrointestinal symptoms.

The Role of Diet and Specific Nutrients during the COVID-19 Pandemic: What Have We Learned over the Last Three Years?

Nutrients and diets have an important impact on our immune system and infection risk and a huge number of papers have been published dealing with various aspects of nutrition in relation to SARS-CoV-2 infection risk or COVID-19 severity. This narrative review aims to give an update on this association and tries to summarize some of the most important findings after three years of pandemic. The analysis of major studies and systematic reviews leads to the conclusion that a healthy plant-based diet reduces the risks for SARS-CoV-2 infection and especially COVID-19 severity. Regarding micronutrients, vitamin D is to the fore, but also zinc, vitamin C and, to some extent, selenium may play a role in COVID-19. Furthermore, omega-3-fatty acids with their anti-inflammatory effects also deserve attention. Therefore, a major aim of societal nutritional efforts in future should be to foster a high quality plant-based diet, which not only exerts beneficial effects on the immune system but also reduces the risk for non-communicable diseases such as type 2 diabetes or obesity which are also primary risk factors for worse COVID-19 outcomes. Another aim should be to focus on a good supply of critical immune-effective nutrients, such as vitamin D and zinc.

COVID-19 pandemic: A multidisciplinary perspective on the pathogenesis of a novel coronavirus from infection, immunity and pathological responses

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus2 (SARS-CoV-2), has spread to more than 200 countries and regions, having a huge impact on human health, hygiene, and economic activities. The epidemiological and clinical phenotypes of COVID-19 have increased since the onset of the epidemic era, and studies into its pathogenic mechanisms have played an essential role in clinical treatment, drug development, and prognosis prevention. This paper reviews the research progress on the pathogenesis of the novel coronavirus (SARS-CoV-2), focusing on the pathogenic characteristics, loci of action, and pathogenic mechanisms leading to immune response malfunction of SARS-CoV-2, as well as summarizing the pathological damage and pathological manifestations it causes. This will update researchers on the latest SARS-CoV-2 research and provide directions for future therapeutic drug development.

The associations between COVID-19 diagnosis, type 1 diabetes, and the risk of diabetic ketoacidosis: A nationwide cohort from the US using the Cerner Real-World Data

OBJECTIVE

To assess the risk of new-onset type 1 diabetes mellitus (T1D) diagnosis following COVID-19 diagnosis and the impact of COVID-19 diagnosis on the risk of diabetic ketoacidosis (DKA) in patients with prior T1D diagnosis.

RESEARCH DESIGN AND METHODS

Retrospective data consisting of 27,292,879 patients from the Cerner Real-World Data were used. Odds ratios, overall and stratified by demographic predictors, were calculated to assess associations between COVID-19 and T1D. Odds ratios from multivariable logistic regression models, adjusted for demographic and clinical predictors, were calculated to assess adjusted associations between COVID-19 and DKA. Multiple imputation with multivariate imputation by chained equations (MICE) was used to account for missing data.

RESULTS

The odds of developing new-onset T1D significantly increased in patients with COVID-19 diagnosis (OR: 1.42, 95% CI: 1.38, 1.46) compared to those without COVID-19. Risk varied by demographic groups, with the largest risk among pediatric patients ages 0-1 years (OR: 6.84, 95% CI: 2.75, 17.02) American Indian/Alaskan Natives (OR: 2.30, 95% CI: 1.86, 2.82), Asian or Pacific Islanders (OR: 2.01, 95% CI: 1.61, 2.53), older adult patients ages 51-65 years (OR: 1.77, 95% CI: 1.66, 1.88), those living in the Northeast (OR: 1.71, 95% CI: 1.61, 1.81), those living in the West (OR: 1.65, 95% CI: 1.56, 1.74), and Black patients (OR: 1.59, 95% CI: 1.47, 1.71). Among patients with diagnosed T1D at baseline (n = 55,359), 26.7% (n = 14,759) were diagnosed with COVID-19 over the study period. The odds of developing DKA for those with COVID-19 were significantly higher (OR 2.26, 95% CI: 2.04, 2.50) than those without COVID-19, and the largest risk was among patients with higher Elixhauser Comorbidity Index.

CONCLUSIONS

COVID-19 diagnosis is associated with significantly increased risk of new-onset T1D, and American Indian/Alaskan Native, Asian/Pacific Islander, and Black populations are disproportionately at risk. In patients with pre-existing T1D, the risk of developing DKA is significantly increased following COVID-19 diagnosis.

Oxidative Stress-Related Mechanisms in SARS-CoV-2 Infections

The COVID-19 pandemic caused relatively high mortality in patients, especially in those with concomitant diseases (i.e., diabetes, hypertension, and chronic obstructive pulmonary disease (COPD)). In most of aforementioned comorbidities, the oxidative stress appears to be an important player in their pathogenesis. The direct cause of death in critically ill patients with COVID-19 is still far from being elucidated. Although some preliminary data suggests that the lung vasculature injury and the loss of the functioning part of pulmonary alveolar population are crucial, the precise mechanism is still unclear. On the other hand, at least two classes of medications used with some clinical benefits in COVID-19 treatment seem to have a major influence on ROS (reactive oxygen species) and RNS (reactive nitrogen species) production. However, oxidative stress is one of the important mechanisms in the antiviral immune response and innate immunity. Therefore, it would be of interest to summarize the data regarding the oxidative stress in severe COVID-19. In this review, we discuss the role of oxidative and antioxidant mechanisms in severe COVID-19 based on available studies. We also present the role of ROS and RNS in other viral infections in humans and in animal models. Although reactive oxygen and nitrogen species play an important role in the innate antiviral immune response, in some situations, they might have a deleterious effect, e.g., in some coronaviral infections. The understanding of the redox mechanisms in severe COVID-19 disease may have an impact on its treatment.

Does Oxidative Stress Management Help Alleviation of COVID-19 Symptoms in Patients Experiencing Diabetes?

Severe acute respiratory syndrome (SARS)-CoV-2 virus causes novel coronavirus disease 2019 (COVID-19) with other comorbidities such as diabetes. Diabetes is the most common cause of diabetic nephropathy, which is attributed to hyperglycemia. COVID-19 produces severe complications in people with diabetes mellitus. This article explains how SARS-CoV-2 causes more significant kidney damage in diabetic patients. Importantly, COVID-19 and diabetes share inflammatory pathways of disease progression. SARS-CoV-2 binding with ACE-2 causes depletion of ACE-2 (angiotensin-converting enzyme 2) from blood vessels, and subsequently, angiotensin-II interacts with angiotensin receptor-1 from vascular membranes that produce NADPH (nicotinamide adenine dinucleotide hydrogen phosphate) oxidase, oxidative stress, and constriction of blood vessels. Since diabetes and COVID-19 can create oxidative stress, we hypothesize that COVID-19 with comorbidities such as diabetes can synergistically increase oxidative stress leading to end-stage renal failure and death. Antioxidants may therefore prevent renal damage-induced death by inhibiting oxidative damage and thus can help protect people from COVID-19 related comorbidities. A few clinical trials indicated how effective the antioxidant therapy is against improving COVID-19 symptoms, based on a limited number of patients who experienced COVID-19. In this review, we tried to understand how effective antioxidants (such as vitamin D and flavonoids) can act as food supplements or therapeutics against COVID-19 with diabetes as comorbidity based on recently available clinical, preclinical, or in silico studies.

Diabetic ketoacidosis (DKA) in type 1 diabetes mellitus (T1DM) temporally related to COVID-19 vaccination

SARS-CoV-2 pandemic has claimed millions of lives since its first identification in December 2019. Patients with diabetes are at a high risk of adverse outcomes after COVID-19 infection, whereas infection itself can be associated with severe hyperglycemia, including hyperglycemic emergencies. While the accelerated vaccine development and rollout have considerably decreased morbidity and mortality with reasonable safety, there are emerging reports of worsening of hyperglycemia in response to vaccination, with possible shared pathophysiology with COVID-19 infection-related hyperglycemia. We hereby report two young patients with type 1 diabetes (T1DM) who presented with severe diabetic ketoacidosis (DKA) after receiving second doses of COVISHIELD (ChAdOx1 nCoV-19) and COVAXIN (BBV152- inactivated whole virion) vaccines. Though a causal link cannot be established, post-vaccination immune response can potentially explain this transient worsening of hyperglycemia and hyperglycemic emergencies. We, hence report diabetic ketoacidosis (DKA) following COVID-19 vaccination in T1DM. We suggest that people with diabetes, particularly patients with T1DM with inadequate glycemic control should ideally be closely monitored for hyperglycemia and ketonemia for at least 2 weeks after receiving vaccination for COVID 19.