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Sooy MGQ, Pyle L, Alonso GT, Broncucia HC, Rewers A, Gottlieb PA, Simmons KMW, Rewers MJ, Steck AK. Lower Prevalence of Diabetic Ketoacidosis at Diagnosis in Research Participants Monitored for Hyperglycemia. J Clin Endocrinol Metab 2024:dgae158. [PMID: 38470864 DOI: 10.1210/clinem/dgae158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/18/2024] [Accepted: 03/11/2024] [Indexed: 03/14/2024]
Abstract
CONTEXT In Colorado children, the prevalence of diabetic ketoacidosis (DKA) at diagnosis of type 1 diabetes (T1D) has been increasing over time. OBJECTIVE Evaluate the prevalence of and factors involved in DKA at T1D diagnosis among participants followed in monitoring research studies before diagnosis compared to patients from the community. SETTING AND PARTICIPANTS Patients < 18 years diagnosed with T1D between 2005 and 2021 at the Barbara Davis Center for Diabetes. OUTCOME Prevalence of and factors associated with DKA at diagnosis among participants in preclinical monitoring studies compared to those diagnosed in the community. RESULTS Of 5049 subjects, 164 were active study participants, 42 inactive study participants, and 4843 were community patients. Active study participants, compared to community patients, had lower HbA1c (7.3% vs 11.9%]; P < 0.001) and less frequently experienced DKA (4.9% vs 48.5%; P < 0.001), including severe DKA (1.2% vs 16.2%; P < 0.001). Inactive study participants had intermediate levels for both prevalence and severity of DKA. DKA prevalence increased in community patients, from 44.0% to 55%, with less evidence for a temporal trend in study participants. DKA prevalence was highest in children <2 years (13% in active study participants vs 83% in community patients). In community patients, younger age (P = 0.0038), public insurance (P < 0.0001), rural residence (P < 0.0076), higher HbA1c (P < 0.0001), and ethnicity minority status (P < 0.0001) were associated with DKA at diagnosis. CONCLUSIONS While DKA prevalence increases in community patients over time, it stayed <5% in active research participants, who have a 10 times lower prevalence of DKA at diagnosis, including in minorities.
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Affiliation(s)
- Morgan G Q Sooy
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Laura Pyle
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - G Todd Alonso
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Hali C Broncucia
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Arleta Rewers
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimber M W Simmons
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marian J Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
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Virostko J, Wright JJ, Williams JM, Hilmes MA, Triolo TM, Broncucia H, Du L, Kang H, Nallaparaju S, Valencia LG, Reyes D, Hammel B, Russell WE, Philipson LH, Waibel M, Kay TW, Thomas HE, Greeley SAW, Steck AK, Powers AC, Moore DJ. Longitudinal Assessment of Pancreas Volume by MRI Predicts Progression to Stage 3 Type 1 Diabetes. Diabetes Care 2024; 47:393-400. [PMID: 38151474 PMCID: PMC10909689 DOI: 10.2337/dc23-1681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/30/2023] [Indexed: 12/29/2023]
Abstract
OBJECTIVE This multicenter prospective cohort study compared pancreas volume as assessed by MRI, metabolic scores derived from oral glucose tolerance testing (OGTT), and a combination of pancreas volume and metabolic scores for predicting progression to stage 3 type 1 diabetes (T1D) in individuals with multiple diabetes-related autoantibodies. RESEARCH DESIGN AND METHODS Pancreas MRI was performed in 65 multiple autoantibody-positive participants enrolled in the Type 1 Diabetes TrialNet Pathway to Prevention study. Prediction of progression to stage 3 T1D was assessed using pancreas volume index (PVI), OGTT-derived Index60 score and Diabetes Prevention Trial-Type 1 Risk Score (DPTRS), and a combination of PVI and DPTRS. RESULTS PVI, Index60, and DPTRS were all significantly different at study entry in 11 individuals who subsequently experienced progression to stage 3 T1D compared with 54 participants who did not experience progression (P < 0.005). PVI did not correlate with metabolic testing across individual study participants. PVI declined longitudinally in the 11 individuals diagnosed with stage 3 T1D, whereas Index60 and DPTRS increased. The area under the receiver operating characteristic curve for predicting progression to stage 3 from measurements at study entry was 0.76 for PVI, 0.79 for Index60, 0.79 for DPTRS, and 0.91 for PVI plus DPTRS. CONCLUSIONS These findings suggest that measures of pancreas volume and metabolism reflect distinct components of risk for developing stage 3 type 1 diabetes and that a combination of these measures may provide superior prediction than either alone.
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Affiliation(s)
- John Virostko
- Department of Diagnostic Medicine, Dell Medical School, University of Texas at Austin, Austin, TX
- Livestrong Cancer Institutes, Dell Medical School, University of Texas at Austin, Austin, TX
- Department of Oncology, Dell Medical School, University of Texas at Austin, Austin, TX
- Oden Institute for Computational Engineering and Sciences, University of Texas at Austin, Austin, TX
| | - Jordan J. Wright
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN
- VA Tennessee Valley Healthcare System, Nashville, TN
| | - Jonathan M. Williams
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa A. Hilmes
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Taylor M. Triolo
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Hali Broncucia
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Liping Du
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Shreya Nallaparaju
- Department of Diagnostic Medicine, Dell Medical School, University of Texas at Austin, Austin, TX
| | | | - Demetra Reyes
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL
| | - Brenna Hammel
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - William E. Russell
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN
| | - Louis H. Philipson
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL
| | - Michaela Waibel
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
| | - Thomas W.H. Kay
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Helen E. Thomas
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Siri Atma W. Greeley
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL
| | - Andrea K. Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Alvin C. Powers
- Department of Medicine, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, TN
- VA Tennessee Valley Healthcare System, Nashville, TN
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Daniel J. Moore
- Department of Pathology, Immunology, and Microbiology, Vanderbilt University, Nashville, TN
- Department of Pediatrics, Ian Burr Division of Endocrinology and Diabetes, Monroe Carell Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, TN
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3
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Ylescupidez A, Speake C, Pietropaolo SL, Wilson DM, Steck AK, Sherr JL, Gaglia JL, Bender C, Lord S, Greenbaum CJ. OGTT Metrics Surpass Continuous Glucose Monitoring Data for T1D Prediction in Multiple-Autoantibody-Positive Individuals. J Clin Endocrinol Metab 2023; 109:57-67. [PMID: 37572381 PMCID: PMC10735531 DOI: 10.1210/clinem/dgad472] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/14/2023]
Abstract
CONTEXT The value of continuous glucose monitoring (CGM) for monitoring autoantibody (AAB)-positive individuals in clinical trials for progression of type 1 diabetes (T1D) is unknown. OBJECTIVE Compare CGM with oral glucose tolerance test (OGTT)-based metrics in prediction of T1D. METHODS At academic centers, OGTT and CGM data from multiple-AAB relatives were evaluated for associations with T1D diagnosis. Participants were multiple-AAB-positive individuals in a TrialNet Pathway to Prevention (TN01) CGM ancillary study (n = 93). The intervention was CGM for 1 week at baseline, 6 months, and 12 months. Receiver operating characteristic (ROC) curves of CGM and OGTT metrics for prediction of T1D were analyzed. RESULTS Five of 7 OGTT metrics and 29/48 CGM metrics but not HbA1c differed between those who subsequently did or did not develop T1D. ROC area under the curve (AUC) of individual CGM values ranged from 50% to 69% and increased when adjusted for age and AABs. However, the highest-ranking metrics were derived from OGTT: 4/7 with AUC ∼80%. Compared with adjusted multivariable models using CGM data, OGTT-derived variables, Index60 and DPTRS (Diabetes Prevention Trial-Type 1 Risk Score), had higher discriminative ability (higher ROC AUC and positive predictive value with similar negative predictive value). CONCLUSION Every 6-month CGM measures in multiple-AAB-positive individuals are predictive of subsequent T1D, but less so than OGTT-derived variables. CGM may have feasibility advantages and be useful in some settings. However, our data suggest there is insufficient evidence to replace OGTT measures with CGM in the context of clinical trials.
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Affiliation(s)
- Alyssa Ylescupidez
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Cate Speake
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Susan L Pietropaolo
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
| | - Darrell M Wilson
- Division of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Jennifer L Sherr
- Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, CT 06511, USA
| | - Jason L Gaglia
- Joslin Diabetes Center, Harvard Medical School, Boston, MA 02215, USA
| | - Christine Bender
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Sandra Lord
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Carla J Greenbaum
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA 98101, USA
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O'Donnell HK, Rasmussen CG, Dong F, Simmons KM, Steck AK, Frohnert BI, Bautista K, Rewers MJ, Baxter J. Anxiety and Risk Perception in Parents of Children Identified by Population Screening as High Risk for Type 1 Diabetes. Diabetes Care 2023; 46:2155-2161. [PMID: 37673098 DOI: 10.2337/dc23-0350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 08/16/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE To assess anxiety and risk perception among parents whose children screened positive for islet autoantibodies, indicating elevated risk for type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS The Autoimmunity Screening for Kids (ASK) study identified 319 children age 1 to 17 years at risk for T1D via screening for islet autoantibodies; 280 children with confirmed islet autoantibodies and their caregivers enrolled in a follow-up education and monitoring program to prevent diabetic ketoacidosis at diagnosis. Parents completed questionnaires at each monitoring visit, including a 6-item version of the State Anxiety Inventory (SAI), to assess anxiety about their child developing T1D, and a single question to assess risk perception. RESULTS At the first ASK follow-up monitoring visit, mean parental anxiety was elevated above the clinical cutoff of 40 (SAI 46.1 ± 11.2). At the second follow-up monitoring visit (i.e., visit 2), mean anxiety remained elevated but started to trend down. Approximately half (48.9%) of parents reported their child was at increased risk for T1D at the initial follow-up monitoring visit (visit 1). Parents of children with more than one islet autoantibody and a first-degree relative with T1D were more likely to report their child was at increased risk. CONCLUSIONS Most parents of autoantibody-positive children have high anxiety about their child developing T1D. Information about the risk of developing T1D is difficult to convey, as evidenced by the wide range of risk perception reported in this sample.
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Affiliation(s)
- Holly K O'Donnell
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Cristy Geno Rasmussen
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Fran Dong
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Kimber M Simmons
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K Steck
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Brigitte I Frohnert
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Kimberly Bautista
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Marian J Rewers
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Judith Baxter
- Department of Pediatrics, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
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5
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Simmons KMW, Frohnert BI, O'Donnell HK, Bautista K, Geno Rasmussen C, Gerard Gonzalez A, Steck AK, Rewers MJ. Historical Insights and Current Perspectives on the Diagnosis and Management of Presymptomatic Type 1 Diabetes. Diabetes Technol Ther 2023; 25:790-799. [PMID: 37695674 DOI: 10.1089/dia.2023.0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
Objective: The article provides practical guidance for (1) interpreting and confirming islet autoantibody screening results for type 1 diabetes (T1D) and (2) follow-up of individuals with early stages of T1D with the goal of ensuring medical safety and providing patients and their families with an assessment of risk for progression to a clinical diagnosis of T1D. Research Design and Methods: We used an explicit a priori methodology to identify areas of agreement and disagreement in how to manage patients with early T1D. We used a modified Delphi method, which is a systematic, iterative approach to identifying consensus. We developed a list of topic questions, ranked them by importance, and developed consensus statements based on available evidence and expert opinion around each of the 30 topic questions consistently ranked as being most important. Results: Consensus statements for screening and monitoring are supported with figures proposing an algorithm for confirmation of T1D diagnosis and management of early T1D until clinical diagnosis. Conclusions: Disseminating and increasing knowledge related to how to interpret T1D screening tests, confirm early T1D diagnosis and monitor for medical safety and clinical disease risk prediction is critically important as there are currently no clinical recommendations. Published guidance will promote better management of T1D screening-detected individuals.
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Affiliation(s)
| | | | | | | | | | | | - Andrea K Steck
- Barbara Davis Center for Diabetes, Aurora, Colorado, USA
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6
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Libman I, Bingley PJ, Becker D, Buckner JH, DiMeglio LA, Gitelman SE, Greenbaum C, Haller MJ, Ismail HM, Krischer J, Moore WV, Moran A, Muir AB, Raman V, Steck AK, Toledo FG, Wentworth J, Wherrett D, White P, You L, Herold KC. Hydroxychloroquine in Stage 1 Type 1 Diabetes. Diabetes Care 2023; 46:2035-2043. [PMID: 37708415 PMCID: PMC10620539 DOI: 10.2337/dc23-1096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 08/21/2023] [Indexed: 09/16/2023]
Abstract
OBJECTIVE Innate immune responses may be involved in the earliest phases of type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS To test whether blocking innate immaune cells modulated progression of the disease, we randomly assigned 273 individuals with stage 1 T1D to treatment with hydroxychloroquine (n = 183; 5 mg/kg per day to a maximum of 400 mg) or placebo (n = 90) and assessed whether hydroxychloroquine treatment delayed or prevented progression to stage 2 T1D (i.e., two or more islet autoantibodies with abnormal glucose tolerance). RESULTS After a median follow-up of 23.3 months, the trial was stopped prematurely by the data safety monitoring board because of futility. There were no safety concerns in the hydroxychloroquine arm, including in annual ophthalmologic examinations. Preplanned secondary analyses showed a transient decrease in the glucose average area under the curve to oral glucose in the hydroxychloroquine-treated arm at month 6 and reduced titers of anti-GAD and anti-insulin autoantibodies and acquisition of positive autoantibodies in the hydroxychloroquine arm (P = 0.032). CONCLUSIONS We conclude that hydroxychloroquine does not delay progression to stage 2 T1D in individuals with stage 1 disease. Drug treatment reduces the acquisition of additional autoantibodies and the titers of autoantibodies to GAD and insulin.
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Affiliation(s)
- Ingrid Libman
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Polly J. Bingley
- School of Clinical Sciences, University of Bristol, Bristol, U.K
| | - Dorothy Becker
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Jane H. Buckner
- Center for Translational immunology, Benaroya Research Institute, Seattle, WA
| | | | - Stephen E. Gitelman
- Department of Pediatrics, University of California at San Francisco, San Francisco, CA
| | - Carla Greenbaum
- Center for Interventional Immunology, Benaroya Research Institute, Seattle, WA
| | | | - Heba M. Ismail
- Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Jeffrey Krischer
- Departments of Pediatrics and Internal Medicine, Health Informatics Institute, University of South Florida, Tampa, FL
| | | | | | | | - Vana Raman
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Frederico G.S. Toledo
- Division of Endocrinology and Metabolism, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Diane Wherrett
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Perrin White
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX
| | - Lu You
- Departments of Pediatrics and Internal Medicine, Health Informatics Institute, University of South Florida, Tampa, FL
| | - Kevan C. Herold
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT
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You L, Ferrat LA, Oram RA, Parikh HM, Steck AK, Krischer J, Redondo MJ. Type 1 Diabetes Risk Phenotypes Using Cluster Analysis. medRxiv 2023:2023.10.10.23296375. [PMID: 37873281 PMCID: PMC10593014 DOI: 10.1101/2023.10.10.23296375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Background Although statistical models for predicting type 1 diabetes risk have been developed, approaches that reveal clinically meaningful clusters in the at-risk population and allow for non-linear relationships between predictors are lacking. We aimed to identify and characterize clusters of islet autoantibody-positive individuals that share similar characteristics and type 1 diabetes risk. Methods We tested a novel outcome-guided clustering method in initially non-diabetic autoantibody-positive relatives of individuals with type 1 diabetes, using the TrialNet Pathway to Prevention (PTP) study data (n=1127). The outcome of the analysis was time to type 1 diabetes and variables in the model included demographics, genetics, metabolic factors and islet autoantibodies. An independent dataset (Diabetes Prevention Trial of Type 1 Diabetes, DPT-1 study) (n=704) was used for validation. Findings The analysis revealed 8 clusters with varying type 1 diabetes risks, categorized into three groups. Group A had three clusters with high glucose levels and high risk. Group B included four clusters with elevated autoantibody titers. Group C had three lower-risk clusters with lower autoantibody titers and glucose levels. Within the groups, the clusters exhibit variations in characteristics such as glucose levels, C-peptide levels, age, and genetic risk. A decision rule for assigning individuals to clusters was developed. The validation dataset confirms that the clusters can identify individuals with similar characteristics. Interpretation Demographic, metabolic, immunological, and genetic markers can be used to identify clusters of distinctive characteristics and different risks of progression to type 1 diabetes among autoantibody-positive individuals with a family history of type 1 diabetes. The results also revealed the heterogeneity in the population and complex interactions between variables.
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Affiliation(s)
- Lu You
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | | | - Hemang M Parikh
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Maria J Redondo
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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8
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Felton JL, Griffin KJ, Oram RA, Speake C, Long SA, Onengut-Gumuscu S, Rich SS, Monaco GSF, Evans-Molina C, DiMeglio LA, Ismail HM, Steck AK, Dabelea D, Johnson RK, Urazbayeva M, Gitelman S, Wentworth JM, Redondo MJ, Sims EK. Disease-modifying therapies and features linked to treatment response in type 1 diabetes prevention: a systematic review. Commun Med (Lond) 2023; 3:130. [PMID: 37794169 PMCID: PMC10550983 DOI: 10.1038/s43856-023-00357-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/15/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) results from immune-mediated destruction of insulin-producing beta cells. Prevention efforts have focused on immune modulation and supporting beta cell health before or around diagnosis; however, heterogeneity in disease progression and therapy response has limited translation to clinical practice, highlighting the need for precision medicine approaches to T1D disease modification. METHODS To understand the state of knowledge in this area, we performed a systematic review of randomized-controlled trials with ≥50 participants cataloged in PubMed or Embase from the past 25 years testing T1D disease-modifying therapies and/or identifying features linked to treatment response, analyzing bias using a Cochrane-risk-of-bias instrument. RESULTS We identify and summarize 75 manuscripts, 15 describing 11 prevention trials for individuals with increased risk for T1D, and 60 describing treatments aimed at preventing beta cell loss at disease onset. Seventeen interventions, mostly immunotherapies, show benefit compared to placebo (only two prior to T1D onset). Fifty-seven studies employ precision analyses to assess features linked to treatment response. Age, beta cell function measures, and immune phenotypes are most frequently tested. However, analyses are typically not prespecified, with inconsistent methods of reporting, and tend to report positive findings. CONCLUSIONS While the quality of prevention and intervention trials is overall high, the low quality of precision analyses makes it difficult to draw meaningful conclusions that inform clinical practice. To facilitate precision medicine approaches to T1D prevention, considerations for future precision studies include the incorporation of uniform outcome measures, reproducible biomarkers, and prespecified, fully powered precision analyses into future trial design.
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Affiliation(s)
- Jamie L Felton
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kurt J Griffin
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
- Sanford Research, Sioux Falls, SD, USA
| | - Richard A Oram
- NIHR Exeter Biomedical Research Centre (BRC), Academic Kidney Unit, University of Exeter, Devon, UK
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, Devon, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, Devon, UK
| | - Cate Speake
- Center for Interventional Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - S Alice Long
- Center for Translational Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - Suna Onengut-Gumuscu
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Gabriela S F Monaco
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carmella Evans-Molina
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA
- Richard L. Roudebush VAMC, Indianapolis, IN, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heba M Ismail
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA
| | | | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, Aurora, CO, USA
| | - Randi K Johnson
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | | | - Stephen Gitelman
- Department of Pediatrics, Diabetes Center; University of California at San Francisco, San Francisco, CA, USA
| | - John M Wentworth
- Royal Melbourne Hospital Department of Diabetes and Endocrinology, Walter and Eliza Hall Institute, Parkville, VIC, Australia
- University of Melbourne Department of Medicine, Parkville, VIC, Australia
| | - Maria J Redondo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
| | - Emily K Sims
- Department of Pediatrics, Center for Diabetes and Metabolic Diseases, Indianapolis, IN, USA.
- Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN, USA.
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Tobias DK, Merino J, Ahmad A, Aiken C, Benham JL, Bodhini D, Clark AL, Colclough K, Corcoy R, Cromer SJ, Duan D, Felton JL, Francis EC, Gillard P, Gingras V, Gaillard R, Haider E, Hughes A, Ikle JM, Jacobsen LM, Kahkoska AR, Kettunen JLT, Kreienkamp RJ, Lim LL, Männistö JME, Massey R, Mclennan NM, Miller RG, Morieri ML, Most J, Naylor RN, Ozkan B, Patel KA, Pilla SJ, Prystupa K, Raghavan S, Rooney MR, Schön M, Semnani-Azad Z, Sevilla-Gonzalez M, Svalastoga P, Takele WW, Tam CHT, Thuesen ACB, Tosur M, Wallace AS, Wang CC, Wong JJ, Yamamoto JM, Young K, Amouyal C, Andersen MK, Bonham MP, Chen M, Cheng F, Chikowore T, Chivers SC, Clemmensen C, Dabelea D, Dawed AY, Deutsch AJ, Dickens LT, DiMeglio LA, Dudenhöffer-Pfeifer M, Evans-Molina C, Fernández-Balsells MM, Fitipaldi H, Fitzpatrick SL, Gitelman SE, Goodarzi MO, Grieger JA, Guasch-Ferré M, Habibi N, Hansen T, Huang C, Harris-Kawano A, Ismail HM, Hoag B, Johnson RK, Jones AG, Koivula RW, Leong A, Leung GKW, Libman IM, Liu K, Long SA, Lowe WL, Morton RW, Motala AA, Onengut-Gumuscu S, Pankow JS, Pathirana M, Pazmino S, Perez D, Petrie JR, Powe CE, Quinteros A, Jain R, Ray D, Ried-Larsen M, Saeed Z, Santhakumar V, Kanbour S, Sarkar S, Monaco GSF, Scholtens DM, Selvin E, Sheu WHH, Speake C, Stanislawski MA, Steenackers N, Steck AK, Stefan N, Støy J, Taylor R, Tye SC, Ukke GG, Urazbayeva M, Van der Schueren B, Vatier C, Wentworth JM, Hannah W, White SL, Yu G, Zhang Y, Zhou SJ, Beltrand J, Polak M, Aukrust I, de Franco E, Flanagan SE, Maloney KA, McGovern A, Molnes J, Nakabuye M, Njølstad PR, Pomares-Millan H, Provenzano M, Saint-Martin C, Zhang C, Zhu Y, Auh S, de Souza R, Fawcett AJ, Gruber C, Mekonnen EG, Mixter E, Sherifali D, Eckel RH, Nolan JJ, Philipson LH, Brown RJ, Billings LK, Boyle K, Costacou T, Dennis JM, Florez JC, Gloyn AL, Gomez MF, Gottlieb PA, Greeley SAW, Griffin K, Hattersley AT, Hirsch IB, Hivert MF, Hood KK, Josefson JL, Kwak SH, Laffel LM, Lim SS, Loos RJF, Ma RCW, Mathieu C, Mathioudakis N, Meigs JB, Misra S, Mohan V, Murphy R, Oram R, Owen KR, Ozanne SE, Pearson ER, Perng W, Pollin TI, Pop-Busui R, Pratley RE, Redman LM, Redondo MJ, Reynolds RM, Semple RK, Sherr JL, Sims EK, Sweeting A, Tuomi T, Udler MS, Vesco KK, Vilsbøll T, Wagner R, Rich SS, Franks PW. Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine. Nat Med 2023; 29:2438-2457. [PMID: 37794253 PMCID: PMC10735053 DOI: 10.1038/s41591-023-02502-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/14/2023] [Indexed: 10/06/2023]
Abstract
Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.
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Affiliation(s)
- Deirdre K Tobias
- Division of Preventative Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jordi Merino
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Abrar Ahmad
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Catherine Aiken
- Department of Obstetrics and Gynaecology, The Rosie Hospital, Cambridge, UK
- NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Jamie L Benham
- Departments of Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Dhanasekaran Bodhini
- Department of Molecular Genetics, Madras Diabetes Research Foundation, Chennai, India
| | - Amy L Clark
- Division of Pediatric Endocrinology, Department of Pediatrics, Saint Louis University School of Medicine, SSM Health Cardinal Glennon Children's Hospital, St. Louis, MO, USA
| | - Kevin Colclough
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Rosa Corcoy
- CIBER-BBN, ISCIII, Madrid, Spain
- Institut d'Investigació Biomèdica Sant Pau (IIB SANT PAU), Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Sara J Cromer
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Daisy Duan
- Division of Endocrinology, Diabetes and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jamie L Felton
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ellen C Francis
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, NJ, USA
| | | | - Véronique Gingras
- Department of Nutrition, Université de Montréal, Montreal, Quebec, Quebec, Canada
- Research Center, Sainte-Justine University Hospital Center, Montreal, Quebec, Quebec, Canada
| | - Romy Gaillard
- Department of Pediatrics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Eram Haider
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Alice Hughes
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Jennifer M Ikle
- Department of Pediatrics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | | | - Anna R Kahkoska
- Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jarno L T Kettunen
- Helsinki University Hospital, Abdominal Centre/Endocrinology, Helsinki, Finland
- Folkhalsan Research Center, Helsinki, Finland
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Raymond J Kreienkamp
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Pediatrics, Division of Endocrinology, Boston Children's Hospital, Boston, MA, USA
| | - Lee-Ling Lim
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Asia Diabetes Foundation, Hong Kong SAR, China
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jonna M E Männistö
- Departments of Pediatrics and Clinical Genetics, Kuopio University Hospital, Kuopio, Finland
- Department of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Robert Massey
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Niamh-Maire Mclennan
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel G Miller
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mario Luca Morieri
- Metabolic Disease Unit, University Hospital of Padova, Padova, Italy
- Department of Medicine, University of Padova, Padova, Italy
| | - Jasper Most
- Department of Orthopedics, Zuyderland Medical Center, Sittard-Geleen, The Netherlands
| | - Rochelle N Naylor
- Departments of Pediatrics and Medicine, University of Chicago, Chicago, IL, USA
| | - Bige Ozkan
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Kashyap Amratlal Patel
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Scott J Pilla
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Katsiaryna Prystupa
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Sridharan Raghavan
- Section of Academic Primary Care, US Department of Veterans Affairs Eastern Colorado Health Care System, Aurora, CO, USA
- Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mary R Rooney
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Martin Schön
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- Institute of Experimental Endocrinology, Biomedical Research Center, Slovak Academy of Sciences, Bratislava, Slovakia
| | - Zhila Semnani-Azad
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Magdalena Sevilla-Gonzalez
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Clinical and Translational Epidemiology Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Pernille Svalastoga
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | - Wubet Worku Takele
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Claudia Ha-Ting Tam
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Anne Cathrine B Thuesen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Mustafa Tosur
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
- Children's Nutrition Research Center, USDA/ARS, Houston, TX, USA
| | - Amelia S Wallace
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Caroline C Wang
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jessie J Wong
- Stanford University School of Medicine, Stanford, CA, USA
| | | | - Katherine Young
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Chloé Amouyal
- Department of Diabetology, APHP, Paris, France
- Sorbonne Université, INSERM, NutriOmic team, Paris, France
| | - Mette K Andersen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Maxine P Bonham
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | - Mingling Chen
- Monash Centre for Health Research and Implementation, Monash University, Clayton, Victoria, Australia
| | - Feifei Cheng
- Health Management Center, The Second Affiliated Hospital of Chongqing Medical University, Chongqing Medical University, Chongqing, China
| | - Tinashe Chikowore
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- MRC/Wits Developmental Pathways for Health Research Unit, Department of Paediatrics, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Channing Division of Network Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sian C Chivers
- Department of Women and Children's Health, King's College London, London, UK
| | - Christoffer Clemmensen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Adem Y Dawed
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Aaron J Deutsch
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Laura T Dickens
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
- Richard L. Roudebush VAMC, Indianapolis, IN, USA
| | - María Mercè Fernández-Balsells
- Biomedical Research Institute Girona, IdIBGi, Girona, Spain
- Diabetes, Endocrinology and Nutrition Unit Girona, University Hospital Dr Josep Trueta, Girona, Spain
| | - Hugo Fitipaldi
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
| | - Stephanie L Fitzpatrick
- Institute of Health System Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Stephen E Gitelman
- University of California at San Francisco, Department of Pediatrics, Diabetes Center, San Francisco, CA, USA
| | - Mark O Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Jessica A Grieger
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Marta Guasch-Ferré
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Public Health and Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Nahal Habibi
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Torben Hansen
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chuiguo Huang
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Arianna Harris-Kawano
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Heba M Ismail
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Benjamin Hoag
- Division of Endocrinology and Diabetes, Department of Pediatrics, Sanford Children's Hospital, Sioux Falls, SD, USA
- University of South Dakota School of Medicine, E Clark St, Vermillion, SD, USA
| | - Randi K Johnson
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA
| | - Angus G Jones
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Robert W Koivula
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - Aaron Leong
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Gloria K W Leung
- Department of Nutrition, Dietetics and Food, Monash University, Melbourne, Victoria, Australia
| | | | - Kai Liu
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - S Alice Long
- Center for Translational Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - William L Lowe
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Morton
- Department of Pathology & Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Translational Medicine, Medical Science, Novo Nordisk Foundation, Hellerup, Denmark
| | - Ayesha A Motala
- Department of Diabetes and Endocrinology, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Suna Onengut-Gumuscu
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - James S Pankow
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Maleesa Pathirana
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sofia Pazmino
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
| | - Dianna Perez
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John R Petrie
- School of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Camille E Powe
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Department of Obstetrics, Gynecology, and Reproductive Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alejandra Quinteros
- Adelaide Medical School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, South Australia, Australia
| | - Rashmi Jain
- Sanford Children's Specialty Clinic, Sioux Falls, SD, USA
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
| | - Debashree Ray
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Mathias Ried-Larsen
- Centre for Physical Activity Research, Rigshospitalet, Copenhagen, Denmark
- Institute for Sports and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
| | - Zeb Saeed
- Department of Medicine, Division of Endocrinology, Diabetes and Metabolism, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Vanessa Santhakumar
- Division of Preventative Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sarah Kanbour
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- AMAN Hospital, Doha, Qatar
| | - Sudipa Sarkar
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Gabriela S F Monaco
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Denise M Scholtens
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Elizabeth Selvin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wayne Huey-Herng Sheu
- Institute of Molecular and Genomic Medicine, National Health Research Institutes, Zhunan, Taiwan
- Divsion of Endocrinology and Metabolism, Taichung Veterans General Hospital, Taichung, Taiwan
- Division of Endocrinology and Metabolism, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cate Speake
- Center for Interventional Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - Maggie A Stanislawski
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Nele Steenackers
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Norbert Stefan
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Institute of Diabetes Research and Metabolic Diseases (IDM), Helmholtz Center Munich, Neuherberg, Germany
- University Hospital of Tübingen, Tübingen, Germany
| | - Julie Støy
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Aarhus, Denmark
| | | | - Sok Cin Tye
- Sections on Genetics and Epidemiology, Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Marzhan Urazbayeva
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
- Gastroenterology, Baylor College of Medicine, Houston, TX, USA
| | - Bart Van der Schueren
- Department of Chronic Diseases and Metabolism, Clinical and Experimental Endocrinologyó, KU Leuven, Leuven, Belgium
- Department of Endocrinology, University Hospitals Leuven, Leuven, Belgium
| | - Camille Vatier
- Sorbonne University, Inserm U938, Saint-Antoine Research Centre, Institute of Cardiometabolism and Nutrition, Paris, France
- Department of Endocrinology, Diabetology and Reproductive Endocrinology, Assistance Publique-Hôpitaux de Paris, Saint-Antoine University Hospital, National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), Paris, France
| | - John M Wentworth
- Royal Melbourne Hospital Department of Diabetes and Endocrinology, Parkville, Victoria, Australia
- Walter and Eliza Hall Institute, Parkville, Victoria, Australia
- University of Melbourne Department of Medicine, Parkville, Victoria, Australia
| | - Wesley Hannah
- Deakin University, Melbourne, Victoria, Australia
- Department of Epidemiology, Madras Diabetes Research Foundation, Chennai, India
| | - Sara L White
- Department of Women and Children's Health, King's College London, London, UK
- Department of Diabetes and Endocrinology, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Gechang Yu
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Yingchai Zhang
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Shao J Zhou
- Robinson Research Institute, The University of Adelaide, Adelaide, South Australia, Australia
- School of Agriculture, Food and Wine, University of Adelaide, Adelaide, South Australia, Australia
| | - Jacques Beltrand
- Institut Cochin, Inserm U 10116, Paris, France
- Pediatric Endocrinology and Diabetes, Hopital Necker Enfants Malades, APHP Centre, Université de Paris, Paris, France
| | - Michel Polak
- Institut Cochin, Inserm U 10116, Paris, France
- Pediatric Endocrinology and Diabetes, Hopital Necker Enfants Malades, APHP Centre, Université de Paris, Paris, France
| | - Ingvild Aukrust
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Elisa de Franco
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Sarah E Flanagan
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Kristin A Maloney
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew McGovern
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Janne Molnes
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medical Genetics, Haukeland University Hospital, Bergen, Norway
| | - Mariam Nakabuye
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Pål Rasmus Njølstad
- Mohn Center for Diabetes Precision Medicine, Department of Clinical Science, University of Bergen, Bergen, Norway
- Children and Youth Clinic, Haukeland University Hospital, Bergen, Norway
| | - Hugo Pomares-Millan
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Michele Provenzano
- Nephrology, Dialysis and Renal Transplant Unit, IRCCS-Azienda Ospedaliero-Universitaria di Bologna, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Cécile Saint-Martin
- Department of Medical Genetics, AP-HP Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Cuilin Zhang
- Global Center for Asian Women's Health, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yeyi Zhu
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA, USA
| | - Sungyoung Auh
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Russell de Souza
- Population Health Research Institute, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Andrea J Fawcett
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
- Department of Clinical and Organizational Development, Chicago, IL, USA
| | | | - Eskedar Getie Mekonnen
- College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
- Global Health Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Emily Mixter
- Department of Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Diana Sherifali
- Population Health Research Institute, Hamilton, Ontario, Canada
- School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Robert H Eckel
- Division of Endocrinology, Metabolism, Diabetes, University of Colorado, Aurora, CO, USA
| | - John J Nolan
- Department of Clinical Medicine, School of Medicine, Trinity College Dublin, Dublin, Ireland
- Department of Endocrinology, Wexford General Hospital, Wexford, Ireland
| | - Louis H Philipson
- Department of Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Rebecca J Brown
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Liana K Billings
- Division of Endocrinology, NorthShore University HealthSystem, Skokie, IL, USA
- Department of Medicine, Prtizker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Kristen Boyle
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Tina Costacou
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - John M Dennis
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
| | - Jose C Florez
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Anna L Gloyn
- Department of Pediatrics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Stanford Diabetes Research Center, Stanford School of Medicine, Stanford University, Stanford, CA, USA
- Department of Genetics, Stanford School of Medicine, Stanford University, Stanford, CA, USA
| | - Maria F Gomez
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden
- Faculty of Health, Aarhus University, Aarhus, Denmark
| | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Siri Atma W Greeley
- Departments of Pediatrics and Medicine and Kovler Diabetes Center, University of Chicago, Chicago, IL, USA
| | - Kurt Griffin
- Department of Pediatrics, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
- Sanford Research, Sioux Falls, SD, USA
| | - Andrew T Hattersley
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, WA, USA
| | - Marie-France Hivert
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
- Department of Medicine, Universite de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Korey K Hood
- Stanford University School of Medicine, Stanford, CA, USA
| | - Jami L Josefson
- Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Soo Heon Kwak
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - Siew S Lim
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ruth J F Loos
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ronald C W Ma
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong SAR, China
- Laboratory for Molecular Epidemiology in Diabetes, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Hong Kong SAR, China
- Hong Kong Institute of Diabetes and Obesity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | | | | | - James B Meigs
- Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute, Cambridge, MA, USA
| | - Shivani Misra
- Division of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Diabetes & Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Viswanathan Mohan
- Department of Diabetology, Madras Diabetes Research Foundation & Dr. Mohan's Diabetes Specialities Centre, Chennai, India
| | - Rinki Murphy
- Department of Medicine, Faculty of Medicine and Health Sciences, University of Auckland, Auckland, New Zealand
- Auckland Diabetes Centre, Te Whatu Ora Health New Zealand, Auckland, New Zealand
- Medical Bariatric Service, Te Whatu Ora Counties, Health New Zealand, Auckland, New Zealand
| | - Richard Oram
- Department of Clinical and Biomedical Sciences, University of Exeter Medical School, Exeter, UK
- Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Katharine R Owen
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Susan E Ozanne
- University of Cambridge, Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome-MRC Institute of Metabolic Science, Cambridge, UK
| | - Ewan R Pearson
- Division of Population Health & Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Wei Perng
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Toni I Pollin
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Maria J Redondo
- Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
- Division of Pediatric Diabetes and Endocrinology, Texas Children's Hospital, Houston, TX, USA
| | - Rebecca M Reynolds
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Robert K Semple
- Centre for Cardiovascular Science, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- MRC Human Genetics Unit, Institute of Genetics and Cancer, University of Edinburgh, Edinburgh, UK
| | | | - Emily K Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Herman B Wells Center for Pediatric Research, University School of Medicine, Indianapolis, IN, USA
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Arianne Sweeting
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Tiinamaija Tuomi
- Helsinki University Hospital, Abdominal Centre/Endocrinology, Helsinki, Finland
- Folkhalsan Research Center, Helsinki, Finland
- Institute for Molecular Medicine Finland FIMM, University of Helsinki, Helsinki, Finland
| | - Miriam S Udler
- Diabetes Unit, Endocrine Division, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Programs in Metabolism and Medical & Population Genetics, Broad Institute, Cambridge, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Kimberly K Vesco
- Kaiser Permanente Northwest, Kaiser Permanente Center for Health Research, Portland, OR, USA
| | - Tina Vilsbøll
- Clinial Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Robert Wagner
- Institute for Clinical Diabetology, German Diabetes Center, Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
- Department of Endocrinology and Diabetology, University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Stephen S Rich
- Center for Public Health Genomics, Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Paul W Franks
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
- Department of Clinical Sciences, Lund University Diabetes Centre, Lund University, Malmö, Sweden.
- Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK.
- Department of Translational Medicine, Medical Science, Novo Nordisk Foundation, Hellerup, Denmark.
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10
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Felton JL, Griffin KJ, Oram RA, Speake C, Long SA, Onengut-Gumuscu S, Rich SS, Monaco GS, Evans-Molina C, DiMeglio LA, Ismail HM, Steck AK, Dabelea D, Johnson RK, Urazbayeva M, Gitelman S, Wentworth JM, Redondo MJ, Sims EK. Type 1 Diabetes Prevention: a systematic review of studies testing disease-modifying therapies and features linked to treatment response. medRxiv 2023:2023.04.12.23288421. [PMID: 37131690 PMCID: PMC10153317 DOI: 10.1101/2023.04.12.23288421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Background Type 1 diabetes (T1D) results from immune-mediated destruction of insulin-producing beta cells. Efforts to prevent T1D have focused on modulating immune responses and supporting beta cell health; however, heterogeneity in disease progression and responses to therapies have made these efforts difficult to translate to clinical practice, highlighting the need for precision medicine approaches to T1D prevention. Methods To understand the current state of knowledge regarding precision approaches to T1D prevention, we performed a systematic review of randomized-controlled trials from the past 25 years testing disease-modifying therapies in T1D and/or identifying features linked to treatment response, analyzing bias using a Cochrane-risk-of-bias instrument. Results We identified 75 manuscripts, 15 describing 11 prevention trials for individuals with increased risk for T1D, and 60 describing treatments aimed at preventing beta cell loss in individuals at disease onset. Seventeen agents tested, mostly immunotherapies, showed benefit compared to placebo (only two prior to T1D onset). Fifty-seven studies employed precision analyses to assess features linked to treatment response. Age, measures of beta cell function and immune phenotypes were most frequently tested. However, analyses were typically not prespecified, with inconsistent methods reporting, and tended to report positive findings. Conclusions While the quality of prevention and intervention trials was overall high, low quality of precision analyses made it difficult to draw meaningful conclusions that inform clinical practice. Thus, prespecified precision analyses should be incorporated into the design of future studies and reported in full to facilitate precision medicine approaches to T1D prevention. Plain Language Summary Type 1 diabetes (T1D) results from the destruction of insulin-producing cells in the pancreas, necessitating lifelong insulin dependence. T1D prevention remains an elusive goal, largely due to immense variability in disease progression. Agents tested to date in clinical trials work in a subset of individuals, highlighting the need for precision medicine approaches to prevention. We systematically reviewed clinical trials of disease-modifying therapy in T1D. While age, measures of beta cell function, and immune phenotypes were most commonly identified as factors that influenced treatment response, the overall quality of these studies was low. This review reveals an important need to proactively design clinical trials with well-defined analyses to ensure that results can be interpreted and applied to clinical practice.
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11
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Wilson DM, Pietropaolo SL, Acevedo-Calado M, Huang S, Anyaiwe D, Scheinker D, Steck AK, Vasudevan MM, McKay SV, Sherr JL, Herold KC, Dunne JL, Greenbaum CJ, Lord SM, Haller MJ, Schatz DA, Atkinson MA, Nelson PW, Pietropaolo M. CGM Metrics Identify Dysglycemic States in Participants From the TrialNet Pathway to Prevention Study. Diabetes Care 2023; 46:526-534. [PMID: 36730530 PMCID: PMC10020029 DOI: 10.2337/dc22-1297] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/28/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Continuous glucose monitoring (CGM) parameters may identify individuals at risk for progression to overt type 1 diabetes. We aimed to determine whether CGM metrics provide additional insights into progression to clinical stage 3 type 1 diabetes. RESEARCH DESIGN AND METHODS One hundred five relatives of individuals in type 1 diabetes probands (median age 16.8 years; 89% non-Hispanic White; 43.8% female) from the TrialNet Pathway to Prevention study underwent 7-day CGM assessments and oral glucose tolerance tests (OGTTs) at 6-month intervals. The baseline data are reported here. Three groups were evaluated: individuals with 1) stage 2 type 1 diabetes (n = 42) with two or more diabetes-related autoantibodies and abnormal OGTT; 2) stage 1 type 1 diabetes (n = 53) with two or more diabetes-related autoantibodies and normal OGTT; and 3) negative test for all diabetes-related autoantibodies and normal OGTT (n = 10). RESULTS Multiple CGM metrics were associated with progression to stage 3 type 1 diabetes. Specifically, spending ≥5% time with glucose levels ≥140 mg/dL (P = 0.01), ≥8% time with glucose levels ≥140 mg/dL (P = 0.02), ≥5% time with glucose levels ≥160 mg/dL (P = 0.0001), and ≥8% time with glucose levels ≥160 mg/dL (P = 0.02) were all associated with progression to stage 3 disease. Stage 2 participants and those who progressed to stage 3 also exhibited higher mean daytime glucose values; spent more time with glucose values over 120, 140, and 160 mg/dL; and had greater variability. CONCLUSIONS CGM could aid in the identification of individuals, including those with a normal OGTT, who are likely to rapidly progress to stage 3 type 1 diabetes.
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Affiliation(s)
- Darrell M. Wilson
- Division of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA
| | - Susan L. Pietropaolo
- Division of Endocrinology, Diabetes, and Metabolism, Diabetes Research Center, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Maria Acevedo-Calado
- Division of Endocrinology, Diabetes, and Metabolism, Diabetes Research Center, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Shuai Huang
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA
| | - Destiny Anyaiwe
- Department of Mathematics & Computer Science, Lawrence Technological University, Southfield, MI
| | - David Scheinker
- Division of Pediatric Endocrinology, Stanford University School of Medicine, Palo Alto, CA
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Madhuri M. Vasudevan
- Division of Endocrinology, Diabetes, and Metabolism, Diabetes Research Center, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Siripoom V. McKay
- Division of Endocrinology, Diabetes, and Metabolism, Diabetes Research Center, Department of Medicine, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jennifer L. Sherr
- Division of Pediatric Endocrinology, Yale University School of Medicine, New Haven, CT
| | - Kevan C. Herold
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT
| | | | - Carla J. Greenbaum
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA
| | - Sandra M. Lord
- Center for Interventional Immunology and Diabetes Program, Benaroya Research Institute, Seattle, WA
| | - Michael J. Haller
- Department of Pediatrics, University of Florida Diabetes Institute, College of Medicine, University of Florida, Gainesville, FL
| | - Desmond A. Schatz
- Department of Pediatrics, University of Florida Diabetes Institute, College of Medicine, University of Florida, Gainesville, FL
| | - Mark A. Atkinson
- Department of Pediatrics, University of Florida Diabetes Institute, College of Medicine, University of Florida, Gainesville, FL
| | - Patrick W. Nelson
- Department of Mathematics & Computer Science, Lawrence Technological University, Southfield, MI
| | - Massimo Pietropaolo
- Division of Endocrinology, Diabetes, and Metabolism, Diabetes Research Center, Department of Medicine, Baylor College of Medicine, Houston, TX
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12
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Kinney M, You L, Sims EK, Wherrett D, Schatz D, Lord S, Krischer J, Russell WE, Gottlieb PA, Libman I, Buckner J, DiMeglio LA, Herold KC, Steck AK. Barriers to Screening: An Analysis of Factors Impacting Screening for Type 1 Diabetes Prevention Trials. J Endocr Soc 2023; 7:bvad003. [PMID: 36741943 PMCID: PMC9891344 DOI: 10.1210/jendso/bvad003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Indexed: 01/12/2023] Open
Abstract
Context Participants with stage 1 or 2 type 1 diabetes (T1D) qualify for prevention trials, but factors involved in screening for such trials are largely unknown. Objective To identify factors associated with screening for T1D prevention trials. Methods This study included TrialNet Pathway to Prevention participants who were eligible for a prevention trial: oral insulin (TN-07, TN-20), teplizumab (TN-10), abatacept (TN-18), and oral hydroxychloroquine (TN-22). Univariate and multivariate logistic regression models were used to examine participant, site, and study factors at the time of prevention trial accrual. Results Screening rates for trials were: 50% for TN-07 (584 screened/1172 eligible), 9% for TN-10 (106/1249), 24% for TN-18 (313/1285), 17% for TN-20 (113/667), and 28% for TN-22 (371/1336). Younger age and male sex were associated with higher screening rates for prevention trials overall and for oral therapies. Participants with an offspring with T1D showed lower rates of screening for all trials and oral drug trials compared with participants with other first-degree relatives as probands. Site factors, including larger monitoring volume and US site vs international site, were associated with higher prevention trial screening rates. Conclusions Clear differences exist between participants who screen for prevention trials and those who do not screen and between the research sites involved in prevention trial screening. Participant age, sex, and relationship to proband are significantly associated with prevention trial screening in addition to key site factors. Identifying these factors can facilitate strategic recruitment planning to support rapid and successful enrollment into prevention trials.
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Affiliation(s)
- Mara Kinney
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Lu You
- Health Informatics Institute, University of South Florida, Tampa, FL 33620, USA
| | - Emily K Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Diane Wherrett
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto M5G 1X8, Canada
| | - Desmond Schatz
- Department of Pediatrics, University of Florida, Gainesville, FL 32611, USA
| | - Sandra Lord
- Diabetes Research Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Jeffrey Krischer
- Health Informatics Institute, University of South Florida, Tampa, FL 33620, USA
| | | | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Ingrid Libman
- Division of Endocrinology, Diabetes and Metabolism, University of Pittsburgh and UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15213, USA
| | - Jane Buckner
- Diabetes Research Program, Benaroya Research Institute, Seattle, WA 98101, USA
| | - Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN 46202, USA
| | - Kevan C Herold
- Departments of Immunobiology and Internal Medicine, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
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13
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Frost HM, Geno Rasmussen C, Shorrosh H, Pyle L, Bautista K, Frohnert BI, Stahl M, Simmons K, Steck AK, Jia X, Yu L, Rewers M. Prevalence of SARS-CoV-2 Antibodies Among Healthy Children From Colorado From 2020 to 2021: A Brief Report. J Prim Care Community Health 2023; 14:21501319231189147. [PMID: 37501515 PMCID: PMC10375226 DOI: 10.1177/21501319231189147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 07/29/2023] Open
Abstract
There are few estimates of the seroprevalence of SARS-CoV-2 antibodies among children in the United States. We measured vaccine and infection induced seroprevalence among nearly 5000 healthy 1 to 17-year-old children in Colorado from 2020 to 2021. By December 2021, 89% of older children, ages 12 to 18, had antibodies detected. The increase was largely driven from vaccination rather than infection.
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Affiliation(s)
- Holly M. Frost
- Denver Health and Hospital Authority, Denver, CO, USA
- University of Colorado, Aurora, CO, USA
| | | | | | | | | | | | | | | | | | | | - Liping Yu
- University of Colorado, Aurora, CO, USA
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14
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Ismail HM, Cuthbertson D, Gitelman SE, Skyler JS, Steck AK, Rodriguez H, Atkinson M, Nathan BM, Redondo MJ, Herold KC, Evans-Molina C, DiMeglio LA, Sosenko J. The Transition From a Compensatory Increase to a Decrease in C-peptide During the Progression to Type 1 Diabetes and Its Relation to Risk. Diabetes Care 2022; 45:2264-2270. [PMID: 35998266 PMCID: PMC9643141 DOI: 10.2337/dc22-0167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/14/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To define the relationship between glucose and C-peptide during the progression to type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS We longitudinally studied glucose and C-peptide response curves (GCRCs), area under curve (AUC) for glucose, and AUC C-peptide from oral glucose tolerance tests (OGTTs), and Index60 (which integrates OGTT glucose and C-peptide values) in Diabetes Prevention Trial-Type 1 (DPT-1) (n = 72) and TrialNet Pathway to Prevention Study (TNPTP) (n = 82) participants who had OGTTs at baseline and follow-up time points before diagnosis. RESULTS Similar evolutions of GCRC configurations were evident between DPT-1 and TNPTP from baseline to 0.5 years prediagnosis. Whereas AUC glucose increased throughout from baseline to 0.5 years prediagnosis, AUC C-peptide increased from baseline until 1.5 years prediagnosis (DPT-1, P = 0.004; TNPTP, P = 0.012) and then decreased from 1.5 to 0.5 years prediagnosis (DPT-1, P = 0.017; TNPTP, P = 0.093). This change was mostly attributable to change in the late AUC C-peptide response (i.e., 60- to 120-min AUC C-peptide). Median Index60 values of DPT-1 (1.44) and TNPTP (1.05) progressors to T1D 1.5 years prediagnosis (time of transition from increasing to decreasing AUC C-peptide) were used as thresholds to identify individuals at high risk for T1D in the full cohort at baseline (5-year risk of 0.75-0.88 for those above thresholds). CONCLUSIONS A transition from an increase to a decrease in AUC C-peptide ∼1.5 years prediagnosis was validated in two independent cohorts. The median Index60 value at that time point can be used as a pathophysiologic-based threshold for identifying individuals at high risk for T1D.
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Affiliation(s)
- Heba M. Ismail
- Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - David Cuthbertson
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Stephen E. Gitelman
- Division of Endocrinology, Department of Pediatrics, University of California, San Francisco, San Francisco, CA
| | - Jay S. Skyler
- Division of Endocrinology, Diabetes, and Metabolism, and Diabetes Research Institute, University of Miami, Miami, FL
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Henry Rodriguez
- USF Diabetes and Endocrinology Center, University of South Florida, Tampa, FL
| | - Mark Atkinson
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | | | - Maria J. Redondo
- Texas Children’s Hospital, Baylor College of Medicine, Houston, TX
| | - Kevan C. Herold
- Department of Immunobiology, Yale University School of Medicine, New Haven, CT
| | - Carmella Evans-Molina
- Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Linda A. DiMeglio
- Division of Pediatric Endocrinology and Diabetology, Department of Pediatrics, Indiana University, Indianapolis, IN
| | - Jay Sosenko
- Division of Endocrinology, Diabetes, and Metabolism, and Diabetes Research Institute, University of Miami, Miami, FL
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15
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Carry PM, Waugh K, Vanderlinden LA, Johnson RK, Buckner T, Rewers M, Steck AK, Yang I, Fingerlin TE, Kechris K, Norris JM. Changes in the Coexpression of Innate Immunity Genes During Persistent Islet Autoimmunity Are Associated With Progression of Islet Autoimmunity: Diabetes Autoimmunity Study in the Young (DAISY). Diabetes 2022; 71:2048-2057. [PMID: 35724268 PMCID: PMC9450568 DOI: 10.2337/db21-1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 06/08/2022] [Indexed: 11/13/2022]
Abstract
Longitudinal changes in gene expression during islet autoimmunity (IA) may provide insight into biological processes that explain progression to type 1 diabetes (T1D). We identified individuals from Diabetes Autoimmunity Study in the Young (DAISY) who developed IA, autoantibodies present on two or more visits. Illumina's NovaSeq 6000 was used to quantify gene expression in whole blood. With linear mixed models we tested for changes in expression after IA that differed across individuals who progressed to T1D (progressors) (n = 25), reverted to an autoantibody-negative stage (reverters) (n = 47), or maintained IA positivity but did not develop T1D (maintainers) (n = 66). Weighted gene coexpression network analysis was used to identify coexpression modules. Gene Ontology pathway analysis of the top 150 differentially expressed genes (nominal P < 0.01) identified significantly enriched pathways including leukocyte activation involved in immune response, innate immune response, and regulation of immune response. We identified a module of 14 coexpressed genes with roles in the innate immunity. The hub gene, LTF, is known to have immunomodulatory properties. Another gene within the module, CAMP, is potentially relevant based on its role in promoting β-cell survival in a murine model. Overall, results provide evidence of alterations in expression of innate immune genes prior to onset of T1D.
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Affiliation(s)
- Patrick M. Carry
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Kathleen Waugh
- Barbara Davis Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | - Randi K. Johnson
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Teresa Buckner
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Andrea K. Steck
- Barbara Davis Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ivana Yang
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tasha E. Fingerlin
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO
| | | | - Jill M. Norris
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Barbara Davis Center, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
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16
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Mitchell AM, Baschal EE, McDaniel KA, Simmons KM, Pyle L, Waugh K, Steck AK, Yu L, Gottlieb PA, Rewers MJ, Nakayama M, Michels AW. Temporal development of T cell receptor repertoires during childhood in health and disease. JCI Insight 2022; 7:161885. [PMID: 35998036 PMCID: PMC9675557 DOI: 10.1172/jci.insight.161885] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/17/2022] [Indexed: 12/05/2022] Open
Abstract
T cell receptor (TCR) sequences are exceptionally diverse and can now be comprehensively measured with next-generation sequencing technologies. However, a thorough investigation of longitudinal TCR repertoires throughout childhood in health and during development of a common childhood disease, type 1 diabetes (T1D), has not been undertaken. Here, we deep sequenced the TCR-β chain repertoires from longitudinal peripheral blood DNA samples at 4 time points beginning early in life (median age of 1.4 years) from children who progressed to T1D (n = 29) and age/sex-matched islet autoantibody-negative controls (n = 25). From 53 million TCR-β sequences, we show that the repertoire is extraordinarily diverse early in life and narrows with age independently of disease. We demonstrate the ability to identify specific TCR sequences, including those known to recognize influenza A and, separately, those specific for insulin and its precursor, preproinsulin. Insulin-reactive TCR-β sequences were more common and frequent in number as the disease progressed in those who developed T1D compared with genetically at risk nondiabetic children, and this was not the case for influenza-reactive sequences. As an independent validation, we sequenced and analyzed TCR-β repertoires from a cohort of new-onset T1D patients (n = 143), identifying the same preproinsulin-reactive TCRs. These results demonstrate an enrichment of preproinsulin-reactive TCR sequences during the progression to T1D, highlighting the importance of using disease-relevant TCR sequences as powerful biomarkers in autoimmune disorders.
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Affiliation(s)
- Angela M Mitchell
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Erin E Baschal
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Kristen A McDaniel
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Kimber M Simmons
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Laura Pyle
- Department of Biostatistics and Informatics, University of Colorado School of Pubic Health, Aurora, United States of America
| | - Kathleen Waugh
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Liping Yu
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Peter A Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Marian J Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Maki Nakayama
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
| | - Aaron W Michels
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, United States of America
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17
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He L, Jia X, Rasmussen CG, Waugh K, Miao D, Dong F, Frohnert B, Steck AK, Simmons KM, Rewers M, Yu L. High-Throughput Multiplex Electrochemiluminescence Assay Applicable to General Population Screening for Type 1 Diabetes and Celiac Disease. Diabetes Technol Ther 2022; 24:502-509. [PMID: 35238620 PMCID: PMC9464081 DOI: 10.1089/dia.2021.0517] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Objective: Large-scale screening of the general population for islet autoantibodies (IAbs) to detect type 1 diabetes (T1D) has started worldwide. The standard screening method of separate radio-binding assay (RBA) for each IAb is an inefficient bottleneck. Furthermore, most positive results by RBA in screening of general population individuals without a clinical diagnosis of T1D are low-affinity and not predictive of future diabetes. Research Design and Methods: We have developed and validated a novel 6-Plex assay based on electrochemiluminescence (ECL) technology that combines in a single well high-affinity IAbs (to insulin, GAD, IA-2, and ZnT8), transglutaminase autoantibodies for celiac disease, and severe acute respiratory syndrome coronavirus 2 antibodies. The Autoimmunity Screening for Kids (ASK) provided 880 serum samples, from 828 children aged 1-17 years without diabetes who were previously tested for IAbs using single ECL assays and RBA assays. Results: Levels of all six antibodies in the 6-Plex ECL assay correlated well with respective single ECL assay levels. Similar to single ECL assays, the 6-Plex ECL assay positivity was congruent with the RBA in 95% (35/37) of children who later developed T1D and in 88% (105/119) high-risk children with multiple IAbs. In contrast, only 56% (86/154, P < 0.0001) of children with persistent single IAb by RBA were found to be positive by 6-Plex ECL assay. Of 555 samples negative for all IAbs by RBA, few (0.2%-0.5%) were positive at low levels in the 6-Plex ECL assay. Conclusions: The study demonstrated that the 6-Plex ECL assay compares favorably to the standard RBAs in terms of disease specificity for general population screening in children. The 6-Plex ECL assay was therefore adopted as the primary screening tool in the general population screening ASK program with advantages of high efficiency, low cost, and low serum volume.
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Affiliation(s)
- Ling He
- Department of Endocrinology, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong, China
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Xiaofan Jia
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Cristy Geno Rasmussen
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathleen Waugh
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Dongmei Miao
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Fran Dong
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Brigitte Frohnert
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimber M. Simmons
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marian Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
- Address correspondence to: Marian Rewers, MD, PhD, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, 1775 Aurora Ct, B140, Aurora, CO 80045, USA
| | - Liping Yu
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
- Address correspondence to: Liping Yu, MD, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, 1775 Aurora Ct, B140, Aurora, CO 80045, USA
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18
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Snell-Bergeon JK, Waugh K, Dong F, Steck AK, Norris JM, Rewers M. Physical activity and progression to type 1 diabetes in children and youth with islet autoimmunity: The diabetes autoimmunity study in the young. Pediatr Diabetes 2022; 23:462-468. [PMID: 35142009 PMCID: PMC9133062 DOI: 10.1111/pedi.13323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 01/20/2022] [Accepted: 02/01/2022] [Indexed: 11/29/2022] Open
Abstract
AIMS/HYPOTHESES Physical inactivity may contribute to islet autoimmunity and progression to clinical type 1 diabetes. To test this hypothesis, we evaluated physical activity, assessed by accelerometer, as an independent risk factor for progression to clinical diabetes among genetically at risk for type 1 diabetes children and youth with islet autoimmunity. METHODS Accelerometer data were obtained for 95 children and youth participating in the diabetes autoimmunity study in the young who had islet autoimmunity. Islet autoimmunity was defined as the presence of islet autoantibodies to insulin, glutamic acid decarboxylase, tyrosine phosphatase-like protein IA-2, or zinc transporter 8. RESULTS During prospective follow-up for up to 7 years, 13 of the 95 participants progressed to clinical diabetes. In multivariable survival analysis, none of the physical activity parameters examined predicted a higher risk of developing diabetes. In survival analysis with time-varying physical activity parameters, none of the physical activity parameters over time were associated with the risk of developing type 1 diabetes. CONCLUSIONS/INTERPRETATION It does not appear that low-physical activity is a risk factor for progression from islet autoantibodies to diabetes in children and youth at high-genetic risk for type 1 diabetes.
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Affiliation(s)
- Janet K Snell-Bergeon
- University of Colorado Anschutz Medical Campus, Barbara Davis Center for Diabetes, Aurora, CO,Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Kathleen Waugh
- University of Colorado Anschutz Medical Campus, Barbara Davis Center for Diabetes, Aurora, CO
| | - Fran Dong
- University of Colorado Anschutz Medical Campus, Barbara Davis Center for Diabetes, Aurora, CO
| | - Andrea K Steck
- University of Colorado Anschutz Medical Campus, Barbara Davis Center for Diabetes, Aurora, CO
| | - Jill M Norris
- Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Marian Rewers
- University of Colorado Anschutz Medical Campus, Barbara Davis Center for Diabetes, Aurora, CO
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19
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DuBose SN, Kanapka LG, Bradfield B, Sooy M, Beck RW, Steck AK. Continuous Glucose Monitoring Profiles in Healthy, Nondiabetic Young Children. J Endocr Soc 2022; 6:bvac060. [PMID: 35506147 PMCID: PMC9049110 DOI: 10.1210/jendso/bvac060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Indexed: 11/19/2022] Open
Abstract
Abstract
Context
Continuous glucose monitoring (CGM) is increasingly being used for both day-to-day management in patients with diabetes and in clinical research. While data on glycemic profiles of healthy, non-diabetic individuals exists, data on non-diabetic very young children are lacking.
Objective
To establish reference sensor glucose ranges in healthy, non-diabetic young children, using a current generation CGM sensor.
Design
Prospective observational study
Setting
Institutional practice
Participants
Healthy, non-diabetic children 1-6 years old; with normal body mass index
Intervention
A blinded Dexcom G6 Pro CGM was worn for approximately 10 days by each participant.
Main Outcome Measure
CGM metrics of mean glucose, hyperglycemia, hypoglycemia, and glycemic variability
Results
39 participants were included in the analyses. Mean average glucose was 103 mg/dL (5.7 mmol/L). Median % time between 70-140 mg/dL (3.9-7.8 mmol/L) was 96% (IQR 92%-97%), mean within-individual coefficient of variation was 17±3%, median time spent with glucose levels >140mg/dL was 3.4% (49 min/day), and median time <70 mg/dL (3.9 mmol/L) was 0.4% (6 min/day).
Conclusions
Collecting normative sensor glucose data and describing glycemic measures for young children fills an important informational gap and will be useful as a benchmark for future clinical studies.
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Affiliation(s)
| | | | - Brenda Bradfield
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Morgan Sooy
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
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20
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Sims EK, Besser RE, Dayan C, Geno Rasmussen C, Greenbaum C, Griffin KJ, Hagopian W, Knip M, Long AE, Martin F, Mathieu C, Rewers M, Steck AK, Wentworth JM, Rich SS, Kordonouri O, Ziegler AG, Herold KC. Screening for Type 1 Diabetes in the General Population: A Status Report and Perspective. Diabetes 2022; 71:610-623. [PMID: 35316839 PMCID: PMC9114719 DOI: 10.2337/dbi20-0054] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Accepted: 01/05/2022] [Indexed: 01/10/2023]
Abstract
Most screening programs to identify individuals at risk for type 1 diabetes have targeted relatives of people living with the disease to improve yield and feasibility. However, ∼90% of those who develop type 1 diabetes do not have a family history. Recent successes in disease-modifying therapies to impact the course of early-stage disease have ignited the consideration of the need for and feasibility of population screening to identify those at increased risk. Existing population screening programs rely on genetic or autoantibody screening, and these have yielded significant information about disease progression and approaches for timing for screening in clinical practice. At the March 2021 Type 1 Diabetes TrialNet Steering Committee meeting, a session was held in which ongoing efforts for screening in the general population were discussed. This report reviews the background of these efforts and the details of those programs. Additionally, we present hurdles that need to be addressed for successful implementation of population screening and provide initial recommendations for individuals with positive screens so that standardized guidelines for monitoring and follow-up can be established.
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Affiliation(s)
- Emily K. Sims
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN
| | - Rachel E.J. Besser
- Department of Paediatrics, National Institute for Health Research Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, U.K
- Wellcome Centre for Human Genetics, University of Oxford, Oxford, U.K
| | - Colin Dayan
- Cardiff University School of Medicine, Cardiff, U.K
| | - Cristy Geno Rasmussen
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | | | | | | | - Mikael Knip
- Pediatric Research Center, Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Tampere Center for Child Health Research, Tampere University Hospital, Tampere, Finland
| | - Anna E. Long
- Bristol Medical School, University of Bristol, Bristol, U.K
| | | | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Marian Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - John M. Wentworth
- Departments of Diabetes and Endocrinology and Population Health and Immunity, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Stephen S. Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Olga Kordonouri
- Kinder und Jugendkrankenhaus Auf der Bult, Hannover, Germany
| | - Anette-Gabriele Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, German Research Center for Environmental Health, Munich-Neuherberg, Germany
- School of Medicine, Technical University of Munich, Munich, Germany
| | - Kevan C. Herold
- Department of Immunobiology and Department of Internal Medicine, Yale University, New Haven, CT
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21
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So M, O'Rourke C, Ylescupidez A, Bahnson HT, Steck AK, Wentworth JM, Bruggeman BS, Lord S, Greenbaum CJ, Speake C. Characterising the age-dependent effects of risk factors on type 1 diabetes progression. Diabetologia 2022; 65:684-694. [PMID: 35041021 PMCID: PMC9928893 DOI: 10.1007/s00125-021-05647-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/23/2021] [Indexed: 12/21/2022]
Abstract
AIMS/HYPOTHESIS Age is known to be one of the most important stratifiers of disease progression in type 1 diabetes. However, what drives the difference in rate of progression between adults and children is poorly understood. Evidence suggests that many type 1 diabetes disease predictors do not have the same effect across the age spectrum. Without a comprehensive analysis describing the varying risk profiles of predictors over the age continuum, researchers and clinicians are susceptible to inappropriate assessment of risk when examining populations of differing ages. We aimed to systematically assess and characterise how the effect of key type 1 diabetes risk predictors changes with age. METHODS Using longitudinal data from single- and multiple-autoantibody-positive at-risk individuals recruited between the ages of 1 and 45 years in TrialNet's Pathway to Prevention Study, we assessed and visually characterised the age-varying effect of key demographic, immune and metabolic predictors of type 1 diabetes by employing a flexible spline model. Two progression outcomes were defined: participants with single autoantibodies (n=4893) were analysed for progression to multiple autoantibodies or type 1 diabetes, and participants with multiple autoantibodies were analysed (n=3856) for progression to type 1 diabetes. RESULTS Several predictors exhibited significant age-varying effects on disease progression. Amongst single-autoantibody participants, HLA-DR3 (p=0.007), GAD65 autoantibody positivity (p=0.008), elevated BMI (p=0.007) and HOMA-IR (p=0.002) showed a significant increase in effect on disease progression with increasing age. Insulin autoantibody positivity had a diminishing effect with older age in single-autoantibody-positive participants (p<0.001). Amongst multiple-autoantibody-positive participants, male sex (p=0.002) was associated with an increase in risk for progression, and HLA DR3/4 (p=0.05) showed a decreased effect on disease progression with older age. In both single- and multiple-autoantibody-positive individuals, significant changes in HR with age were seen for multiple measures of islet function. Risk estimation using prediction risk score Index60 was found to be better at a younger age for both single- and multiple-autoantibody-positive individuals (p=0.007 and p<0.001, respectively). No age-varying effect was seen for prediction risk score DPTRS (p=0.861 and p=0.178, respectively). Multivariable analyses suggested that incorporating the age-varying effect of the individual components of these validated risk scores has the potential to enhance the risk estimate. CONCLUSIONS/INTERPRETATION Analysing the age-varying effect of disease predictors improves understanding and prediction of type 1 diabetes disease progression, and should be leveraged to refine prediction models and guide mechanistic studies.
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Affiliation(s)
- Michelle So
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA.
- Immunology and Diabetes Unit, St Vincent's Institute, Fitzroy, VIC, Australia.
| | - Colin O'Rourke
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Alyssa Ylescupidez
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Henry T Bahnson
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - John M Wentworth
- Royal Melbourne Hospital Department of Diabetes and Endocrinology and Walter and Eliza Hall Institute Division of Population Health and Immunity, Parkville, VIC, Australia
| | - Brittany S Bruggeman
- Division of Pediatric Endocrinology, University of Florida, Gainesville, FL, USA
| | - Sandra Lord
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Carla J Greenbaum
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
| | - Cate Speake
- Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA, USA
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22
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Triolo TM, Pyle L, Broncucia H, Armstrong T, Yu L, Gottlieb PA, Steck AK. Association of High-Affinity Autoantibodies With Type 1 Diabetes High-Risk HLA Haplotypes. J Clin Endocrinol Metab 2022; 107:e1510-e1517. [PMID: 34850014 PMCID: PMC8947772 DOI: 10.1210/clinem/dgab853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Electrochemiluminescence (ECL) assays are high-affinity autoantibody (Ab) tests that are more specific than Abs detected by traditional radiobinding assays (RBA) for risk screening and prediction of progression to type 1 diabetes. We sought to characterize the association of high-risk human leukocyte antigen (HLA) haplotypes and genotypes with ECL positivity and levels in relatives of individuals with type 1 diabetes. METHODS We analyzed 602 participants from the TrialNet Pathway to Prevention Study who were positive for at least 1 RBA diabetes-related Ab [glutamic acid decarboxylase autoantibodies (GADA) or insulin autoantibodies (IAA)] and for whom ECL and HLA data were available. ECL and RBA Ab levels were converted to SD units away from mean (z-scores) for analyses. RESULTS Mean age at initial visit was 19.4 ± 13.7 years; 344 (57.1%) were female and 104 (17.3%) carried the high-risk HLA-DR3/4*0302 genotype. At initial visit 424/602 (70.4%) participants were positive for either ECL-GADA or ECL-IAA, and 178/602 (29.6%) were ECL negative. ECL and RBA-GADA positivity were associated with both HLA-DR3 and DR4 haplotypes (all Ps < 0.05), while ECL and RBA-GADA z-score titers were higher in participants with HLA-DR3 haplotypes only (both Ps < 0.001). ECL-IAA (but not RBA-IAA) positivity was associated with the HLA-DR4 haplotype (P < 0.05). CONCLUSIONS ECL-GADA positivity is associated with the HLA-DR3 and HLA-DR4 haplotypes and levels are associated with the HLA-DR3 haplotype. ECL-IAA positivity is associated with HLA-DR4 haplotype. These studies further contribute to the understanding of genetic risk and islet autoimmunity endotypes in type 1 diabetes.
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Affiliation(s)
- Taylor M Triolo
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
- Correspondence: Taylor M. Triolo, MD, University of Colorado Denver School of Medicine, Barbara Davis Center for Diabetes, 1775 Aurora Ct, MS #A140, Aurora, CO, USA 80045-2581.
| | - Laura Pyle
- Department of Pediatrics, University of Colorado, Aurora, CO, USA
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO, USA
| | - Hali Broncucia
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Taylor Armstrong
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Peter A Gottlieb
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO, USA
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23
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Jacobsen LM, Vehik K, Veijola R, Warncke K, Toppari J, Steck AK, Gesualdo P, Akolkar B, Lundgren M, Hagopian WA, She JX, Rewers M, Ziegler AG, Krischer JP, Larsson HE, Haller MJ. Heterogeneity of DKA Incidence and Age-Specific Clinical Characteristics in Children Diagnosed With Type 1 Diabetes in the TEDDY Study. Diabetes Care 2022; 45:624-633. [PMID: 35043162 PMCID: PMC8918232 DOI: 10.2337/dc21-0422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 12/11/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The Environmental Determinants of Diabetes in the Young (TEDDY) study is uniquely capable of investigating age-specific differences associated with type 1 diabetes. Because age is a primary driver of heterogeneity in type 1 diabetes, we sought to characterize by age metabolic derangements prior to diagnosis and clinical features associated with diabetic ketoacidosis (DKA). RESEARCH DESIGN AND METHODS The 379 TEDDY children who developed type 1 diabetes were grouped by age at onset (0-4, 5-9, and 10-14 years; n = 142, 151, and 86, respectively) with comparisons of autoantibody profiles, HLAs, family history of diabetes, presence of DKA, symptomatology at onset, and adherence to TEDDY protocol. Time-varying analysis compared those with oral glucose tolerance test data with TEDDY children who did not progress to diabetes. RESULTS Increasing fasting glucose (hazard ratio [HR] 1.09 [95% CI 1.04-1.14]; P = 0.0003), stimulated glucose (HR 1.50 [1.42-1.59]; P < 0.0001), fasting insulin (HR 0.89 [0.83-0.95]; P = 0.0009), and glucose-to-insulin ratio (HR 1.29 [1.16-1.43]; P < 0.0001) were associated with risk of progression to type 1 diabetes. Younger children had fewer autoantibodies with more symptoms at diagnosis. Twenty-three children (6.1%) had DKA at onset, only 1 (0.97%) of 103 with and 22 (8.0%) of 276 children without a first-degree relative (FDR) with type 1 diabetes (P = 0.008). Children with DKA were more likely to be nonadherent to study protocol (P = 0.047), with longer duration between their last TEDDY evaluation and diagnosis (median 10.2 vs. 2.0 months without DKA; P < 0.001). CONCLUSIONS DKA at onset in TEDDY is uncommon, especially for FDRs. For those without familial risk, metabolic monitoring continues to provide a primary benefit of reduced DKA but requires regular follow-up. Clinical and laboratory features vary by age at onset, adding to the heterogeneity of type 1 diabetes.
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Affiliation(s)
| | - Kendra Vehik
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Riitta Veijola
- PEDEGO Research Unit, Department of Pediatrics, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Katharina Warncke
- Institute of Diabetes Research, Helmholtz Zentrum München and Forschergruppe Diabetes e.V., Neuherberg, Germany
| | - Jorma Toppari
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, Centre for Population Health Research, University of Turku, Turku, Finland
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Patricia Gesualdo
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Beena Akolkar
- Diabetes Division, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | - Markus Lundgren
- Department of Clinical Sciences Malmö, Lund University, Skåne University Hospital, Malmö, Sweden
| | | | - Jin-Xiong She
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Georgia Regents University, Augusta, GA
| | - Marian Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Anette-G. Ziegler
- PEDEGO Research Unit, Department of Pediatrics, Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Jeffrey P. Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Helena Elding Larsson
- Department of Clinical Sciences Malmö, Lund University, Skåne University Hospital, Malmö, Sweden
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Steck AK, Dong F, Geno Rasmussen C, Bautista K, Sepulveda F, Baxter J, Yu L, Frohnert BI, Rewers MJ. CGM Metrics Predict Imminent Progression to Type 1 Diabetes: Autoimmunity Screening for Kids (ASK) Study. Diabetes Care 2022; 45:365-371. [PMID: 34880069 DOI: 10.2337/dc21-0602] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 11/15/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Children identified with stage 1 type 1 diabetes are at high risk for progressing to stage 3 (clinical) diabetes and require accurate monitoring. Our aim was to establish continuous glucose monitoring (CGM) metrics that could predict imminent progression to diabetes. RESEARCH DESIGN AND METHODS In the Autoimmunity Screening for Kids study, 91 children who were persistently islet autoantibody positive (median age 11.5 years; 48% non-Hispanic White; 57% female) with a baseline CGM were followed for development of diabetes for a median of 6 (range 0.2-34) months. Of these, 16 (18%) progressed to clinical diabetes in a median of 4.5 (range 0.4-29) months. RESULTS Compared with children who did not progress to clinical diabetes (nonprogressors), those who did (progressors) had significantly higher average sensor glucose levels (119 vs. 105 mg/dL, P < 0.001) and increased glycemic variability (SD 27 vs. 16, coefficient of variation, 21 vs. 15, mean of daily differences 24 vs. 16, and mean amplitude of glycemic excursions 43 vs. 26, all P < 0.001). For progressors, 21% of the time was spent with glucose levels >140 mg/dL (TA140) and 8% of time >160 mg/dL, compared with 3% and 1%, respectively, for nonprogressors. In survival analyses, the risk of progression to diabetes in 1 year was 80% in those with TA140 >10%; in contrast, it was only 5% in the other participants. Performance of prediction by receiver operating curve analyses showed area under the curve of ≥0.89 for both individual and combined CGM metric models. CONCLUSIONS TA140 >10% is associated with a high risk of progression to clinical diabetes within the next year in autoantibody-positive children. CGM should be included in the ongoing monitoring of high-risk children and could be used as potential entry criterion for prevention trials.
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Jia X, He L, Miao D, Waugh K, Rasmussen CG, Dong F, Steck AK, Rewers M, Yu L. High-affinity ZnT8 Autoantibodies by Electrochemiluminescence Assay Improve Risk Prediction for Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:3455-3463. [PMID: 34343303 PMCID: PMC8864749 DOI: 10.1210/clinem/dgab575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 01/13/2023]
Abstract
CONTEXT Single ZnT8 autoantibody (ZnT8A) positivity by standard radiobinding assay (RBA) is commonly seen in nondiabetes population-based screening and the risk of progression to type 1 diabetes (T1D) in subjects with single ZnT8A is unknown. OBJECTIVE Identify the risk of progression to T1D in individuals positive only for ZnT8A. METHODS We developed an electrochemiluminescence (ECL) assay to detect high-affinity ZnT8A and validated it in 3 populations: 302 patients newly diagnosed with T1D, 135 nondiabetic children positive for ZnT8A by RBA among 23 400 children screened by the Autoimmunity Screening for Kids (ASK) study, and 123 nondiabetic children multiple autoantibody positive or single ZnT8A positive by RBA participating in the Diabetes Autoimmunity Study in the Young (DAISY). RESULTS In 302 patients with T1D at diagnosis, the positivity for ZnT8A was 62% both in RBA and ECL. Among ASK 135 participants positive for RBA-ZnT8A, 64 were detected ZnT8A as the only islet autoantibody. Of these 64, only 9 were confirmed by ECL-ZnT8A, found to be of high affinity with increased T1D risk. The overall positive predictive value of ECL-ZnT8A for T1D risk was 87.1%, significantly higher than that of RBA-ZnT8A (53.5%, P < .001). In DAISY, 11 of 2547 children who had no positivity previously detected for other islet autoantibodies were identified as single ZnT8A by RBA; of these, 3 were confirmed positive by ECL-ZnT8A and all 3 progressed to clinical T1D. CONCLUSION A large proportion of ZnT8A by RBA are single ZnT8A with low T1D risk, whereas ZnT8A by ECL was of high affinity and high prediction for T1D development.
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Affiliation(s)
- Xiaofan Jia
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Department of Endocrinology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, P. R. China
| | - Ling He
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Department of Endocrinology, Guangzhou First People’s Hospital, School of Medicine, South China University of Technology, Guangzhou, Guangdong 510180, P. R. China
| | - Dongmei Miao
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Kathleen Waugh
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Cristy Geno Rasmussen
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Fran Dong
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Marian Rewers
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
| | - Liping Yu
- Barbara Davis Center for Diabetes University of Colorado School of Medicine, Aurora, Colorado 80045, USA
- Correspondence: Liping Yu, MD, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, 1775 Aurora Ct, B-140, Aurora, CO 80045, USA.
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Voss MG, Cuthbertson DD, Cleves MM, Xu P, Evans-Molina C, Palmer JP, Redondo MJ, Steck AK, Lundgren M, Larsson H, Moore WV, Atkinson MA, Sosenko JM, Ismail HM. Time to Peak Glucose and Peak C-Peptide During the Progression to Type 1 Diabetes in the Diabetes Prevention Trial and TrialNet Cohorts. Diabetes Care 2021; 44:2329-2336. [PMID: 34362815 PMCID: PMC8740940 DOI: 10.2337/dc21-0226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 07/12/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the progression of type 1 diabetes using time to peak glucose or C-peptide during oral glucose tolerance tests (OGTTs) in autoantibody-positive relatives of people with type 1 diabetes. RESEARCH DESIGN AND METHODS We examined 2-h OGTTs of participants in the Diabetes Prevention Trial Type 1 (DPT-1) and TrialNet Pathway to Prevention (PTP) studies. We included 706 DPT-1 participants (mean ± SD age, 13.84 ± 9.53 years; BMI Z-score, 0.33 ± 1.07; 56.1% male) and 3,720 PTP participants (age, 16.01 ± 12.33 years; BMI Z-score, 0.66 ± 1.3; 49.7% male). Log-rank testing and Cox regression analyses with adjustments (age, sex, race, BMI Z-score, HOMA-insulin resistance, and peak glucose/C-peptide levels, respectively) were performed. RESULTS In each of DPT-1 and PTP, higher 5-year diabetes progression risk was seen in those with time to peak glucose >30 min and time to peak C-peptide >60 min (P < 0.001 for all groups), before and after adjustments. In models examining strength of association with diabetes development, associations were greater for time to peak C-peptide versus peak C-peptide value (DPT-1: χ2 = 25.76 vs. χ2 = 8.62; PTP: χ2 = 149.19 vs. χ2 = 79.98; all P < 0.001). Changes in the percentage of individuals with delayed glucose and/or C-peptide peaks were noted over time. CONCLUSIONS In two independent at-risk populations, we show that those with delayed OGTT peak times for glucose or C-peptide are at higher risk of diabetes development within 5 years, independent of peak levels. Moreover, time to peak C-peptide appears more predictive than the peak level, suggesting its potential use as a specific biomarker for diabetes progression.
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Affiliation(s)
- Michael G Voss
- Department of Medicine, Indiana University, School of Medicine, Indianapolis, IN
| | - David D Cuthbertson
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Mario M Cleves
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Ping Xu
- Department of Pediatrics, Morsani College of Medicine, University of South Florida, Tampa, Florida
| | | | - Jerry P Palmer
- Veterans Affairs Puget Sound Health Care System, Seattle, WA
| | - Maria J Redondo
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Markus Lundgren
- Unit for Pediatric Endocrinology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Helena Larsson
- Unit for Pediatric Endocrinology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
| | - Wayne V Moore
- Division of Endocrinology and Diabetes, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Mark A Atkinson
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Jay M Sosenko
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, FL
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So M, Speake C, Steck AK, Lundgren M, Colman PG, Palmer JP, Herold KC, Greenbaum CJ. Advances in Type 1 Diabetes Prediction Using Islet Autoantibodies: Beyond a Simple Count. Endocr Rev 2021; 42:584-604. [PMID: 33881515 DOI: 10.1210/endrev/bnab013] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Indexed: 02/06/2023]
Abstract
Islet autoantibodies are key markers for the diagnosis of type 1 diabetes. Since their discovery, they have also been recognized for their potential to identify at-risk individuals prior to symptoms. To date, risk prediction using autoantibodies has been based on autoantibody number; it has been robustly shown that nearly all multiple-autoantibody-positive individuals will progress to clinical disease. However, longitudinal studies have demonstrated that the rate of progression among multiple-autoantibody-positive individuals is highly heterogenous. Accurate prediction of the most rapidly progressing individuals is crucial for efficient and informative clinical trials and for identification of candidates most likely to benefit from disease modification. This is increasingly relevant with the recent success in delaying clinical disease in presymptomatic subjects using immunotherapy, and as the field moves toward population-based screening. There have been many studies investigating islet autoantibody characteristics for their predictive potential, beyond a simple categorical count. Predictive features that have emerged include molecular specifics, such as epitope targets and affinity; longitudinal patterns, such as changes in titer and autoantibody reversion; and sequence-dependent risk profiles specific to the autoantibody and the subject's age. These insights are the outworking of decades of prospective cohort studies and international assay standardization efforts and will contribute to the granularity needed for more sensitive and specific preclinical staging. The aim of this review is to identify the dynamic and nuanced manifestations of autoantibodies in type 1 diabetes, and to highlight how these autoantibody features have the potential to improve study design of trials aiming to predict and prevent disease.
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Affiliation(s)
- Michelle So
- Diabetes Clinical Research Program, and Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA 98101, USA
| | - Cate Speake
- Diabetes Clinical Research Program, and Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA 98101, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO 80045, USA
| | - Markus Lundgren
- Department of Clinical Sciences Malmö, Lund University, Malmö 22200, Sweden
| | - Peter G Colman
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Jerry P Palmer
- VA Puget Sound Health Care System, Department of Medicine, University of Washington, Seattle, WA 98108, USA
| | - Kevan C Herold
- Department of Immunobiology, and Department of Internal Medicine, Yale University, New Haven, CT 06520, USA
| | - Carla J Greenbaum
- Diabetes Clinical Research Program, and Center for Interventional Immunology, Benaroya Research Institute at Virginia Mason, Seattle, WA 98101, USA
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28
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Redondo MJ, Warnock MV, Libman IM, Bocchino LE, Cuthbertson D, Geyer S, Pugliese A, Steck AK, Evans-Molina C, Becker D, Sosenko JM, Bacha F. TCF7L2 Genetic Variants Do Not Influence Insulin Sensitivity or Secretion Indices in Autoantibody-Positive Individuals at Risk for Type 1 Diabetes. Diabetes Care 2021; 44:2039-2044. [PMID: 34326068 PMCID: PMC8740915 DOI: 10.2337/dc21-0531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 06/10/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed to test whether type 2 diabetes (T2D)-associated TCF7L2 genetic variants affect insulin sensitivity or secretion in autoantibody-positive relatives at risk for type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS We studied autoantibody-positive TrialNet Pathway to Prevention study participants (N = 1,061) (mean age 16.3 years) with TCF7L2 single nucleotide polymorphism (SNP) information and baseline oral glucose tolerance test (OGTT) to calculate indices of insulin sensitivity and secretion. With Bonferroni correction for multiple comparisons, P values < 0.0086 were considered statistically significant. RESULTS None, one, and two T2D-linked TCF7L2 alleles were present in 48.1%, 43.9%, and 8.0% of the participants, respectively. Insulin sensitivity (as reflected by 1/fasting insulin [1/IF]) decreased with increasing BMI z score and was lower in Hispanics. Insulin secretion (as measured by 30-min C-peptide index) positively correlated with age and BMI z score. Oral disposition index was negatively correlated with age, BMI z score, and Hispanic ethnicity. None of the indices were associated with TCF7L2 SNPs. In multivariable analysis models with age, BMI z score, ethnicity, sex, and TCF7L2 alleles as independent variables, C-peptide index increased with age, while BMI z score was associated with higher insulin secretion (C-peptide index), lower insulin sensitivity (1/IF), and lower disposition index; there was no significant effect of TCF7L2 SNPs on any of these indices. When restricting the analyses to participants with a normal OGTT (n = 743; 70%), the results were similar. CONCLUSIONS In nondiabetic autoantibody-positive individuals, TCF7L2 SNPs were not related to insulin sensitivity or secretion indices after accounting for BMI z score, age, sex, and ethnicity.
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Affiliation(s)
- Maria J Redondo
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | | | | | - Laura E Bocchino
- University of South Florida, Tampa, FL.,Jaeb Center for Health Research, Tampa, FL
| | | | - Susan Geyer
- University of South Florida, Tampa, FL.,Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Carmella Evans-Molina
- Center for Diabetes and Metabolic Diseases, Indiana University School of Medicine, Indianapolis, IN
| | | | - Jay M Sosenko
- Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | - Fida Bacha
- Texas Children's Hospital, Baylor College of Medicine, Houston, TX.,Children's Nutrition Research Center, Agricultural Research Service, U.S. Department of Agriculture, Houston, TX
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29
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Virostko J, Craddock RC, Williams JM, Triolo TM, Hilmes MA, Kang H, Du L, Wright JJ, Kinney M, Maki JH, Medved M, Waibel M, Kay TWH, Thomas HE, Greeley SAW, Steck AK, Moore DJ, Powers AC. Development of a standardized MRI protocol for pancreas assessment in humans. PLoS One 2021; 16:e0256029. [PMID: 34428220 PMCID: PMC8384163 DOI: 10.1371/journal.pone.0256029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/29/2021] [Indexed: 11/26/2022] Open
Abstract
Magnetic resonance imaging (MRI) has detected changes in pancreas volume and other characteristics in type 1 and type 2 diabetes. However, differences in MRI technology and approaches across locations currently limit the incorporation of pancreas imaging into multisite trials. The purpose of this study was to develop a standardized MRI protocol for pancreas imaging and to define the reproducibility of these measurements. Calibrated phantoms with known MRI properties were imaged at five sites with differing MRI hardware and software to develop a harmonized MRI imaging protocol. Subsequently, five healthy volunteers underwent MRI at four sites using the harmonized protocol to assess pancreas size, shape, apparent diffusion coefficient (ADC), longitudinal relaxation time (T1), magnetization transfer ratio (MTR), and pancreas and hepatic fat fraction. Following harmonization, pancreas size, surface area to volume ratio, diffusion, and longitudinal relaxation time were reproducible, with coefficients of variation less than 10%. In contrast, non-standardized image processing led to greater variation in MRI measurements. By using a standardized MRI image acquisition and processing protocol, quantitative MRI of the pancreas performed at multiple locations can be incorporated into clinical trials comparing pancreas imaging measures and metabolic state in individuals with type 1 or type 2 diabetes.
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Affiliation(s)
- John Virostko
- Department of Diagnostic Medicine, University of Texas at Austin, Austin, Texas, United States of America
- Livestrong Cancer Institutes, University of Texas at Austin, Austin, Texas, United States of America
- Department of Oncology, University of Texas at Austin, Austin, Texas, United States of America
- * E-mail:
| | - Richard C. Craddock
- Department of Diagnostic Medicine, University of Texas at Austin, Austin, Texas, United States of America
| | - Jonathan M. Williams
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Taylor M. Triolo
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Melissa A. Hilmes
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Hakmook Kang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Liping Du
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Jordan J. Wright
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Mara Kinney
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Jeffrey H. Maki
- Department of Radiology, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Milica Medved
- Department of Radiology, University of Chicago, Chicago, IL, United States of America
| | - Michaela Waibel
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
| | - Thomas W. H. Kay
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
- Department of Medicine, St. Vincent’s Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Helen E. Thomas
- Immunology and Diabetes Unit, St Vincent’s Institute, Fitzroy, Victoria, Australia
- Department of Medicine, St. Vincent’s Hospital, The University of Melbourne, Fitzroy, Victoria, Australia
| | - Siri Atma W. Greeley
- Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, Kovler Diabetes Center, University of Chicago, Chicago, IL, United States of America
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado, United States of America
| | - Daniel J. Moore
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Pathology, Immunology, and Microbiology, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Alvin C. Powers
- Division of Diabetes, Endocrinology, and Metabolism, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee, United States of America
- VA Tennessee Valley Healthcare System, Nashville, Tennessee, United States of America
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30
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Robertson CC, Inshaw JRJ, Onengut-Gumuscu S, Chen WM, Santa Cruz DF, Yang H, Cutler AJ, Crouch DJM, Farber E, Bridges SL, Edberg JC, Kimberly RP, Buckner JH, Deloukas P, Divers J, Dabelea D, Lawrence JM, Marcovina S, Shah AS, Greenbaum CJ, Atkinson MA, Gregersen PK, Oksenberg JR, Pociot F, Rewers MJ, Steck AK, Dunger DB, Wicker LS, Concannon P, Todd JA, Rich SS. Fine-mapping, trans-ancestral and genomic analyses identify causal variants, cells, genes and drug targets for type 1 diabetes. Nat Genet 2021; 53:962-971. [PMID: 34127860 PMCID: PMC8273124 DOI: 10.1038/s41588-021-00880-5] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 05/05/2021] [Indexed: 12/13/2022]
Abstract
We report the largest and most diverse genetic study of type 1 diabetes (T1D) to date (61,427 participants), yielding 78 genome-wide-significant (P < 5 × 10-8) regions, including 36 that are new. We define credible sets of T1D-associated variants and show that they are enriched in immune-cell accessible chromatin, particularly CD4+ effector T cells. Using chromatin-accessibility profiling of CD4+ T cells from 115 individuals, we map chromatin-accessibility quantitative trait loci and identify five regions where T1D risk variants co-localize with chromatin-accessibility quantitative trait loci. We highlight rs72928038 in BACH2 as a candidate causal T1D variant leading to decreased enhancer accessibility and BACH2 expression in T cells. Finally, we prioritize potential drug targets by integrating genetic evidence, functional genomic maps and immune protein-protein interactions, identifying 12 genes implicated in T1D that have been targeted in clinical trials for autoimmune diseases. These findings provide an expanded genomic landscape for T1D.
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Affiliation(s)
- Catherine C Robertson
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
- Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA, USA
| | - Jamie R J Inshaw
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Suna Onengut-Gumuscu
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Wei-Min Chen
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - David Flores Santa Cruz
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Hanzhi Yang
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - Antony J Cutler
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Daniel J M Crouch
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Emily Farber
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
| | - S Louis Bridges
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
- Division of Rheumatology, Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Jeffrey C Edberg
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Robert P Kimberly
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jane H Buckner
- Center for Translational Immunology, Benaroya Research Institute, Seattle, WA, USA
| | - Panos Deloukas
- Clinical Pharmacology, William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Princess Al-Jawhara Al-Brahim Centre of Excellence in Research of Hereditary Disorders (PACER-HD), King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jasmin Divers
- Division of Health Services Research, Department of Foundations of Medicine, New York University Long Island School of Medicine, Mineola, NY, USA
| | - Dana Dabelea
- Colorado School of Public Health and Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jean M Lawrence
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, USA
| | - Santica Marcovina
- Northwest Lipid Metabolism and Diabetes Research Laboratories, University of Washington, Seattle, WA, USA
- Medpace Reference Laboratories, Cincinnati, OH, USA
| | - Amy S Shah
- Cincinnati Children's Hospital Medical Center and the University of Cincinnati, Cincinnati, OH, USA
| | - Carla J Greenbaum
- Center for Interventional Immunology, Benaroya Research Institute, Seattle, WA, USA
- Diabetes Program, Benaroya Research Institute, Seattle, WA, USA
| | - Mark A Atkinson
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
| | - Peter K Gregersen
- Robert S. Boas Center for Genomics and Human Genetics, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Jorge R Oksenberg
- Department of Neurology and Weill Institute for Neurosciences, University of California at San Francisco, San Francisco, CA, USA
| | - Flemming Pociot
- Department of Pediatrics, Herlev University Hospital, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Type 1 Diabetes Biology, Department of Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Marian J Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David B Dunger
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Wellcome Trust Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Linda S Wicker
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Patrick Concannon
- Department of Pathology, Immunology, and Laboratory Medicine, University of Florida, Gainesville, FL, USA
- Genetics Institute, University of Florida, Gainesville, FL, USA
| | - John A Todd
- JDRF/Wellcome Diabetes and Inflammation Laboratory, Wellcome Centre for Human Genetics, Nuffield Department of Medicine, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK.
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA, USA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
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31
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Carry PM, Vanderlinden LA, Johnson RK, Buckner T, Fiehn O, Steck AK, Kechris K, Yang I, Fingerlin TE, Rewers M, Norris JM. Phospholipid Levels at Seroconversion Are Associated With Resolution of Persistent Islet Autoimmunity: The Diabetes Autoimmunity Study in the Young. Diabetes 2021; 70:1592-1601. [PMID: 33863802 PMCID: PMC8336007 DOI: 10.2337/db20-1251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 04/11/2021] [Indexed: 12/14/2022]
Abstract
Reversion of islet autoimmunity (IA) may point to mechanisms that prevent IA progression. We followed 199 individuals who developed IA during the Diabetes Autoimmunity Study in the Young. Untargeted metabolomics was performed in serum samples following IA. Cox proportional hazards models were used to test whether the metabolites (2,487) predicted IA reversion: two or more consecutive visits negative for all autoantibodies. We conducted a principal components analysis (PCA) of the top metabolites; |hazard ratio (HR) >1.25| and nominal P < 0.01. Phosphatidylcholine (16:0_18:1(9Z)) was the strongest individual metabolite (HR per 1 SD 2.16, false discovery rate (FDR)-adjusted P = 0.0037). Enrichment analysis identified four clusters (FDR P < 0.10) characterized by an overabundance of sphingomyelin (d40:0), phosphatidylcholine (16:0_18:1(9Z)), phosphatidylcholine (30:0), and l-decanoylcarnitine. Overall, 63 metabolites met the criteria for inclusion in the PCA. PC1 (HR 1.4, P < 0.0001), PC2 (HR 0.85, P = 0.0185), and PC4 (HR 1.28, P = 0.0103) were associated with IA reversion. Given the potential influence of diet on the metabolome, we investigated whether nutrients were correlated with PCs. We identified 20 nutrients that were correlated with the PCs (P < 0.05). Total sugar intake was the top nutrient. Overall, we identified an association between phosphatidylcholine, sphingomyelin, and carnitine levels and reversion of IA.
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Affiliation(s)
- Patrick M Carry
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | | | - Randi K Johnson
- Colorado Center for Personalized Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Teresa Buckner
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
| | | | - Andrea K Steck
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Katerina Kechris
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Ivana Yang
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Tasha E Fingerlin
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
- Department of Immunology and Genomic Medicine, National Jewish Health, Denver, CO
| | - Marian Rewers
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jill M Norris
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO
- Barbara Davis Center for Diabetes, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
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Steck AK, Liu X, Krischer JP, Haller MJ, Veijola R, Lundgren M, Ahmed S, Akolkar B, Toppari J, Hagopian WA, Rewers MJ, Elding Larsson H. Factors Associated With the Decline of C-Peptide in a Cohort of Young Children Diagnosed With Type 1 Diabetes. J Clin Endocrinol Metab 2021; 106:e1380-e1388. [PMID: 33035311 PMCID: PMC8244121 DOI: 10.1210/clinem/dgaa715] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Indexed: 12/30/2022]
Abstract
CONTEXT Understanding factors involved in the rate of C-peptide decline is needed to tailor therapies for type 1 diabetes (T1D). OBJECTIVE Evaluate factors associated with rate of C-peptide decline after a T1D diagnosis in young children. DESIGN Observational study. SETTING Academic centers. PARTICIPANTS A total of 57 participants from the Environmental Determinants of Diabetes in the Young (TEDDY) study who were enrolled at 3 months of age and followed until T1D, and 56 age-matched children diagnosed with T1D in the community. INTERVENTION A mixed meal tolerance test was used to measure the area under the curve (AUC) C-peptide at 1, 3, 6, 12, and 24 months postdiagnosis. OUTCOME Factors associated with rate of C-peptide decline during the first 2 years postdiagnosis were evaluated using mixed effects models, adjusting for age at diagnosis and baseline C-peptide. RESULTS Adjusted slopes of AUC C-peptide decline did not differ between TEDDY subjects and community controls (P = 0.21), although the former had higher C-peptide baseline levels. In univariate analyses combining both groups (n = 113), younger age, higher weight and body mass index z-scores, female sex, an increased number increased number of islet autoantibodies, and IA-2A or ZnT8A positivity at baseline were associated with a higher rate of C-peptide loss. Younger age, female sex, and higher weight z-score remained significant in multivariate analysis (all P < 0.02). At 3 months after diagnosis, higher HbA1c became an additional independent factor associated with a higher rate of C-peptide decline (P < 0.01). CONCLUSION Younger age at diagnosis, female sex, higher weight z-score, and HbA1c were associated with a higher rate of C-peptide decline after T1D diagnosis in young children.
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Affiliation(s)
- Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Xiang Liu
- Health Informatics Institute, University of South Florida, Tampa, Florida
| | - Jeffrey P Krischer
- Health Informatics Institute, University of South Florida, Tampa, Florida
| | - Michael J Haller
- Department of Pediatrics, University of Florida, Gainesville, Florida
| | - Riitta Veijola
- Department of Pediatrics, PEDEGO Research Unit, MRC Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Markus Lundgren
- Department of Clinical Sciences, Lund University CRC, Skåne University Hospital, Malmö, Sweden
| | - Simi Ahmed
- Immunology of T1D, JDRF International, New York, New York
| | - Beena Akolkar
- Division of Diabetes, Endocrinology and Metabolism, National Institute of Diabetes, Digestive, and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, University of Turku, Turku, Finland
- Pacific Diabetes Research Institute, Seattle, Washington
| | | | - Marian J Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Helena Elding Larsson
- Department of Clinical Sciences, Lund University CRC, Skåne University Hospital, Malmö, Sweden
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Triolo TM, Pyle L, Seligova S, Yu L, Simmons K, Gottlieb P, Evans-Molina C, Steck AK. Proinsulin:C-peptide ratio trajectories over time in relatives at increased risk of progression to type 1 diabetes. J Transl Autoimmun 2021; 4:100089. [PMID: 33748733 PMCID: PMC7972972 DOI: 10.1016/j.jtauto.2021.100089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 02/12/2021] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Biomarkers are needed to characterize heterogeneity within populations at risk for type 1 diabetes. The ratio of proinsulin to C-peptide (PI:C ratio), has been proposed as a biomarker of beta cell dysfunction and is associated with progression to type 1 diabetes. However, relationships between PI:C ratios and autoantibody type and number have not been examined. We sought to characterize PI:C ratios in multiple islet autoantibody positive, single autoantibody positive and autoantibody negative relatives of individuals with type 1 diabetes. METHODS We measured PI:C ratios and autoantibodies with both electrochemiluminescence (ECL) assays (ECL-IAA, ECL-GADA and ECL-IA2A) and radiobinding (RBA) assays (mIAA, GADA, IA2A and ZnT8A) in 98 relatives of individuals with type 1 diabetes followed in the TrialNet Pathway to Prevention Study at the Barbara Davis Center for a mean of 7.4 ± 4.1 years. Of these subjects, eight progressed to T1D, 31 were multiple autoantibody (Ab) positive, 37 were single Ab positive and 22 were Ab negative (by RBA). RESULTS In cross-sectional analyses, there were no significant differences in PI:C ratios between type 1 diabetes and/or multiple Ab positive subjects (4.16 ± 4.06) compared to single Ab positive subjects (4.08 ± 4.34) and negative Ab subjects (3.72 ± 3.78) (p = 0.92) overall or after adjusting for age, sex and BMI. Higher PI:C ratios were associated with mIAA titers (p = 0.03) and showed an association with ECL-IA2A titers (p = 0.09), but not with ECL-IAA, GADA, ECL-GADA, IA2A nor ZnT8A titers. In mixed-effects longitudinal models, the trajectories of PI:C ratio over time were significantly different between the Ab negative and multiple Ab positive/type 1 diabetes groups, after adjusting for sex, age, and BMI (p = 0.04). CONCLUSIONS PI:C ratio trajectories increase over time in subjects who have multiple Ab or develop type 1 diabetes and may be a helpful biomarker to further characterize and stratify risk of progression to type 1 diabetes over time.
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Affiliation(s)
- Taylor M Triolo
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Laura Pyle
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA.,University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, CO, USA
| | - Sona Seligova
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Liping Yu
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Kimber Simmons
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Peter Gottlieb
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
| | - Carmella Evans-Molina
- Indiana University School of Medicine, Indianapolis, IN, USA.,Indiana University Center for Diabetes and Metabolic Diseases. Indianapolis, IN, USA
| | - Andrea K Steck
- University of Colorado Denver School of Medicine - the Barbara Davis Center for Diabetes, Aurora, CO, USA
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Quattrin T, Haller MJ, Steck AK, Felner EI, Li Y, Xia Y, Leu JH, Zoka R, Hedrick JA, Rigby MR, Vercruysse F. Golimumab and Beta-Cell Function in Youth with New-Onset Type 1 Diabetes. N Engl J Med 2020; 383:2007-2017. [PMID: 33207093 DOI: 10.1056/nejmoa2006136] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Type 1 diabetes is an autoimmune disease characterized by progressive loss of pancreatic beta cells. Golimumab is a human monoclonal antibody specific for tumor necrosis factor α that has already been approved for the treatment of several autoimmune conditions in adults and children. Whether golimumab could preserve beta-cell function in youth with newly diagnosed overt (stage 3) type 1 diabetes is unknown. METHODS In this phase 2, multicenter, placebo-controlled, double-blind, parallel-group trial, we randomly assigned, in a 2:1 ratio, children and young adults (age range, 6 to 21 years) with newly diagnosed overt type 1 diabetes to receive subcutaneous golimumab or placebo for 52 weeks. The primary end point was endogenous insulin production, as assessed according to the area under the concentration-time curve for C-peptide level in response to a 4-hour mixed-meal tolerance test (4-hour C-peptide AUC) at week 52. Secondary and additional end points included insulin use, the glycated hemoglobin level, the number of hypoglycemic events, the ratio of fasting proinsulin to C-peptide over time, and response profile. RESULTS A total of 84 participants underwent randomization - 56 were assigned to the golimumab group and 28 to the placebo group. The mean (±SD) 4-hour C-peptide AUC at week 52 differed significantly between the golimumab group and the placebo group (0.64±0.42 pmol per milliliter vs. 0.43±0.39 pmol per milliliter, P<0.001). A treat-to-target approach led to good glycemic control in both groups, and there was no significant difference between the groups in glycated hemoglobin level. Insulin use was lower with golimumab than with placebo. A partial-remission response (defined as an insulin dose-adjusted glycated hemoglobin level score [calculated as the glycated hemoglobin level plus 4 times the insulin dose] of ≤9) was observed in 43% of participants in the golimumab group and in 7% of those in the placebo group (difference, 36 percentage points; 95% CI, 22 to 55). The mean number of hypoglycemic events did not differ between the trial groups. Hypoglycemic events that were recorded as adverse events at the discretion of investigators were reported in 13 participants (23%) in the golimumab group and in 2 (7%) of those in the placebo group. Antibodies to golimumab were detected in 30 participants who received the drug; 29 had antibody titers lower than 1:1000, of whom 12 had positive results for neutralizing antibodies. CONCLUSIONS Among children and young adults with newly diagnosed overt type 1 diabetes, golimumab resulted in better endogenous insulin production and less exogenous insulin use than placebo. (Funded by Janssen Research and Development; T1GER ClinicalTrials.gov number, NCT02846545.).
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Affiliation(s)
- Teresa Quattrin
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Michael J Haller
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Andrea K Steck
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Eric I Felner
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Yinglei Li
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Yichuan Xia
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Jocelyn H Leu
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Ramineh Zoka
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Joseph A Hedrick
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Mark R Rigby
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
| | - Frank Vercruysse
- From the Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and Diabetes Center, John R. Oishei Children's Hospital, Buffalo, NY (T.Q.); the Department of Pediatrics, University of Florida, Gainesville (M.J.H.); the Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora (A.K.S.); the Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta (E.I.F.); Janssen Research and Development, Spring House (Y.L., Y.X., J.H.L.) and Horsham (R.Z., J.A.H., M.R.R.) - both in Pennsylvania; and Janssen Research and Development, Beerse, Belgium (F.V.)
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Gardner JA, Johnson RK, Dong F, Hoffman M, Steck AK, Frohnert BI, Rewers M, Norris JM. Gluten intake and risk of thyroid peroxidase autoantibodies in the Diabetes Autoimmunity Study In the Young (DAISY). Endocrine 2020; 70:331-337. [PMID: 32651851 PMCID: PMC7584755 DOI: 10.1007/s12020-020-02412-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/27/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Autoimmune diseases co-occur, perhaps due to common risk factors. The age at gluten introduction and gluten intake in early childhood has been associated with the autoimmunity preceding celiac disease (CD) and type-1 diabetes (T1D). We explored their associations with the development of thyroid autoimmunity. METHODS DAISY has prospectively followed children at increased risk for T1D and CD since 1993. During follow-up, 107 children developed thyroid autoimmunity, defined as positivity for autoantibodies against thyroid peroxidase on at least two study visits. Age at gluten introduction was ascertained from food history interviews every 3 months until 15 months of age. Gluten intake (g/day) at age 1-2 years was estimated using a food frequency questionnaire. RESULTS From multivariable Cox regression, there was no association between the age of gluten introduction nor the amount of gluten intake and development of thyroid autoimmunity. However, females (hazard ratio = 2.19, 95% CI: 1.46, 3.27) and cases of islet autoimmunity (HR = 2.20, 95% CI: 1.39, 3.50) were significantly more likely to develop thyroid autoimmunity, while exposure to environmental tobacco smoke decreased the risk (HR = 0.46, 95% CI: 0.30, 0.71). CONCLUSIONS Neither the age of gluten introduction nor the amount of gluten consumed in early childhood is associated with risk of thyroid autoimmunity.
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Affiliation(s)
| | - Randi K Johnson
- Division of Bioinformatics and Personalized Medicine, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Fran Dong
- Barbara Davis Center for Diabetes, Aurora, CO, USA
| | | | | | | | | | - Jill M Norris
- Department of Epidemiology, Colorado School of Public Health, Aurora, CO, USA.
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Simmons KM, Sosenko JM, Warnock M, Geyer S, Ismail HM, Elding Larsson H, Steck AK. One-Hour Oral Glucose Tolerance Tests for the Prediction and Diagnostic Surveillance of Type 1 Diabetes. J Clin Endocrinol Metab 2020; 105:5897237. [PMID: 32844178 PMCID: PMC7514797 DOI: 10.1210/clinem/dgaa592] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 08/21/2020] [Indexed: 01/13/2023]
Abstract
CONTEXT Once islet autoantibody-positive individuals are identified, predicting which individuals are at highest risk for type 1 diabetes (T1D) is important. A metabolic risk score derived from 2-hour oral glucose tolerance test (OGTT) data, the Diabetes Prevention Trial-Type 1 risk score (DPTRS), can accurately predict T1D. However, 2-hour OGTTs are time-consuming and costly. OBJECTIVE We aimed to determine whether a risk score derived from 1-hour OGTT data can predict T1D as accurately as the DPTRS. Secondarily, we evaluated whether a 1-hour glucose value can be used for diagnostic surveillance. METHODS The DPTRS was modified to derive a 1-hour OGTT risk score (DPTRS60) using fasting C-peptide, 1-hour glucose and C-peptide, age, and body mass index. Areas under receiver operating curves (ROCAUCs) were used to compare prediction accuracies of DPTRS60 with DPTRS in Diabetes Prevention Trial-Type 1 (DPT-1) (n = 654) and TrialNet Pathway to Prevention (TNPTP) (n = 4610) participants. Negative predictive values (NPV) for T1D diagnosis were derived for 1-hour glucose thresholds. RESULTS ROCAUCs for T1D prediction 5 years from baseline were similar between DPTRS60 and DPTRS (DPT-1: 0.805 and 0.794; TNPTP: 0.832 and 0.847, respectively). DPTRS60 predicted T1D significantly better than 2-hour glucose (P < .001 in both cohorts). A 1-hour glucose of less than 180 mg/dL had a similar NPV, positive predictive value, and specificity for T1D development before the next 6-month visit as the standard 2-hour threshold of less than 140 mg/dL (both ≥ 98.5%). CONCLUSION A 1-hour OGTT can predict T1D as accurately as a 2-hour OGTT with minimal risk of missing a T1D diagnosis before the next visit.
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Affiliation(s)
- Kimber M Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
- Correspondence and Reprint Requests: Kimber M. Simmons, MD, Barbara Davis Center for Diabetes, University of Colorado School of Medicine, 1775 Aurora Ct, Mail Stop A140, Aurora, CO 80045, USA. E-mail:
| | - Jay M Sosenko
- Division of Endocrinology, University of Miami, Miami, Florida, USA
| | | | - Susan Geyer
- University of South Florida, Tampa, Florida, USA
| | - Heba M Ismail
- Department of Pediatrics, Indiana University, Indianapolis, Indiana, USA
| | - Helena Elding Larsson
- Department of Clinical Sciences and Department of Pediatrics, Skåne University Hospital, Malmö, Sweden
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
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Redondo MJ, Hagopian WA, Oram R, Steck AK, Vehik K, Weedon M, Balasubramanyam A, Dabelea D. The clinical consequences of heterogeneity within and between different diabetes types. Diabetologia 2020; 63:2040-2048. [PMID: 32894314 PMCID: PMC8498993 DOI: 10.1007/s00125-020-05211-7] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/26/2020] [Indexed: 12/26/2022]
Abstract
Advances in molecular methods and the ability to share large population-based datasets are uncovering heterogeneity within diabetes types, and some commonalities between types. Within type 1 diabetes, endotypes have been discovered based on demographic (e.g. age at diagnosis, race/ethnicity), genetic, immunological, histopathological, metabolic and/or clinical course characteristics, with implications for disease prediction, prevention, diagnosis and treatment. In type 2 diabetes, the relative contributions of insulin resistance and beta cell dysfunction are heterogeneous and relate to demographics, genetics and clinical characteristics, with substantial interaction from environmental exposures. Investigators have proposed approaches that vary from simple to complex in combining these data to identify type 2 diabetes clusters relevant to prognosis and treatment. Advances in pharmacogenetics and pharmacodynamics are also improving treatment. Monogenic diabetes is a prime example of how understanding heterogeneity within diabetes types can lead to precision medicine, since phenotype and treatment are affected by which gene is mutated. Heterogeneity also blurs the classic distinctions between diabetes types, and has led to the definition of additional categories, such as latent autoimmune diabetes in adults, type 1.5 diabetes and ketosis-prone diabetes. Furthermore, monogenic diabetes shares many features with type 1 and type 2 diabetes, which make diagnosis difficult. These challenges to the current classification framework in adult and paediatric diabetes require new approaches. The 'palette model' and the 'threshold hypothesis' can be combined to help explain the heterogeneity within and between diabetes types. Leveraging such approaches for therapeutic benefit will be an important next step for precision medicine in diabetes. Graphical abstract.
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MESH Headings
- Age of Onset
- Autoimmunity/genetics
- Autoimmunity/immunology
- Diabetes Mellitus/genetics
- Diabetes Mellitus/immunology
- Diabetes Mellitus/metabolism
- Diabetes Mellitus/therapy
- Diabetes Mellitus, Type 1/genetics
- Diabetes Mellitus, Type 1/immunology
- Diabetes Mellitus, Type 1/metabolism
- Diabetes Mellitus, Type 1/therapy
- Diabetes Mellitus, Type 2/genetics
- Diabetes Mellitus, Type 2/immunology
- Diabetes Mellitus, Type 2/metabolism
- Diabetes Mellitus, Type 2/therapy
- Gene-Environment Interaction
- Genetic Predisposition to Disease
- Health Services Accessibility
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/genetics
- Infant, Newborn, Diseases/immunology
- Infant, Newborn, Diseases/metabolism
- Infant, Newborn, Diseases/therapy
- Inflammation/genetics
- Inflammation/immunology
- Insulin Resistance
- Latent Autoimmune Diabetes in Adults/genetics
- Latent Autoimmune Diabetes in Adults/immunology
- Latent Autoimmune Diabetes in Adults/metabolism
- Latent Autoimmune Diabetes in Adults/therapy
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Affiliation(s)
- Maria J Redondo
- Section of Diabetes and Endocrinology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, MWT 10th floor, Houston, TX, 77030, USA.
| | | | - Richard Oram
- University of Exeter Medical School, Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Kendra Vehik
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | | | | | - Dana Dabelea
- Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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38
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McQueen RB, Geno Rasmussen C, Waugh K, Frohnert BI, Steck AK, Yu L, Baxter J, Rewers M. Cost and Cost-effectiveness of Large-scale Screening for Type 1 Diabetes in Colorado. Diabetes Care 2020; 43:1496-1503. [PMID: 32327420 PMCID: PMC7305000 DOI: 10.2337/dc19-2003] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 04/01/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the costs and project the potential lifetime cost-effectiveness of the ongoing Autoimmunity Screening for Kids (ASK) program, a large-scale, presymptomatic type 1 diabetes screening program for children and adolescents in the metropolitan Denver region. RESEARCH DESIGN AND METHODS We report the resource utilization, costs, and effectiveness measures from the ongoing ASK program compared with usual care (i.e., no screening). Additionally, we report a practical screening scenario by including utilization and costs relevant to routine screening in clinical practice. Finally, we project the potential cost-effectiveness of ASK and routine screening by identifying clinical benchmarks (i.e., diabetic ketoacidosis [DKA] events avoided, HbA1c improvements vs. no screening) needed to meet value thresholds of $50,000-$150,000 per quality-adjusted life-year (QALY) gained over a lifetime horizon. RESULTS Cost per case detected was $4,700 for ASK screening and $14,000 for routine screening. To achieve value thresholds of $50,000-$150,000 per QALY gained, screening costs would need to be offset by cost savings through 20% reductions in DKA events at diagnosis in addition to 0.1% (1.1 mmol/mol) improvements in HbA1c over a lifetime compared with no screening for patients who develop type 1 diabetes. Value thresholds were not met from avoiding DKA events alone in either scenario. CONCLUSIONS Presymptomatic type 1 diabetes screening may be cost-effective in areas with a high prevalence of DKA and an infrastructure facilitating screening and monitoring if the benefits of avoiding DKA events and improved HbA1c persist over long-run time horizons. As more data are collected from ASK, the model will be updated with direct evidence on screening effects.
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Affiliation(s)
- R Brett McQueen
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Cristy Geno Rasmussen
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Kathleen Waugh
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Brigitte I Frohnert
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Liping Yu
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Judith Baxter
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
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39
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Triolo TM, Pyle L, Seligova S, Yu L, Gottlieb PA, Steck AK. Risk of Islet and Celiac Autoimmunity in Cotwins of Probands With Type 1 Diabetes. J Endocr Soc 2020; 4:bvaa053. [PMID: 32537543 PMCID: PMC7278281 DOI: 10.1210/jendso/bvaa053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/07/2020] [Indexed: 11/19/2022] Open
Abstract
Context Concordance for persistent islet autoimmunity (IA) and type 1 diabetes in monozygotic twins after probands are diagnosed is variable (30%-70%). Risk for development of IA in dizygotic twins is thought to be similar to nontwin siblings. Little is known in regard to the development of celiac autoimmunity (CDA) in twins of subjects with type 1 diabetes. Objective Our aim was to investigate the development of IA and CDA in cotwins of probands with type 1 diabetes. Methods Since 1995, the Twin Family Study has followed 336 twins (168 twin probands with type 1 diabetes and 168 cotwins) for a median of 14 years (interquartile range:10-18 years). Cotwins were followed for the development of IA, type 1 diabetes, and CDA. Results In monozygotic cotwins, cumulative incidence by age 20 was 14% for IA and 10% for CDA. Development of IA and CDA by age 20 was 9% and 12% in dizygotic cotwins, respectively. While the numbers are small, IA by age 30 years was 26% in monozygotic and 39% in dizygotic twins. In proportional hazards models, the proband’s younger age at diagnosis, but not sex or human leukocyte antigen were associated with time to IA and CDA in cotwins. Conclusion CDA risk by age 20 in cotwins was 10% to 12%. With long-term follow-up, cumulative incidence for IA is high in dizygotic twins, similar to monozygotic twins, suggesting a role of possible early environmental factors shared by type 1 diabetes discordant cotwins.
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Affiliation(s)
- Taylor M Triolo
- University of Colorado Anschutz Medical Campus - The Barbara Davis Center for Diabetes, Aurora, Colorado
| | - Laura Pyle
- University of Colorado Anschutz Medical Campus, Pediatrics, Aurora, Colorado.,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Sona Seligova
- University of Colorado Anschutz Medical Campus - The Barbara Davis Center for Diabetes, Aurora, Colorado
| | - Liping Yu
- University of Colorado Anschutz Medical Campus - The Barbara Davis Center for Diabetes, Aurora, Colorado
| | - Peter A Gottlieb
- University of Colorado Anschutz Medical Campus - The Barbara Davis Center for Diabetes, Aurora, Colorado
| | - Andrea K Steck
- University of Colorado Anschutz Medical Campus - The Barbara Davis Center for Diabetes, Aurora, Colorado
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40
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Carry PM, Vanderlinden LA, Johnson RK, Dong F, Steck AK, Frohnert BI, Rewers M, Yang IV, Kechris K, Norris JM. DNA methylation near the INS gene is associated with INS genetic variation (rs689) and type 1 diabetes in the Diabetes Autoimmunity Study in the Young. Pediatr Diabetes 2020; 21:597-605. [PMID: 32061050 PMCID: PMC7378362 DOI: 10.1111/pedi.12995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 02/06/2020] [Accepted: 02/12/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Mechanisms underlying the role of non-human leukocyte antigen (HLA) genetic risk variants in type 1 diabetes (T1D) are poorly understood. We aimed to test the association between methylation and non-HLA genetic risk. METHODS We conducted a methylation quantitative trait loci (mQTL) analysis in a nested case-control study from the Dietary Autoimmunity Study in the Young. Controls (n = 83) were frequency-matched to T1D cases (n = 83) based on age, race/ethnicity, and sample availability. We evaluated 13 non-HLA genetic markers known be associated with T1D. Genome-wide methylation profiling was performed on peripheral blood samples collected prior to T1D using the Illumina 450 K (discovery set) and infinium methylation EPIC beadchip (EPIC validation) platforms. Linear regression models, adjusting for age and sex, were used to test to each single nucleotide polymorphism (SNP) -probe combination. Logistic regression models were used to test the association between T1D and methylation levels among probes with a significant mQTL. A meta-analysis was used to combine odds ratios from the two platforms. RESULTS We identified 10 SNP-methylation probe pairs (false discovery rate (FDR) adjusted P < .05 and validation P < .05). Probes were associated with the GSDMB, C1QTNF6, IL27, and INS genes. The cg03366382 (OR: 1.9, meta-P = .0495), cg21574853 (OR: 2.5, meta-P = .0232), and cg25336198 (odds ratio: 6.6, meta-P = .0081) probes were significantly associated with T1D. The three probes were located upstream from the INS transcription start site. CONCLUSIONS We confirmed an association between DNA methylation and rs689 that has been identified in related studies. Measurements in our study preceded the onset of T1D suggesting methylation may have a role in the relationship between INS variation and T1D development.
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Affiliation(s)
- Patrick M. Carry
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Lauren A. Vanderlinden
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Randi K. Johnson
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Fran Dong
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrea K. Steck
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado,University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Brigitte I. Frohnert
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado,University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Marian Rewers
- Barbara Davis Center, University of Colorado Anschutz Medical Campus, Aurora, Colorado,University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Ivana V. Yang
- University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Katerina Kechris
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Jill M. Norris
- Department of Epidemiology, Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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41
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Chan CL, Steck AK, Severn C, Pyle L, Rewers M, Zeitler PS. Lessons From Continuous Glucose Monitoring in Youth With Pre-Type 1 Diabetes, Obesity, and Cystic Fibrosis. Diabetes Care 2020; 43:e35-e37. [PMID: 31937609 PMCID: PMC7035587 DOI: 10.2337/dc19-1690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 12/18/2019] [Indexed: 02/03/2023]
Affiliation(s)
- Christine L Chan
- Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Cameron Severn
- Department of Biostatistics, Colorado School of Public Health, Aurora, CO
| | - Laura Pyle
- Department of Biostatistics, Colorado School of Public Health, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Philip S Zeitler
- Pediatric Endocrinology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
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42
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Frohnert BI, Webb-Robertson BJ, Bramer LM, Reehl SM, Waugh K, Steck AK, Norris JM, Rewers M. Predictive Modeling of Type 1 Diabetes Stages Using Disparate Data Sources. Diabetes 2020; 69:238-248. [PMID: 31740441 PMCID: PMC6971485 DOI: 10.2337/db18-1263] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 11/11/2019] [Indexed: 12/18/2022]
Abstract
This study aims to model genetic, immunologic, metabolomics, and proteomic biomarkers for development of islet autoimmunity (IA) and progression to type 1 diabetes in a prospective high-risk cohort. We studied 67 children: 42 who developed IA (20 of 42 progressed to diabetes) and 25 control subjects matched for sex and age. Biomarkers were assessed at four time points: earliest available sample, just prior to IA, just after IA, and just prior to diabetes onset. Predictors of IA and progression to diabetes were identified across disparate sources using an integrative machine learning algorithm and optimization-based feature selection. Our integrative approach was predictive of IA (area under the receiver operating characteristic curve [AUC] 0.91) and progression to diabetes (AUC 0.92) based on standard cross-validation (CV). Among the strongest predictors of IA were change in serum ascorbate, 3-methyl-oxobutyrate, and the PTPN22 (rs2476601) polymorphism. Serum glucose, ADP fibrinogen, and mannose were among the strongest predictors of progression to diabetes. This proof-of-principle analysis is the first study to integrate large, diverse biomarker data sets into a limited number of features, highlighting differences in pathways leading to IA from those predicting progression to diabetes. Integrated models, if validated in independent populations, could provide novel clues concerning the pathways leading to IA and type 1 diabetes.
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Affiliation(s)
- Brigitte I Frohnert
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
| | - Bobbie-Jo Webb-Robertson
- Computational and Statistical Analytics Division, Pacific Northwest National Laboratory, Richland, WA
| | - Lisa M Bramer
- Computational and Statistical Analytics Division, Pacific Northwest National Laboratory, Richland, WA
| | - Sara M Reehl
- Computational and Statistical Analytics Division, Pacific Northwest National Laboratory, Richland, WA
| | - Kathy Waugh
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
| | - Jill M Norris
- Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO
| | - Marian Rewers
- Barbara Davis Center for Diabetes, School of Medicine, University of Colorado, Aurora, CO
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43
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Beyerlein A, Bonifacio E, Vehik K, Hippich M, Winkler C, Frohnert BI, Steck AK, Hagopian WA, Krischer JP, Lernmark Å, Rewers MJ, She JX, Toppari J, Akolkar B, Rich SS, Ziegler AG. Progression from islet autoimmunity to clinical type 1 diabetes is influenced by genetic factors: results from the prospective TEDDY study. J Med Genet 2019; 56:602-605. [PMID: 30287597 PMCID: PMC6690814 DOI: 10.1136/jmedgenet-2018-105532] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/16/2018] [Accepted: 09/13/2018] [Indexed: 11/11/2022]
Abstract
BACKGROUND Progression time from islet autoimmunity to clinical type 1 diabetes is highly variable and the extent that genetic factors contribute is unknown. METHODS In 341 islet autoantibody-positive children with the human leucocyte antigen (HLA) DR3/DR4-DQ8 or the HLA DR4-DQ8/DR4-DQ8 genotype from the prospective TEDDY (The Environmental Determinants of Diabetes in the Young) study, we investigated whether a genetic risk score that had previously been shown to predict islet autoimmunity is also associated with disease progression. RESULTS Islet autoantibody-positive children with a genetic risk score in the lowest quartile had a slower progression from single to multiple autoantibodies (p=0.018), from single autoantibodies to diabetes (p=0.004), and by trend from multiple islet autoantibodies to diabetes (p=0.06). In a Cox proportional hazards analysis, faster progression was associated with an increased genetic risk score independently of HLA genotype (HR for progression from multiple autoantibodies to type 1 diabetes, 1.27, 95% CI 1.02 to 1.58 per unit increase), an earlier age of islet autoantibody development (HR, 0.68, 95% CI 0.58 to 0.81 per year increase in age) and female sex (HR, 1.94, 95% CI 1.28 to 2.93). CONCLUSIONS Genetic risk scores may be used to identify islet autoantibody-positive children with high-risk HLA genotypes who have a slow rate of progression to subsequent stages of autoimmunity and type 1 diabetes.
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Affiliation(s)
- Andreas Beyerlein
- Institute of Diabetes Research, Helmholtz Zentrum München, and Forschergruppe Diabetes, Technical University of Munich, at Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Ezio Bonifacio
- DFG Center for Regenerative Therapies Dresden, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
- Forschergruppe Diabetes eV at Helmholtz Zentrum München, Munich-Neuherberg, Germany
| | - Kendra Vehik
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Markus Hippich
- Institute of Diabetes Research, Helmholtz Zentrum München, and Forschergruppe Diabetes, Technical University of Munich, at Klinikum rechts der Isar, Munich-Neuherberg, Germany
| | - Christiane Winkler
- Institute of Diabetes Research, Helmholtz Zentrum München, and Forschergruppe Diabetes, Technical University of Munich, at Klinikum rechts der Isar, Munich-Neuherberg, Germany
- Forschergruppe Diabetes eV at Helmholtz Zentrum München, Munich-Neuherberg, Germany
| | - Brigitte I Frohnert
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA
| | | | - Jeffrey P Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skåne University Hospital SUS, Malmo, Sweden
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, Colorado, USA
| | - Jin-Xiong She
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Jorma Toppari
- Institute of Biomedicine, Research Centre for Integrative Physiology and Pharmacology, Turku University Hospital, Turku, Finland
- Department of Physiology, University of Turku, Turku, Finland
| | - Beena Akolkar
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland, USA
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, Virginia, USA
| | - Anette-G Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München, and Forschergruppe Diabetes, Technical University of Munich, at Klinikum rechts der Isar, Munich-Neuherberg, Germany
- Forschergruppe Diabetes eV at Helmholtz Zentrum München, Munich-Neuherberg, Germany
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44
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Simmons KM, Fouts A, Pyle L, Clark P, Dong F, Yu L, Usmani-Brown S, Gottlieb P, Herold KC, Steck AK. Unmethylated Insulin as an Adjunctive Marker of Beta Cell Death and Progression to Type 1 Diabetes in Participants at Risk for Diabetes. Int J Mol Sci 2019; 20:ijms20163857. [PMID: 31398795 PMCID: PMC6719233 DOI: 10.3390/ijms20163857] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 12/12/2022] Open
Abstract
Islet autoantibody (iAb)-positive individuals have a high risk of progression to type 1 diabetes (T1D), although the rate of progression is highly variable and factors involved in the rate of progression are largely unknown. The ratio of unmethylated/methylated insulin DNA levels (unmethylated INS ratio) has been shown to be higher in participants at high risk of T1D compared to healthy controls. We aimed to evaluate whether an unmethylated INS ratio may be a useful biomarker of beta cell death and rate of progression to T1D. In TrialNet participants who were followed in the Pathway to Prevention Study and progressed to diabetes (n = 57, median age of onset 15.3 years), we measured unmethylated INS ratio and autoantibodies by electrochemiluminescence (ECL) assays (ECL-IAA, ECL-GADA, and ECL-IA2) and radioimmunoassays (RIA) (mIAA, GADA, IA2A, and ZnT8A) longitudinally for 24 months prior to diagnosis. Linear models were used to test the association between unmethylated INS ratio and the age at T1D diagnosis and unmethylated INS ratio and iAb over time. Close to diabetes onset, the unmethylated INS ratio was associated with mIAA (p = 0.003), ECL-IAA (p = 0.002), and IA2A (p = 0.01) levels, but not with GADA, ECL-GADA, ECL-IA2, or ZnT8A levels. No significant associations were found at baseline (24 months prior to T1D diagnosis). Only mIAA levels were significantly associated with an unmethylated INS ratio over time, with a 0.24 change in the ratio for each 0.1 change in mIAA z-score (p = 0.02). Adjusting for a baseline unmethylated INS ratio, an increased rate of change in unmethylated INS ratio from baseline to diabetes onset was associated with a five-year decrease in age at T1D diagnosis (p = 0.04).
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Grants
- 5RA-2017 Juvenile Diabetes Research Foundation United States of America
- U01 DK061010 NIDDK NIH HHS
- U01 DK103153 NIDDK NIH HHS
- P30 DK045735 NIDDK NIH HHS
- K12 DK094712 NIDDK NIH HHS
- UL1 TR001863 NCATS NIH HHS
- 1-14-CD-17 American Diabetes Association
- U01 DK061010, U01 DK061034, U01 DK061042, U01 DK061058, U01 DK085465, U01 DK085453, U01 DK085461, U01 DK085463, U01 DK085466, U01 DK085499, U01 DK085504, U01 DK085505, U01 DK085509, U01 DK103180, U01-DK103153, U01-DK085476, U01-DK103266 NIH HHS
- DK094712-08 NIDDK NIH HHS
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Affiliation(s)
- Kimber M Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA.
| | - Alexandra Fouts
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA
| | - Laura Pyle
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | | | - Fran Dong
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA
| | - Liping Yu
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA
| | | | - Peter Gottlieb
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA
| | | | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado Anschutz Medical Campus, 1775 Aurora Ct, MSA140, Bldg 20, Aurora, CO 80045, USA
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45
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Redondo MJ, Evans-Molina C, Steck AK, Atkinson MA, Sosenko J. The Influence of Type 2 Diabetes-Associated Factors on Type 1 Diabetes. Diabetes Care 2019; 42:1357-1364. [PMID: 31167894 PMCID: PMC6647039 DOI: 10.2337/dc19-0102] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 04/27/2019] [Indexed: 02/03/2023]
Abstract
Current efforts to prevent progression from islet autoimmunity to type 1 diabetes largely focus on immunomodulatory approaches. However, emerging data suggest that the development of diabetes in islet autoantibody-positive individuals may also involve factors such as obesity and genetic variants associated with type 2 diabetes, and the influence of these factors increases with age at diagnosis. Although these factors have been linked with metabolic outcomes, particularly through their impact on β-cell function and insulin sensitivity, growing evidence suggests that they might also interact with the immune system to amplify the autoimmune response. The presence of factors shared by both forms of diabetes contributes to disease heterogeneity and thus has important implications. Characteristics that are typically considered to be nonimmune should be incorporated into predictive algorithms that seek to identify at-risk individuals and into the designs of trials for disease prevention. The heterogeneity of diabetes also poses a challenge in diagnostic classification. Finally, after clinically diagnosing type 1 diabetes, addressing nonimmune elements may help to prevent further deterioration of β-cell function and thus improve clinical outcomes. This Perspectives in Care article highlights the role of type 2 diabetes-associated genetic factors (e.g., gene variants at transcription factor 7-like 2 [TCF7L2]) and obesity (via insulin resistance, inflammation, β-cell stress, or all three) in the pathogenesis of type 1 diabetes and their impacts on age at diagnosis. Recognizing that type 1 diabetes might result from the sum of effects from islet autoimmunity and type 2 diabetes-associated factors, their interactions, or both affects disease prediction, prevention, diagnosis, and treatment.
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Affiliation(s)
- Maria J Redondo
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Carmella Evans-Molina
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN.,Department of Medicine, Indiana University School of Medicine, Indianapolis, IN.,Herman B Wells Center for Pediatric Research, Indiana University School of Medicine, Indianapolis, IN.,Richard L. Roudebush VA Medical Center, Indianapolis, IN
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Mark A Atkinson
- Departments of Pathology and Pediatrics, University of Florida Diabetes Institute, Gainesville, FL
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Steck AK, Dong F, Taki I, Hoffman M, Simmons K, Frohnert BI, Rewers MJ. Continuous Glucose Monitoring Predicts Progression to Diabetes in Autoantibody Positive Children. J Clin Endocrinol Metab 2019; 104:3337-3344. [PMID: 30844073 PMCID: PMC6589073 DOI: 10.1210/jc.2018-02196] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/01/2019] [Indexed: 01/13/2023]
Abstract
CONTEXT Accurate measures are needed for the prediction and diagnosis of type 1 diabetes (T1D) in at-risk persons. OBJECTIVE The purpose of this study was to explore the value of continuous glucose monitoring (CGM) in predicting T1D onset. DESIGN AND SETTING The Diabetes Autoimmunity Study in the Young (DAISY) prospectively follows children at increased risk for development of islet autoantibodies (islet autoantibody positive; Ab+) and T1D. PARTICIPANTS We analyzed 23 Ab+ participants with available longitudinal CGM data. MAIN OUTCOME MEASURE CGM metrics as glycemic predictors of progression to T1D. RESULTS Of 23 Ab+ participants with a baseline CGM, 8 progressed to diabetes at a median age of 13.8 years during a median follow-up of 17.7 years (interquartile range, 14.6 to 22.0 years). Compared with nonprogressors, participants who progressed to diabetes had significantly increased baseline glycemic variability (SD, 29 vs 21 mg/dL; P = 0.047), daytime sensor average (122 vs 106 mg/dL; P = 0.02), and daytime sensor area under the curve (AUC, 470,370 vs 415,465; P = 0.047). They spent 24% of time at >140 mg/dL and 12% at >160 mg/dL compared with, respectively, 8% and 3% for nonprogressors (both P = 0.005). A receiver-operating characteristic curve analysis showed an AUC of 0.85 for percentage of time spent at >140 or 160 mg/dL. The cutoff of 18% time spent at >140 mg/dL had 75% sensitivity, 100% specificity, and a 100% positive predictive value for diabetes prediction, although these values could change because some nonprogressors may develop diabetes with longer follow-up. CONCLUSIONS Eighteen percent or greater CGM time spent at >140 mg/dL predicts progression to diabetes in Ab+ children.
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Affiliation(s)
- Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
- Correspondence and Reprint Requests: Andrea K. Steck, MD, Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, 1775 Aurora Court, A140, Aurora, Colorado 80045-6511. E-mail:
| | - Fran Dong
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Iman Taki
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Michelle Hoffman
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Kimber Simmons
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Brigitte I Frohnert
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado
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Jacobsen LM, Larsson HE, Tamura RN, Vehik K, Clasen J, Sosenko J, Hagopian WA, She JX, Steck AK, Rewers M, Simell O, Toppari J, Veijola R, Ziegler AG, Krischer JP, Akolkar B, Haller MJ. Predicting progression to type 1 diabetes from ages 3 to 6 in islet autoantibody positive TEDDY children. Pediatr Diabetes 2019; 20:263-270. [PMID: 30628751 PMCID: PMC6456374 DOI: 10.1111/pedi.12812] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/11/2018] [Accepted: 01/04/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The capacity to precisely predict progression to type 1 diabetes (T1D) in young children over a short time span is an unmet need. We sought to develop a risk algorithm to predict progression in children with high-risk human leukocyte antigen (HLA) genes followed in The Environmental Determinants of Diabetes in the Young (TEDDY) study. METHODS Logistic regression and 4-fold cross-validation examined 38 candidate predictors of risk from clinical, immunologic, metabolic, and genetic data. TEDDY subjects with at least one persistent, confirmed autoantibody at age 3 were analyzed with progression to T1D by age 6 serving as the primary endpoint. The logistic regression prediction model was compared to two non-statistical predictors, multiple autoantibody status, and presence of insulinoma-associated-2 autoantibodies (IA-2A). RESULTS A total of 363 subjects had at least one autoantibody at age 3. Twenty-one percent of subjects developed T1D by age 6. Logistic regression modeling identified 5 significant predictors - IA-2A status, hemoglobin A1c, body mass index Z-score, single-nucleotide polymorphism rs12708716_G, and a combination marker of autoantibody number plus fasting insulin level. The logistic model yielded a receiver operating characteristic area under the curve (AUC) of 0.80, higher than the two other predictors; however, the differences in AUC, sensitivity, and specificity were small across models. CONCLUSIONS This study highlights the application of precision medicine techniques to predict progression to diabetes over a 3-year window in TEDDY subjects. This multifaceted model provides preliminary improvement in prediction over simpler prediction tools. Additional tools are needed to maximize the predictive value of these approaches.
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Affiliation(s)
- Laura M. Jacobsen
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
| | - Helena Elding Larsson
- Department of Clinical Sciences Malmö, Lund University, Skåne University Hospital SUS, Malmö, Sweden
| | - Roy N. Tamura
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Kendra Vehik
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Joanna Clasen
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | - Jay Sosenko
- Division of Endocrinology, University of Miami, Miami, Florida, USA
| | | | - Jin-Xiong She
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, Georgia, USA
| | - Andrea K. Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Denver, Colorado, USA
| | - Marian Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Denver, Colorado, USA
| | - Olli Simell
- Department of Pediatrics, Turku University Hospital, Turku, Finland
| | - Jorma Toppari
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Physiology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Riitta Veijola
- Department of Pediatrics, Medical Research Center, PEDEGO Research Unit, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Anette G. Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München and Forschergruppe Diabetes e.V. Neuherberg, Germany
| | - Jeffrey P. Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, Florida, USA
| | | | - Michael J. Haller
- Department of Pediatrics, University of Florida, Gainesville, Florida, USA
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48
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Hippich M, Beyerlein A, Hagopian WA, Krischer JP, Vehik K, Knoop J, Winker C, Toppari J, Lernmark Å, Rewers MJ, Steck AK, She JX, Akolkar B, Robertson CC, Onengut-Gumuscu S, Rich SS, Bonifacio E, Ziegler AG. Genetic Contribution to the Divergence in Type 1 Diabetes Risk Between Children From the General Population and Children From Affected Families. Diabetes 2019; 68:847-857. [PMID: 30655385 PMCID: PMC6425872 DOI: 10.2337/db18-0882] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 01/04/2019] [Indexed: 12/20/2022]
Abstract
The risk for autoimmunity and subsequently type 1 diabetes is 10-fold higher in children with a first-degree family history of type 1 diabetes (FDR children) than in children in the general population (GP children). We analyzed children with high-risk HLA genotypes (n = 4,573) in the longitudinal TEDDY birth cohort to determine how much of the divergent risk is attributable to genetic enrichment in affected families. Enrichment for susceptible genotypes of multiple type 1 diabetes-associated genes and a novel risk gene, BTNL2, was identified in FDR children compared with GP children. After correction for genetic enrichment, the risks in the FDR and GP children converged but were not identical for multiple islet autoantibodies (hazard ratio [HR] 2.26 [95% CI 1.6-3.02]) and for diabetes (HR 2.92 [95% CI 2.05-4.16]). Convergence varied depending upon the degree of genetic susceptibility. Risks were similar in the highest genetic susceptibility group for multiple islet autoantibodies (14.3% vs .12.7%) and diabetes (4.8% vs. 4.1%) and were up to 5.8-fold divergent for children in the lowest genetic susceptibility group, decreasing incrementally in GP children but not in FDR children. These findings suggest that additional factors enriched within affected families preferentially increase the risk of autoimmunity and type 1 diabetes in lower genetic susceptibility strata.
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Affiliation(s)
- Markus Hippich
- Institute of Diabetes Research, Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
| | - Andreas Beyerlein
- Institute of Diabetes Research, Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | | | - Jeffrey P Krischer
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Kendra Vehik
- Health Informatics Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
| | - Jan Knoop
- Institute of Diabetes Research, Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
| | - Christiane Winker
- Institute of Diabetes Research, Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
| | - Jorma Toppari
- Department of Pediatrics, Turku University Hospital, and Research Centre for Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Åke Lernmark
- Department of Clinical Sciences, Lund University/CRC, Skåne University Hospital SUS, Malmo, Sweden
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Jin-Xiong She
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta University, Augusta, GA
| | - Beena Akolkar
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD
| | | | | | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Ezio Bonifacio
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
- DFG Center for Regenerative Therapies Dresden, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Anette-G Ziegler
- Institute of Diabetes Research, Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
- Forschergruppe Diabetes, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
- Forschergruppe Diabetes e.V., Helmholtz Zentrum München (German Research Center for Environmental Health), Munich-Neuherberg, Germany
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49
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Onengut-Gumuscu S, Chen WM, Robertson CC, Bonnie JK, Farber E, Zhu Z, Oksenberg JR, Brant SR, Bridges SL, Edberg JC, Kimberly RP, Gregersen PK, Rewers MJ, Steck AK, Black MH, Dabelea D, Pihoker C, Atkinson MA, Wagenknecht LE, Divers J, Bell RA, Erlich HA, Concannon P, Rich SS. Type 1 Diabetes Risk in African-Ancestry Participants and Utility of an Ancestry-Specific Genetic Risk Score. Diabetes Care 2019; 42:406-415. [PMID: 30659077 PMCID: PMC6385701 DOI: 10.2337/dc18-1727] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 12/14/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Genetic risk scores (GRS) have been developed that differentiate individuals with type 1 diabetes from those with other forms of diabetes and are starting to be used for population screening; however, most studies were conducted in European-ancestry populations. This study identifies novel genetic variants associated with type 1 diabetes risk in African-ancestry participants and develops an African-specific GRS. RESEARCH DESIGN AND METHODS We generated single nucleotide polymorphism (SNP) data with the ImmunoChip on 1,021 African-ancestry participants with type 1 diabetes and 2,928 control participants. HLA class I and class II alleles were imputed using SNP2HLA. Logistic regression models were used to identify genome-wide significant (P < 5.0 × 10-8) SNPs associated with type 1 diabetes in the African-ancestry samples and validate SNPs associated with risk in known European-ancestry loci (P < 2.79 × 10-5). RESULTS African-specific (HLA-DQA1*03:01-HLA-DQB1*02:01) and known European-ancestry HLA haplotypes (HLA-DRB1*03:01-HLA-DQA1*05:01-HLA-DQB1*02:01, HLA-DRB1*04:01-HLA-DQA1*03:01-HLA-DQB1*03:02) were significantly associated with type 1 diabetes risk. Among European-ancestry defined non-HLA risk loci, six risk loci were significantly associated with type 1 diabetes in subjects of African ancestry. An African-specific GRS provided strong prediction of type 1 diabetes risk (area under the curve 0.871), performing significantly better than a European-based GRS and two polygenic risk scores in independent discovery and validation cohorts. CONCLUSIONS Genetic risk of type 1 diabetes includes ancestry-specific, disease-associated variants. The GRS developed here provides improved prediction of type 1 diabetes in African-ancestry subjects and a means to identify groups of individuals who would benefit from immune monitoring for early detection of islet autoimmunity.
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Affiliation(s)
- Suna Onengut-Gumuscu
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | - Wei-Min Chen
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
| | | | - Jessica K Bonnie
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Emily Farber
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Zhennan Zhu
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Jorge R Oksenberg
- Department of Neurology, School of Medicine, University of California, San Francisco, San Francisco, CA
| | - Steven R Brant
- Meyerhoff Inflammatory Bowel Disease Center, Department of Medicine, School of Medicine, and Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - S Louis Bridges
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey C Edberg
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Robert P Kimberly
- Division of Clinical Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, AL
| | - Peter K Gregersen
- Robert S. Boas Center for Genomics & Human Genetics, The Feinstein Institute for Medical Research, Manhasset, NY
| | - Marian J Rewers
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | | | - Dana Dabelea
- Colorado School of Public Health, University of Colorado Denver, Aurora, CO
| | | | - Mark A Atkinson
- Diabetes Institute and Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Lynne E Wagenknecht
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - Jasmin Divers
- Department of Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Ronny A Bell
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | - Henry A Erlich
- Center for Genetics, Children's Hospital Oakland Research Institute, Oakland, CA
| | - Patrick Concannon
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
| | - Stephen S Rich
- Center for Public Health Genomics, University of Virginia, Charlottesville, VA
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA
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50
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Triolo TM, Fouts A, Pyle L, Yu L, Gottlieb PA, Steck AK, Greenbaum CJ, Atkinson M, Baidal D, Battaglia M, Becker D, Bingley P, Bosi E, Buckner J, Clements M, Colman P, DiMeglio L, Gitelman S, Goland R, Gottlieb P, Herold K, Knip M, Krischer J, Lernmark A, Moore W, Moran A, Muir A, Palmer J, Peakman M, Philipson L, Raskin P, Redondo M, Rodriguez H, Russell W, Spain L, Schatz D, Sosenko J, Wentworth J, Wherrett D, Wilson D, Winter W, Ziegler A, Anderson M, Antinozzi P, Benoist C, Blum J, Bourcier K, Chase P, Clare-Salzler M, Clynes R, Eisenbarth G, Fathman C, Grave G, Hering B, Insel R, Kaufman F, Kay T, Leschek E, Mahon J, Marks J, Nanto-Salonen K, Nepom G, Orban T, Parkman R, Pescovitz M, Peyman J, Pugliese A, Roep B, Roncarolo M, Savage P, Simell O, Sherwin R, Siegelman M, Skyler J, Steck A, Thomas J, Trucco M, Wagner J, Krischer JP, Leschek E, Rafkin L, Bourcier K, Cowie C, Foulkes M, Insel R, Krause-Steinrauf H, Lachin JM, Malozowski S, Peyman J, Ridge J, Savage P, Skyler JS, Zafonte SJ, Rafkin L, Sosenko JM, Kenyon NS, Santiago I, Krischer JP, Bundy B, Abbondondolo M, Dixit S, Pasha M, King K, Adcock H, Atterberry L, Fox K, Englert N, Mauras J, Permuy K, Sikes T, Adams T, Berhe B, Guendling L, McLennan L, Paganessi C, Murphy M, Draznin M, Kamboj S, Sheppard V, Lewis L, Coates W, Amado D, Moore G, Babar J, Bedard D, Brenson-Hughes J, Cernich M, Clements R, Duprau S, Goodman L, Hester L, Huerta-Saenz A, Asif I, Karmazin T, Letjen S, Raman D, Morin W, Bestermann E, Morawski J, White A, Brockmyer R, Bays S, Campbell A, Boonstra M, Stapleton N, Stone A, Donoho H, Everett H, Hensley M, Johnson C, Marshall N, Skirvin P, Taylor R, Williams L, Burroughs C, Ray C, Wolverton D, Nickels C, Dothard P, Speiser M, Pellizzari L, Bokor K, Izuora S, Abdelnour P, Cummings S, Cuthbertson D, Paynor M, Leahy M, Riedl S, Shockley R, Saad T, Briones S, Casella C, Herz K, Walsh J, Greening F, Deemer M, Hay S, Hunt N, Sikotra L, Simons D, Karounos R, Oremus L, Dye L, Myers D, Ballard W, Miers R, Eberhard C, Sparks K, Thraikill K, Edwards J, Fowlkes S, Kemp A, Morales L, Holland L, Johnson P, Paul A, Ghatak K, Fiske S, Phelen H, Leyland T, Henderson D, Brenner E, Oppenheimer I, Mamkin C, Moniz C, Clarson M, Lovell A, Peters V, Ford J, Ruelas D, Borut D, Burt M, Jordan S, Castilla P, Flores M, Ruiz L, Hanson J, Green-Blair R, Sheridan K, Garmeson J, Wintergerst G, Pierce A, Omoruyi M, Foster S, Kingery A, Lunsford I, Cervantes T, Parker P, Price J, Urben I, Guillette H, Doughty H, Haydock V, Parker P, Bergman S, Duncum C, Rodda A, Perelman R, Calendo C, Barrera E, Arce-Nunez Y, Geyer S, Martinez M, De la Portilla I, Cardenas L, Garrido M, Villar R, Lorini E, Calandra G, D’Annuzio K, Perri N, Minuto C, Hays B, Rebora R, Callegari O, Ali J, Kramer B, Auble S, Cabrera P, Donohoue R, Fiallo-Scharer M, Hessner P, Wolfgram A, Henderson C, Kansra N, Bettin R, McCuller A, Miller S, Accacha J, Corrigan E, Fiore R, Levine T, Mahoney C, Polychronakos V, Henry M, Gagne H, Starkman M, Fox D, Chin F, Melchionne L, Silverman I, Marshall L, Cerracchio J, Cruz A, Viswanathan J, Heyman K, Wilson S, Chalew S, Valley S, Layburn A, Lala P, Clesi M, Genet G, Uwaifo A, Charron T, Allerton W, Hsiao B, Cefalu L, Melendez-Ramirez R, Richards C, Alleyn E, Gustafson M, Lizanna J, Wahlen S, Aleiwe M, Hansen H, Wahlen C, Karges C, Levy A, Bonaccorso R, Rapaport Y, Tomer D, Chia M, Goldis L, Iazzetti M, Klein C, Levister L, Waldman E, Keaton N, Wallach M, Regelmann Z, Antal M, Aranda C, Reynholds A, Vinik P, Barlow M, Bourcier M, Nevoret J, Couper S, Kinderman A, Beresford N, Thalagne H, Roper J, Gibbons J, Hill S, Balleaut C, Brennan J, Ellis-Gage L, Fear T, Gray L, Law P, Jones C, McNerney L, Pointer N, Price K, Few D, Tomlinson N, Leech D, Wake C, Owens M, Burns J, Leinbach A, Wotherspoon A, Murray K, Short G, Curry S, Kelsey J, Lawson J, Porter S, Stevens E, Thomson S, Winship L, Liu S, Wynn E, Wiltshire J, Krebs P, Cresswell H, Faherty C, Ross L, Denvir J, Drew T, Randell P, Mansell S, Lloyd J, Bell S, Butler Y, Hooton H, Navarra A, Roper G, Babington L, Crate H, Cripps A, Ledlie C, Moulds R, Malloy J, Norton B, Petrova O, Silkstone C, Smith K, Ghai M, Murray V, Viswanathan M, Henegan O, Kawadry J, Olson L, Maddox K, Patterson T, Ahmad B, Flores D, Domek S, Domek K, Copeland M, George J, Less T, Davis M, Short A, Martin J, Dwarakanathan P, O’Donnell B, Boerner L, Larson M, Phillips M, Rendell K, Larson C, Smith K, Zebrowski L, Kuechenmeister M, Miller J, Thevarayapillai M, Daniels H, Speer N, Forghani R, Quintana C, Reh A, Bhangoo P, Desrosiers L, Ireland T, Misla C, Milliot E, Torres S, Wells J, Villar M, Yu D, Berry D, Cook J, Soder A, Powell M, Ng M, Morrison Z, Moore M, Haslam M, Lawson B, Bradley J, Courtney C, Richardson C, Watson E, Keely D, DeCurtis M, Vaccarcello-Cruz Z, Torres K, Muller S, Sandberg H, Hsiang B, Joy D, McCormick A, Powell H, Jones J, Bell S, Hargadon S, Hudson M, Kummer S, Nguyen T, Sauder E, Sutton K, Gensel R, Aguirre-Castaneda V, Benavides, Lopez D, Hemp S, Allen J, Stear E, Davis T, O’Donnell R, Jones A, Roberts J, Dart N, Paramalingam L, Levitt Katz N, Chaudhary K, Murphy S, Willi B, Schwartzman C, Kapadia D, Roberts A, Larson D, McClellan G, Shaibai L, Kelley G, Villa C, Kelley R, Diamond M, Kabbani T, Dajani F, Hoekstra M, Sadler K, Magorno J, Holst V, Chauhan N, Wilson P, Bononi M, Sperl A, Millward M, Eaton L, Dean J, Olshan H, Stavros T, Renna C, Milliard, Brodksy L, Bacon J, Quintos L, Topor S, Bialo B, Bancroft A, Soto W, Lagarde H, Tamura R, Lockemer T, Vanderploeg M, Ibrahim M, Huie V, Sanchez R, Edelen R, Marchiando J, Palmer T, Repas M, Wasson P, Wood K, Auker J, Culbertson T, Kieffer D, Voorhees T, Borgwardt L, DeRaad K, Eckert E, Isaacson H, Kuhn A, Carroll M, Xu P, Schubert G, Francis S, Hagan T, Le M, Penn E, Wickham C, Leyva K, Rivera J, Padilla I, Rodriguez N, Young K, Jospe J, Czyzyk B, Johnson U, Nadgir N, Marlen G, Prakasam C, Rieger N, Glaser E, Heiser B, Harris C, Alies P, Foster H, Slater K, Wheeler D, Donaldson M, Murray D, Hale R, Tragus D, Word J, Lynch L, Pankratz W, Badias F, Rogers R, Newfield S, Holland M, Hashiguchi M, Gottschalk A, Philis-Tsimikas R, Rosal S, Franklin S, Guardado N, Bohannon M, Baker A, Garcia T, Aguinaldo J, Phan V, Barraza D, Cohen J, Pinsker U, Khan J, Wiley L, Jovanovic P, Misra M, Bassi M, Wright D, Cohen K, Huang M, Skiles S, Maxcy C, Pihoker K, Cochrane J, Fosse S, Kearns M, Klingsheim N, Beam C, Wright L, Viles H, Smith S, Heller M, Cunningham A, Daniels L, Zeiden J, Field R, Walker K, Griffin L, Boulware D, Bartholow C, Erickson J, Howard B, Krabbenhoft C, Sandman A, Vanveldhuizen J, Wurlger A, Zimmerman K, Hanisch L, Davis-Keppen A, Bounmananh L, Cotterill J, Kirby M, Harris A, Schmidt C, Kishiyama C, Flores J, Milton W, Martin C, Whysham A, Yerka T, Bream S, Freels J, Hassing J, Webster R, Green P, Carter J, Galloway D, Hoelzer S, Roberts S, Said P, Sullivan H, Freeman D, Allen E, Reiter E, Feinberg C, Johnson L, Newhook D, Hagerty N, White L, Levandoski J, Kyllo M, Johnson C, Gough J, Benoit P, Iyer F, Diamond H, Hosono S, Jackman L, Barette P, Jones I, Sills S, Bzdick J, Bulger R, Ginem J, Weinstock I, Douek R, Andrews G, Modgill G, Gyorffy L, Robin N, Vaidya S, Crouch K, O’Brien C, Thompson N, Granger M, Thorne J, Blumer J, Kalic L, Klepek J, Paulett B, Rosolowski J, Horner M, Watkins J, Casey K, Carpenter C, Michelle Kieffer MH, Burns J, Horton C, Pritchard D, Soetaert A, Wynne C, Chin O, Molina C, Patel R, Senguttuvan M, Wheeler O, Lane P, Furet C, Steuhm D, Jelley S, Goudeau L, Chalmers D, Greer C, Panagiotopoulos D, Metzger D, Nguyen M, Horowitz M, Linton C, Christiansen E, Glades C, Morimoto M, Macarewich R, Norman K, Patin C, Vargas A, Barbanica A, Yu P, Vaidyanathan W, Nallamshetty L, Osborne R, Mehra S, Kaster S, Neace J, Horner G, Reeves C, Cordrey L, Marrs T, Miller S, Dowshen D, Oduah V, Doyle S, Walker D, Catte H, Dean M, Drury-Brown B, Hackman M, Lee S, Malkani K, Cullen K, Johnson P, Parrimon Y, Hampton M, McCarrell C, Curtis E, Paul, Zambrano Y, Paulus K, Pilger J, Ramiro J, Luvon Ritzie AQ, Sharma A, Shor A, Song X, Terry A, Weinberger J, Wootten M, Lachin JM, Foulkes M, Harding P, Krause-Steinrauf H, McDonough S, McGee PF, Owens Hess K, Phoebus D, Quinlan S, Raiden E, Batts E, Buddy C, Kirpatrick K, Ramey M, Shultz A, Webb C, Romesco M, Fradkin J, Leschek E, Spain L, Savage P, Aas S, Blumberg E, Beck G, Brillon D, Gubitosi-Klug R, Laffel L, Vigersky R, Wallace D, Braun J, Lernmark A, Lo B, Mitchell H, Naji A, Nerup J, Orchard T, Steffes M, Tsiatis A, Veatch R, Zinman B, Loechelt B, Baden L, Green M, Weinberg A, Marcovina S, Palmer JP, Weinberg A, Yu L, Babu S, Winter W, Eisenbarth GS, Bingley P, Clynes R, DiMeglio L, Eisenbarth G, Hays B, Leschek E, Marks J, Matheson D, Rafkin L, Rodriguez H, Spain L, Wilson D, Redondo M, Gomez D, McDonald A, Pena S, Pietropaolo M, Shippy K, Batts E, Brown T, Buckner J, Dove A, Hammond M, Hefty D, Klein J, Kuhns K, Letlau M, Lord S, McCulloch-Olson M, Miller L, Nepom G, Odegard J, Ramey M, Sachter E, St. Marie M, Stickney K, VanBuecken D, Vellek B, Webber C, Allen L, Bollyk J, Hilderman N, Ismail H, Lamola S, Sanda S, Vendettuoli H, Tridgell D, Monzavi R, Bock M, Fisher L, Halvorson M, Jeandron D, Kim M, Wood J, Geffner M, Kaufman F, Parkman R, Salazar C, Goland R, Clynes R, Cook S, Freeby M, Pat Gallagher M, Gandica R, Greenberg E, Kurland A, Pollak S, Wolk A, Chan M, Koplimae L, Levine E, Smith K, Trast J, DiMeglio L, Blum J, Evans-Molina C, Hufferd R, Jagielo B, Kruse C, Patrick V, Rigby M, Spall M, Swinney K, Terrell J, Christner L, Ford L, Lynch S, Menendez M, Merrill P, Pescovitz M, Rodriguez H, Alleyn C, Baidal D, Fay S, Gaglia J, Resnick B, Szubowicz S, Weir G, Benjamin R, Conboy D, deManbey A, Jackson R, Jalahej H, Orban T, Ricker A, Wolfsdorf J, Zhang HH, Wilson D, Aye T, Baker B, Barahona K, Buckingham B, Esrey K, Esrey T, Fathman G, Snyder R, Aneja B, Chatav M, Espinoza O, Frank E, Liu J, Perry J, Pyle R, Rigby A, Riley K, Soto A, Gitelman S, Adi S, Anderson M, Berhel A, Breen K, Fraser K, Gerard-Gonzalez A, Jossan P, Lustig R, Moassesfar S, Mugg A, Ng D, Prahalod P, Rangel-Lugo M, Sanda S, Tarkoff J, Torok C, Wesch R, Aslan I, Buchanan J, Cordier J, Hamilton C, Hawkins L, Ho T, Jain A, Ko K, Lee T, Phelps S, Rosenthal S, Sahakitrungruang T, Stehl L, Taylor L, Wertz M, Wong J, Philipson L, Briars R, Devine N, Littlejohn E, Grant T, Gottlieb P, Klingensmith G, Steck A, Alkanani A, Bautista K, Bedoy R, Blau A, Burke B, Cory L, Dang M, Fitzgerald-Miller L, Fouts A, Gage V, Garg S, Gesauldo P, Gutin R, Hayes C, Hoffman M, Ketchum K, Logsden-Sackett N, Maahs D, Messer L, Meyers L, Michels A, Peacock S, Rewers M, Rodriguez P, Sepulbeda F, Sippl R, Steck A, Taki I, Tran BK, Tran T, Wadwa RP, Zeitler P, Barker J, Barry S, Birks L, Bomsburger L, Bookert T, Briggs L, Burdick P, Cabrera R, Chase P, Cobry E, Conley A, Cook G, Daniels J, DiDomenico D, Eckert J, Ehler A, Eisenbarth G, Fain P, Fiallo-Scharer R, Frank N, Goettle H, Haarhues M, Harris S, Horton L, Hutton J, Jeffrrey J, Jenison R, Jones K, Kastelic W, King MA, Lehr D, Lungaro J, Mason K, Maurer H, Nguyen L, Proto A, Realsen J, Schmitt K, Schwartz M, Skovgaard S, Smith J, Vanderwel B, Voelmle M, Wagner R, Wallace A, Walravens P, Weiner L, Westerhoff B, Westfall E, Widmer K, Wright H, Schatz D, Abraham A, Atkinson M, Cintron M, Clare-Salzler M, Ferguson J, Haller M, Hosford J, Mancini D, Rohrs H, Silverstein J, Thomas J, Winter W, Cole G, Cook R, Coy R, Hicks E, Lewis N, Marks J, Pugliese A, Blaschke C, Matheson D, Pugliese A, Sanders-Branca N, Ray Arce LA, Cisneros M, Sabbag S, Moran A, Gibson C, Fife B, Hering B, Kwong C, Leschyshyn J, Nathan B, Pappenfus B, Street A, Boes MA, Peterson Eck S, Finney L, Albright Fischer T, Martin A, Jacqueline Muzamhindo C, Rhodes M, Smith J, Wagner J, Wood B, Becker D, Delallo K, Diaz A, Elnyczky B, Libman I, Pasek B, Riley K, Trucco M, Copemen B, Gwynn D, Toledo F, Rodriguez H, Bollepalli S, Diamond F, Eyth E, Henson D, Lenz A, Shulman D, Raskin P, Adhikari S, Dickson B, Dunnigan E, Lingvay I, Pruneda L, Ramos-Roman M, Raskin P, Rhee C, Richard J, Siegelman M, Sturges D, Sumpter K, White P, Alford M, Arthur J, Aviles-Santa ML, Cordova E, Davis R, Fernandez S, Fordan S, Hardin T, Jacobs A, Kaloyanova P, Lukacova-Zib I, Mirfakhraee S, Mohan A, Noto H, Smith O, Torres N, Wherrett D, Balmer D, Eisel L, Kovalakovska R, Mehan M, Sultan F, Ahenkorah B, Cevallos J, Razack N, Jo Ricci M, Rhode A, Srikandarajah M, Steger R, Russell WE, Black M, Brendle F, Brown A, Moore D, Pittel E, Robertson A, Shannon A, Thomas JW, Herold K, Feldman L, Sherwin R, Tamborlane W, Weinzimer S, Toppari J, Kallio T, Kärkkäinen M, Mäntymäki E, Niininen T, Nurmi B, Rajala P, Romo M, Suomenrinne S, Näntö-Salonen K, Simell O, Simell T, Bosi E, Battaglia M, Bianconi E, Bonfanti R, Grogan P, Laurenzi A, Martinenghi S, Meschi F, Pastore M, Falqui L, Teresa Muscato M, Viscardi M, Bingley P, Castleden H, Farthing N, Loud S, Matthews C, McGhee J, Morgan A, Pollitt J, Elliot-Jones R, Wheaton C, Knip M, Siljander H, Suomalainen H, Colman P, Healy F, Mesfin S, Redl L, Wentworth J, Willis J, Farley M, Harrison L, Perry C, Williams F, Mayo A, Paxton J, Thompson V, Volin L, Fenton C, Carr L, Lemon E, Swank M, Luidens M, Salgam M, Sharma V, Schade D, King C, Carano R, Heiden J, Means N, Holman L, Thomas I, Madrigal D, Muth T, Martin C, Plunkett C, Ramm C, Auchus R, Lane W, Avots E, Buford M, Hale C, Hoyle J, Lane B, Muir A, Shuler S, Raviele N, Ivie E, Jenkins M, Lindsley K, Hansen I, Fadoju D, Felner E, Bode B, Hosey R, Sax J, Jefferies C, Mannering S, Prentis R, She J, Stachura M, Hopkins D, Williams J, Steed L, Asatapova E, Nunez S, Knight S, Dixon P, Ching J, Donner T, Longnecker S, Abel K, Arcara K, Blackman S, Clark L, Cooke D, Plotnick L, Levin P, Bromberger L, Klein K, Sadurska K, Allen C, Michaud D, Snodgrass H, Burghen G, Chatha S, Clark C, Silverberg J, Wittmer C, Gardner J, LeBoeuf C, Bell P, McGlore O, Tennet H, Alba N, Carroll M, Baert L, Beaton H, Cordell E, Haynes A, Reed C, Lichter K, McCarthy P, McCarthy S, Monchamp T, Roach J, Manies S, Gunville F, Marosok L, Nelson T, Ackerman K, Rudolph J, Stewart M, McCormick K, May S, Falls T, Barrett T, Dale K, Makusha L, McTernana C, Penny-Thomas K, Sullivan K, Narendran P, Robbie J, Smith D, Christensen R, Koehler B, Royal C, Arthur T, Houser H, Renaldi J, Watsen S, Wu P, Lyons L, House B, Yu J, Holt H, Nation M, Vickers C, Watling R, Heptulla R, Trast J, Agarwal C, Newell D, Katikaneni R, Gardner C, Del A, Rio A, Logan H, Collier C, Rishton G, Whalley A, Ali S, Ramtoola T, Quattrin L, Mastrandea A, House M, Ecker C, Huang C, Gougeon J, Ho D, Pacuad D, Dunger J, May C, O’Brien C, Acerini B, Salgin A, Thankamony R, Williams J, Buse G, Fuller M, Duclos J, Tricome H, Brown D, Pittard D, Bowlby A, Blue T, Headley S, Bendre K, Lewis K, Sutphin C, Soloranzo J, Puskaric H, Madison M, Rincon M, Carlucci R, Shridharani B, Rusk E, Tessman D, Huffman H, Abrams B, Biederman M, Jones V, Leathers W, Brickman P, Petrie D, Zimmerman J, Howard L, Miller R, Alemzadeh D, Mihailescu R, Melgozza-Walker N, Abdulla C, Boucher-Berry D, Ize-Ludlow R, Levy C, Swenson, Brousell N, Crimmins D, Edler T, Weis C, Schultz D, Rogers D, Latham C, Mawhorter C, Switzer W, Spencer P, Konstantnopoulus S, Broder J, Klein L, Knight L, Szadek G, Welnick B, Thompson R, Hoffman A, Revell J, Cherko K, Carter E, Gilson J, Haines G, Arthur B, Bowen W, Zipf P, Graves R, Lozano D, Seiple K, Spicer A, Chang J, Fregosi J, Harbinson C, Paulson S, Stalters P, Wright D, Zlock A, Freeth J, Victory H, Maheshwari A, Maheshwari T, Holmstrom J, Bueno R, Arguello J, Ahern L, Noreika V, Watson S, Hourse P, Breyer C, Kissel Y, Nicholson M, Pfeifer S, Almazan J, Bajaj M, Quinn K, Funk J, McCance E, Moreno R, Veintimilla A, Wells J, Cook S, Trunnel J, Henske S, Desai K, Frizelis F, Khan R, Sjoberg K, Allen P, Manning G, Hendry B, Taylor S, Jones W, Strader M, Bencomo T, Bailey L, Bedolla C, Roldan C, Moudiotis B, Vaidya C, Anning S, Bunce S, Estcourt E, Folland E, Gordon C, Harrill J, Ireland J, Piper L, Scaife K, Sutton S, Wilkins M, Costelloe J, Palmer L, Casas C, Miller M, Burgard C, Erickson J, Hallanger-Johnson P, Clark W, Taylor A, Lafferty S, Gillett C, Nolan M, Pathak L, Sondrol T, Hjelle S, Hafner J, Kotrba R, Hendrickson A, Cemeroglu T, Symington M, Daniel Y, Appiagyei-Dankah D, Postellon M, Racine L, Kleis K, Barnes S, Godwin H, McCullough K, Shaheen G, Buck L, Noel M, Warren S, Weber S, Parker I, Gillespie B, Nelson C, Frost J, Amrhein E, Moreland A, Hayes J, Peggram J, Aisenberg M, Riordan J, Zasa E, Cummings K, Scott T, Pinto A, Mokashi K, McAssey E, Helden P, Hammond L, Dinning S, Rahman S, Ray C, Dimicri S, Guppy H, Nielsen C, Vogel C, Ariza L, Morales Y, Chang R, Gabbay L, Ambrocio L, Manley R, Nemery W, Charlton P, Smith L, Kerr B, Steindel-Kopp M, Alamaguer D, Liljenquist G, Browning T, Coughenour M, Sulk E, Tsalikan M, Tansey J, Cabbage N. Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes. Diabetes Care 2019; 42:192-199. [PMID: 30061316 PMCID: PMC6341285 DOI: 10.2337/dc18-0288] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 06/28/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings. RESEARCH DESIGN AND METHODS Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years. RESULTS At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects. CONCLUSIONS Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.
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Affiliation(s)
- Taylor M. Triolo
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Alexandra Fouts
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Laura Pyle
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Liping Yu
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Peter A. Gottlieb
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Andrea K. Steck
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO
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