Clinical and Biochemical Characteristics and Treatment Outcomes of Ketosis-Prone Diabetes: The Remission Prone Diabetes

Phenotype and predictors of insulin independence in adults presenting with diabetic ketoacidosis: a prospective cohort study

AIMS/HYPOTHESIS

The aim of this work was to describe the phenotype of adults presenting with a first episode of diabetic ketoacidosis (DKA) in Cape Town, South Africa, and identify predictors of insulin independence at 12 and 60 months after presentation.

METHODS

A prospective, descriptive cohort study of all individuals, 18 years or older, presenting for the first time with DKA to four public-sector hospitals of the Groote Schuur Academic Health Complex was performed. Clinical, biochemical and laboratory data including GAD antibody and C-peptide status were collected at baseline. Insulin was systematically weaned and stopped in individuals who achieved normoglycaemia within the months after DKA. Individuals were followed for 12 months and then annually until 5 years after initial presentation with ketoacidosis.

RESULTS

Eighty-eight individuals newly diagnosed with diabetes when presenting with DKA were included and followed for 5 years. The mean ± SD age was 35±10 years and the median (IQR) BMI at diagnosis was 28.5 (23.3-33.4) kg/m2. Overall, 46% were insulin independent 12 months after diagnosis and 26% remained insulin independent 5 years after presentation. Forty-one participants (47%) tested negative for anti-GAD and anti-IA-2 antibodies and had C-peptide levels >0.3 nmol/l; in this group, 68% were insulin independent at 12 months and 37% at 5 years after diagnosis. The presence of acanthosis nigricans was strongly associated with insulin independence (OR 27.1 [95% CI 7.2, 102.2]; p<0.001); a positive antibody status was associated with a lower likelihood of insulin independence at 12 months (OR 0.10 [95% CI 0.03, 0.36]; p<0.001). On multivariable analysis only acanthosis (OR 11.5 [95% CI 2.5, 53.2]; p=0.004) was predictive of insulin independence 5 years after diagnosis.

CONCLUSIONS/INTERPRETATION

The predominant phenotype of adults presenting with a first episode of DKA in Cape Town, South Africa, was that of ketosis-prone type 2 diabetes. These individuals presented with obesity, acanthosis nigricans, negative antibodies and normal C-peptide and could potentially be weaned off insulin at follow-up. Classic type 1 diabetes (lower weight, antibody positivity, low or unrecordable C-peptide levels and long-term insulin dependence) was less common. The simple clinical sign of acanthosis nigricans is a strong predictor of insulin independence at 12 months and 5 years after initial presentation.

Development and Validation of a Risk Prediction Model for Ketosis-Prone Type 2 Diabetes Mellitus Among Patients Newly Diagnosed with Type 2 Diabetes Mellitus in China

Background

We established a nomogram for ketosis-prone type 2 diabetes mellitus (KP-T2DM) in the Chinese adult population in order to identify high-risk groups early and intervene in the disease progression in a timely manner.

Methods

We reviewed the medical records of 924 adults with newly diagnosed T2DM from January 2018 to June 2021. All patients were randomly divided into the training and validation sets at a ratio of 7:3. The least absolute shrinkage and selection operator regression analysis method was used to screen the predictors of the training set, and the multivariable logistic regression analysis was used to establish the nomogram prediction model. We verified the prediction model using the receiver operating characteristic (ROC) curve, judged the model's goodness-of-fit using the Hosmer-Lemeshow goodness-of-fit test, and predicted the risk of ketosis using the decision curve analysis.

Results

A total of 21 variables were analyzed, and four predictors-hemoglobin A1C, 2-hour postprandial blood glucose, 2-hour postprandial C-peptide, and age-were established. The area under the ROC curve for the training and validation sets were 0.8172 and 0.8084, respectively. The Hosmer-Lemeshow test showed that the prediction model and validation set have a high degree of fit. The decision curve analysis curve showed that the nomogram had better clinical applicability when the threshold probability of the patients was 0.03-0.79.

Conclusion

The nomogram based on hemoglobin A1C, 2-hour postprandial blood glucose, 2-hour postprandial C-peptide, and age has good performance and can serve as a favorable tool for clinicians to predict KP-T2DM.

Type 2 diabetes

Type 2 diabetes accounts for nearly 90% of the approximately 537 million cases of diabetes worldwide. The number affected is increasing rapidly with alarming trends in children and young adults (up to age 40 years). Early detection and proactive management are crucial for prevention and mitigation of microvascular and macrovascular complications and mortality burden. Access to novel therapies improves person-centred outcomes beyond glycaemic control. Precision medicine, including multiomics and pharmacogenomics, hold promise to enhance understanding of disease heterogeneity, leading to targeted therapies. Technology might improve outcomes, but its potential is yet to be realised. Despite advances, substantial barriers to changing the course of the epidemic remain. This Seminar offers a clinically focused review of the recent developments in type 2 diabetes care including controversies and future directions.