Maternal lipid levels during pregnancy and gestational diabetes: a systematic review and meta-analysis

BACKGROUND

Lipid levels during pregnancy in women with gestational diabetes mellitus (GDM) have been extensively studied; however, it remains unclear whether dyslipidaemia is a potential marker of preexisting insulin resistance.

OBJECTIVE

To evaluate the relationship between lipid measures throughout pregnancy and GDM.

SEARCH STRATEGY

We searched PubMed-MedLine and SCOPUS (inception until January 2014) and reference lists of relevant studies.

SELECTION CRITERIA

Publications describing original data with at least one raw lipid (total cholesterol, high-density lipoprotein cholesterol [HDL-C], low-density lipoprotein cholesterol [LDL-C], or triglyceride) measurement during pregnancy in women with GDM and healthy pregnant controls were retained.

DATA COLLECTION AND ANALYSIS

Data extracted from 60 studies were pooled and weighted mean difference (WMD) in lipid levels was calculated using random effects models. Meta-regression was also performed to identify sources of heterogeneity.

MAIN RESULTS

Triglyceride levels were significantly elevated in women with GDM compared with those without GDM (WMD 30.9, 95% confidence interval [95% CI] 25.4-36.4). This finding was consistent in the first, second and third trimesters of pregnancy. HDL-C levels were significantly lower in women with GDM compared with those without GDM in the second (WMD -4.6, 95% CI -6.2 to -3.1) and third (WMD -4.1, 95% CI -6.5 to -1.7) trimesters of pregnancy. There were no differences in aggregate total cholesterol or LDL-C levels between women with GDM and those without insulin resistance.

AUTHOR'S CONCLUSIONS

Our meta-analysis shows that triglycerides are significantly elevated among women with GDM compared with women without insulin resistance and this finding persists across all three trimesters of pregnancy.

Increased residual cardiovascular risk in patients with diabetes and high versus normal triglycerides despite statin-controlled LDL cholesterol

AIM

To determine whether high triglycerides (TG) in the presence of statin-controlled LDL-C influence the risk of cardiovascular disease (CVD) among patients with diabetes in real-world clinical practice.

MATERIALS AND METHODS

We identified adults with diabetes from the Southern California and Pacific Northwest regions of Kaiser Permanente. We included patients undergoing statin therapy with LDL-C from 40-100 mg/dL who were not undergoing other lipid-lowering therapies and had a prior diagnosis of atherosclerotic CVD or at least one other CVD risk factor. We grouped patients into high TG (200-499 mg/dL; n = 5542) or normal TG (<150 mg/dL, n = 22 411) from January 2010 through December 2016 to compare incidence rates and rate ratios of first non-fatal myocardial infarction (MI), non-fatal stroke, unstable angina and coronary revascularization. We adjusted multivariable analyses for age, sex, race/ethnicity, smoking status, blood pressure, HbA1c, serum creatinine, presence of ischaemic heart disease and study site.

RESULTS

Adjusted rate ratios for the four outcomes were all statistically significantly different. The incidence rate for non-fatal MI was 30% higher in the high TG group (rate ratio, 1.30; 95% CI, 1.08-1.58; P = 0.006). The rate was 23% higher for non-fatal stroke (1.23, 1.01-1.49, P = 0.037), 21% higher for coronary revascularization (rate ratio, 1.21; 95% CI, 1.02-1.43; P = 0.027) and was, non-significantly, 33% higher for unstable angina (rate ratio, 1.33; 95% CI, 0.87-2.03; P = 0.185).

CONCLUSIONS

Despite statin-controlled LDL-C levels, CV events were greater among patients with diabetes and high TG levels. Because we controlled for cardiometabolic risk factors, it is likely that the difference in TG levels contributed to the excess risk observed in patients with high TGs.

Glucokinase regulatory protein: complexity at the crossroads of triglyceride and glucose metabolism

PURPOSE OF REVIEW

Glucokinase regulator (GCKR) encodes glucokinase regulatory protein (GKRP), a hepatocyte-specific inhibitor of the glucose-metabolizing enzyme glucokinase (GCK). Genome-wide association studies have identified a common coding variant within GCKR associated with multiple metabolic traits. This review focuses on recent insights into the critical role of GKRP in hepatic glucose metabolism that have stemmed from the study of human genetics. This knowledge has improved our understanding of glucose and lipid physiology and informed the development of targeted molecular therapeutics for diabetes.

RECENT FINDINGS

Rare GCKR variants have effects on GKRP expression, localization, and activity. These variants are collectively associated with hypertriglyceridaemia but are not causal. Crystal structures of GKRP and the GCK-GKRP complex have been solved, providing greater insight into the molecular interactions between these proteins. Finally, small molecules have been identified that directly bind GKRP and reduce blood glucose levels in rodent models of diabetes.

SUMMARY

GCKR variants across the allelic spectrum have effects on glucose and lipid homeostasis. Functional analysis has highlighted numerous molecular mechanisms for GKRP dysfunction. Hepatocyte-specific GCK activation via small molecule GKRP inhibition may be a new avenue for type 2 diabetes treatment, particularly considering evidence indicating GKRP loss-of-function alone does not cause hypertriglyceridaemia.

Familial chylomicronemia syndrome: an under-recognized cause of severe hypertriglyceridaemia

Familial chylomicronemia syndrome (FCS) is a rare autosomal recessive disorder of chylomicron metabolism causing severe elevation of triglyceride (TG) levels (>10 mmol L^-1 ). This condition is associated with a significant risk of recurrent acute pancreatitis (AP). AP caused by hypertriglyceridaemia (HTG) has been associated with a worse prognosis and higher mortality rates compared to pancreatitis of other aetiology. Despite its association with poor quality of life and increased lifelong risk of HTG-AP, few healthcare providers are familiar with FCS. Because this condition is under-recognized, the majority of FCS patients are diagnosed after age 20 often after consulting several physicians. Although other forms of severe HTG such as multifactorial chylomicronemia have been associated with high atherosclerotic cardiovascular disease (ASCVD) risk and metabolic abnormalities, ASCVD and metabolic syndrome are not usually observed in FCS patients. Because FCS is a genetic condition, the optimal diagnosis strategy remains genetic testing. The presence of bi-allelic pathogenic mutations in LPL, APOC2, GPIHBP1, APOA5 or LMF1 genes confirms the diagnosis. However, some cases of FCS caused by autoantibodies against LPL or GPIHBP1 proteins have also been reported. Furthermore, a clinical score for the diagnosis of FCS has been proposed but needs further validation. Available treatment options to lower triglycerides such as fibrates or omega-3 fatty acids are not efficacious in FCS patients. Currently, the cornerstone of treatment remains a lifelong very low-fat diet, which prevents the formation of chylomicrons. Finally, inhibitors of apo C-III and ANGPTL3 are in development and may eventually constitute additional treatment options for FCS patients.

Identification and functional characterization of mutations in LPL gene causing severe hypertriglyceridaemia and acute pancreatitis

Hypertriglyceridaemia is a very rare disorder caused by the mutations of LPL gene, with an autosomal recessive mode of inheritance. Here, we identified two unrelated Chinese patients manifested with severe hypertriglyceridaemia and acute pancreatitis. The clinical symptoms of proband 1 are more severe than proband 2. Whole exome sequencing and Sanger sequencing were performed. Functional analysis of the identified mutations has been done. Whole exome sequencing identified two pairs of variants in LPL gene in the proband 1 (c.162C>A and c.1322+1G>A) and proband 2 (c.835C>G and c.1322+1G>A). The substitution (c.162C>A) leads to the formation of a truncated (p.Cys54*) LPL protein. The substitution (c.835C>G) leads to the replacement of leucine to valine (p.Leu279Val). The splice donor site mutation (c.1322+1G>A) leads to the formation of alternative transcripts with the loss of 134 bp in exon 8 of the LPL gene. The proband 1 and his younger son also harbouring a heterozygous variant (c.553G>T; p.Gly185Cys) in APOA5 gene. The relative expression level of the mutated LPL mRNA (c.162C>A, c.835C>G and c.1322+1G>A) showed significant differences compared to wild‐type LPL mRNA, suggesting that all these three mutations affect the transcription of LPL mRNA. These three mutations (c.162C>A, c.835C>G and c.1322+1G>A) showed noticeably decreased LPL activity in cell culture medium but not in cell lysates. Here, we identified three mutations in LPL gene which causes severe hypertriglyceridaemia with acute pancreatitis in Chinese patients. We also described the significance of whole exome sequencing for identifying the candidate gene and disease‐causing mutation in patients with severe hypertriglyceridaemia and acute pancreatitis.

Clinical and metabolic factors associated with development and regression of nonalcoholic fatty liver disease in nonobese subjects

BACKGROUND & AIMS

The course of NAFLD (nonalcoholic fatty liver disease) and associated factors in nonobese subjects are not well established. We investigated contributing factors for the development and regression of NAFLD in nonobese Koreans, and whether they would differ from those of obese subjects.

METHODS

Two thousand three hundred and seven adults aged over 18 years participated in this longitudinal observational study. The mean duration of follow-up was 28.7 (±13.2) months. The participants were divided into two groups according to the baseline BMI (nonobese group: BMI <25 kg/m(2), obese group: BMI ≥25 kg/m(2)). The presence or absence of NAFLD was assessed by abdominal ultrasonography.

RESULTS

Body weight change was independently associated with both the development and regression of NAFLD in nonobese subjects as well as obese subjects. Among the subjects who developed NAFLD, the amount of weight change was higher in nonobese subjects compared to obese subjects (1.6 ± 3.9% vs 0.6 ± 4.2%, P = 0.022); and among those who showed regression of NAFLD, the amount of weight change was lower in nonobese subjects (-1.9 ± 4.0% vs -5.0 ± 4.6%, P < 0.001). Among all the components of metabolic syndrome, only high triglyceride levels (>150 mg/dl) at the baseline were significantly associated with both the development and regression of NAFLD in nonobese subjects (ORs, 1.54 (1.10-2.14), and 0.60 (0.38-0.96) respectively).

CONCLUSION

Body weight change and baseline triglyceride levels were strong indicators for the development and regression of NAFLD in a nonobese population.

Risk of cardiovascular events in patients with hypertriglyceridaemia: A review of real-world evidence

AIMS

To describe the real-world prevalence and consequences of hypertriglyceridaemia.

MATERIALS AND METHODS

We searched two large patient databases, the National Health and Nutrition Examination Survey (NHANES) database (2007-2014) and the Optum Research Database, as well as electronic medical records from two Kaiser Permanente regions.

RESULTS

The NHANES data showed that ~26% of US adults, including nearly one-third of statin users, had at least borderline hypertriglyceridaemia (triglycerides [TGs] ≥1.69 mmol/L), and ~40% of adults with diabetes had levels of ≥150 mg/dL despite statin use. The Optum analyses demonstrated that those with TG levels ≥1.69 mmol/L who were on statins had a significantly increased risk of composite initial major cardiovascular (CV) events (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.19-1.34; P < 0.001 vs. patients with TGs <150 mg/dL). This was accompanied by increased healthcare utilization and direct healthcare costs (HR 1.12, 95% CI 1.08-1.16; P < 0.001). In the analyses of the Kaiser Permanente records, patients with diabetes and TG levels 2.26-5.64 mmol/L had significantly higher adjusted incidence rates of non-fatal myocardial infarction (rate ratio 1.30, 95% CI 1.08-1.58; P = 0.006), non-fatal stroke (rate ratio 1.23; 95% CI 1.01-1.49; P = 0.037) and coronary revascularization (rate ratio 1.21; 95% CI 1.02-1.43; P = 0.027), but not unstable angina (rate ratio 1.33; 95% CI 0.87-2.03; P = 0.185) compared with patients with TG levels <1.69 mmol/L.

CONCLUSIONS

Real-world analyses suggest that elevated TGs are prevalent and commonly associated with increased CV risk. CV outcomes trials in patients with established hypertriglyceridaemia will clarify whether strategies to reduce TG levels can ameliorate residual CV risk in patients taking statins.

Acarbose is an effective adjunct to dietary therapy in the treatment of hypertriglyceridaemias

AIMS

In diabetics, acarbose causes a reduction of blood glucose and triglyceride levels. The aim of this study was to assess the effect of this drug in non diabetic subjects with hypertriglyceridaemia.

METHODS

Thirty non diabetic patients with hypertriglyceridaemia type IIb or IV (24 males, six females; mean age 51.1+/-10.2 years) were studied. They were stratified into two groups depending on their basal triglyceride concentration (group A: triglyceride values </=4.5 mmol l-1; group B triglyceride values >4.5 mmol l-1 ). Treatment consisted of 4 week courses of diet plus acarbose (50 mg twice daily) alternating with 4 weeks of diet alone for a total period of 16 weeks.

RESULTS

Mean triglyceride values decreased significantly during the first and third cycles of therapy, i.e. diet plus acarbose treatment cycles in both patient groups. Group A also had significant reductions in total cholesterol and HDL cholesterol concentrations after completion of the acarbose treatment. Reduction of triglyceride levels was observed after both acarbose courses in patients affected by hypertriglyceridaemia type IIb. A marked reduction of triglyceride concentrations was achieved by patients affected by hypertriglyceridaemia type IV after the second acarbose course only.

CONCLUSIONS

Diet alone did not reduce triglyceride concentrations to normal values in our patients. The data suggest that acarbose is a useful adjunct to dietary control in non-diabetic patients affected by severe hypertriglyceridaemia.

New susceptibility locus for obesity and dyslipidaemia on chromosome 3q22.3

BACKGROUND

The muscle Ras (MRAS) gene resides on chromosome 3q22.3 and encodes a member of the membrane-associated Ras small GTPase proteins, which function as signal transducers in multiple processes including cell growth and differentiation. Its role in cardiovascular disease is not fully understood yet. In a preliminary study in heterozygous familial hypercholesterolaemia, we identified a locus linking the early onset of coronary artery disease (CAD) to chromosome 3q.22 and elected to sequence the MRAS gene using the MegaBACE DNA analysis system. In the present study, we investigated the association of seven single-nucleotide polymorphisms (SNPs) at this locus with CAD and its dyslipidaemia-related risk traits in 4,650 Saudi angiographed individuals using TaqMan assays by the Applied Biosystems real-time Prism 7900HT Sequence Detection System.

RESULTS

Among the studied SNPs, rs6782181 (p = 0.017) and rs9818870T (p = 0.009) were associated with CAD following adjustment for sex, age and other confounding risk factors. The rs6782181_GG also conferred risk for obesity (1,764 cases vs. 2,586 controls) [1.16(1.03-1.30); p = 0.017], hypercholesterolaemia (1,686 vs. 2,744) [1.23(1.02-1.47); p = 0.019], hypertriglyceridaemia (1,155 vs. 3,496) [1.29(1.01-1.45); p = 0.043] and low high-density lipoprotein-cholesterol (lHDL-chol) levels (1,935 vs. 2,401) [1.15(1.02-1.30); p = 0.023] after adjustment. Additionally, rs253662_(CT+TT) [1.16(1.01-1.32); p = 0.030] was associated with lHDL-chol levels. Interestingly, rs253662 (p = 0.014) and rs6782181 (p = 0.019) were protective against acquiring high low-density lipoprotein-cholesterol (hLDL-chol) levels (p = 0.014), while rs1720819 showed similar effects against CAD (p < 0.0001). More importantly, a 7-mer haplotype, ACCTGAC (χ2 = 7.66; p = 0.0056), constructed from the studied SNPs, its 6-mer derivative CCTGAC (χ2 = 6.90; p = 0.0086) and several other shorter derivatives conferred risk for obesity. hLDL-chol was weakly linked to CTAA (χ2 = 3.79; p = 0.052) and CCT (χ2 = 4.32; p = 0.038), while several other haplotypes were protective against both obesity and hLDL-chol level.

CONCLUSION

Our results demonstrate that the genomic locus for the MRAS gene confers risk for CAD, obesity and dyslipidaemia and point to the possible involvement of other genes or regulatory elements at this locus, rather than changes in the M-Ras protein function, in these events.

Severe Hypertriglyceridaemia and Chylomicronaemia Syndrome-Causes, Clinical Presentation, and Therapeutic Options

We have reviewed the genetic basis of chylomicronaemia, the difference between monogenic and polygenic hypertriglyceridaemia, its effects on pancreatic, cardiovascular, and microvascular complications, and current and potential future pharmacotherapies. Severe hypertriglyceridaemia (TG > 10 mmol/L or 1000 mg/dL) is rare with a prevalence of <1%. It has a complex genetic basis. In some individuals, the inheritance of a single rare variant with a large effect size leads to severe hypertriglyceridaemia and fasting chylomicronaemia of monogenic origin, termed as familial chylomicronaemia syndrome (FCS). Alternatively, the accumulation of multiple low-effect variants causes polygenic hypertriglyceridaemia, which increases the tendency to develop fasting chylomicronaemia in presence of acquired factors, termed as multifactorial chylomicronaemia syndrome (MCS). FCS is an autosomal recessive disease characterized by a pathogenic variant of the lipoprotein lipase (LPL) gene or one of its regulators. The risk of pancreatic complications and associated morbidity and mortality are higher in FCS than in MCS. FCS has a more favourable cardiometabolic profile and a low prevalence of atherosclerotic cardiovascular disease (ASCVD) compared to MCS. The cornerstone of the management of severe hypertriglyceridaemia is a very-low-fat diet. FCS does not respond to traditional lipid-lowering therapies. Several novel pharmacotherapeutic agents are in various phases of development. Data on the correlation between genotype and phenotype in FCS are scarce. Further research to investigate the impact of individual gene variants on the natural history of the disease, and its link with ASCVD, microvascular disease, and acute or recurrent pancreatitis, is warranted. Volanesorsen reduces triglyceride concentration and frequency of pancreatitis effectively in patients with FCS and MCS. Several other therapeutic agents are in development. Understanding the natural history of FCS and MCS is necessary to rationalise healthcare resources and decide when to deploy these high-cost low-volume therapeutic agents.

Endocrine diseases as causes of secondary hyperlipidemia

Cardiovascular diseases are among the leading causes of increased morbidity and mortality in developed and developing countries. One of the most important risk factors responsible for atherosclerosis and subsequent cardiovascular diseases is hyperlipidaemia. Currently, hyperlipidaemias are divided into several clinical entities. The greatest risk is associated with hypercholesterolaemia. As a result, modern guidelines for the treatment and prevention of atherosclerosis focus predominantly on the reduction of LDL-cholesterol. Hypertriglyceridaemia and atherogenic dyslipidaemia, which are responsible for a less significant increase in the cardiovascular risk, are nowadays secondary targets of the treatment. During the work-up for hyperlipidaemia one of the essential actions is the exclusion of secondary causes of the lipid abnormalities. Those include, among others, endocrine diseases, diabetes, drugs, nephrotic syndrome, and pregnancy. Data regarding the impact of endocrine disease and diabetes on the lipid profile are scattered. In this review, the authors aimed to perform a thorough analysis of the available publications regarding the topic and the preparation of a comprehensive review dealing with the incidence, clinical features, and the therapy of hyperlipidaemias in patients with endocrine disease.

Artifactually low glycated haemoglobin in a patient with severe hypertriglyceridaemia

This report describes a case of artifactually low glycated haemoglobin (Hb) in a patient with type II diabetes and severe hypertriglyceridaemia. The effect of hypertriglyceridaemia on glycated Hb determination using the Abbott Vision method was investigated in a series of patients with diabetes. The interference of triglycerides in glycated Hb assays was also investigated by two other methods, the Beckman Synchron CX4 delta immunoturbidimetric method, and the Primus affinity chromatography high performance liquid chromatography assay.

Hypertriglyceridaemia-Induced Acute Pancreatitis: A Different Disease Phenotype

Acute pancreatitis (AP) is the most common gastrointestinal indication requiring hospitalisation. Severe hypertriglyceridaemia (HTG) is the third most common aetiology of AP (HTGAP), with a complication rate and severity that are higher than those of other aetiologies (non-HTGAP). The aim of this study was to evaluate the supposedly higher complication rate of HTGAP compared to non-HTGAP. The secondary objectives were to find different biomarkers for predicting a severe form. This was a retrospective study that included patients admitted with AP in a tertiary department of gastroenterology and hepatology. The patients were divided into two groups: HTGAP and non-HTGAP. We searched for differences regarding age, gender, the presence of diabetes mellitus (DM), the severity of the disease, the types of complications and predictive biomarkers for severity, hospital stay and mortality. A total of 262 patients were included, and 11% (30/262) of the patients had HTGAP. The mean ages were 44.4 ± 9.2 in the HTGAP group and 58.2 ± 17.1 in the non-HTGAP group, p < 0.0001. Male gender was predominant in both groups, at 76% (23/30) in the HTGAP group vs. 54% (126/232) in non-HTGAP, p = 0.02; 53% (16/30) presented with DM vs. 18% (42/232), p < 0.0001. The patients with HTG presented higher CRP 48 h after admission: 207 mg/dL ± 3 mg/dL vs. non-HTGAP 103 mg/dL ± 107 mg/dL, p < 0.0001. Among the patients with HTGAP, there were 60% (18/30) with moderately severe forms vs. 30% (71/232), p = 0.001, and 16% (5/30) SAP vs. 11% (27/232) in non-HTGAP, p = 0.4 Among the predictive markers, only haematocrit (HT) and blood urea nitrogen (BUN) had AUCs > 0.8. According to a multiple regression analysis, only BUN 48 h was independently associated with the development of SAP (p = 0.05). Diabetes mellitus increased the risk of developing severe acute pancreatitis (OR: 1.3; 95% CI: 0.1963−9.7682; p = 0.7). In our cohort, HTGAP more frequently had local complications compared with non-HTGAP. A more severe inflammatory syndrome seemed to be associated with this aetiology; the best predictive markers for complicated forms of HTGAP were BUN 48 h and HT 48 h.

A triglyceride-rich lipoprotein environment exacerbates renal injury in the accelerated nephrotoxic nephritis model

Hyperlipidaemia accompanies chronic renal disease either as a consequence of the renal dysfunction or as part of generalized metabolic derangements. Under both situations, the lipid profile is characterized by accumulation of triglyceride-rich lipoproteins (TGRLs). This lipid profile is recognized as a risk factor for cardiovascular complications. Whether it may pose a risk for renal injury as well remains unclear. A hyper-TGRL state was generated in C57BL/6 mice using poloxamer-407 (P-407) and immune complex-mediated renal injury was triggered using the accelerated nephrotoxic nephritis (ANTN) model. The hyper-TGRL animals were hypersensitive to ANTN demonstrated by greater haematuria and glomerular cellularity. These changes were accompanied by increased glomerular accumulation of CD68⁺ macrophages. The hypersensitive response to ANTN was not seen in low-density lipoprotein receptor knock-out mice fed with a high fat diet, where triglyceride levels were lower but cholesterol levels comparable to those obtained using P-407. These data indicate that a hyper-TGRL state might be more detrimental to the kidneys than low-density lipoprotein-driven hypercholesterolaemia during immune complex-mediated nephritis. We speculate that the hyper-TGRL environment primes the kidney to exacerbated renal damage following an inflammatory insult with increased accumulation of macrophages that may play a key role in mediating the injurious effects.

Management of hypertriglyceridaemia-induced acute pancreatitis in pregnancy

INTRODUCTION

Acute pancreatitis is a recognised rare complication in pregnancy. The reported incidence varies between 3 and 7 in 10 000 pregnancies and is higher in the third trimester. The commonest causes in pregnancy include gallstones, alcohol and hypertriglyceridaemia. Non-gallstone pancreatitis is associated with more complications and poorer outcome with hypertriglyceridaemia-induced acute pancreatitis having mortality rates ranging from 7.5 to 9.0% and 10.0 to 17.5% for mother and foetus, respectively.

CASE HISTORY

A 40-year-old para 4 woman, who presented at 15(+4) weeks' gestation, was diagnosed with acute pancreatitis. Past medical history included Graves' disease and hypertriglyceridaemia. Fenofibrate was discontinued immediately after discovery of the pregnancy. Initial investigations showed elevated amylase (475.0 µ/L) and triglycerides (46.6 mmol/L). Imaging revealed an inflamed pancreas without evidence of biliary obstruction/gallstones hence confirming the diagnosis of hypertriglyceridaemia-induced acute pancreatitis. Laboratory tests gradually improved (triglyceride 5.2 mmol/L on day 17). On day 18, ultrasound confirmed foetal demise (18(+1) weeks) and a hysterotomy was performed as she had had four previous caesarean sections.

CONCLUSION

Management of acute pancreatitis in pregnancy requires a multi-disciplinary approach. Hypertriglyceridaemia-induced acute pancreatitis has poor outcomes when diagnosed in early pregnancy. Identifying those at risk pre-pregnancy and antenatally can allow close monitoring through pregnancy to optimise care.

Insulin detemir may be less efficacious in patients with nonalcoholic fatty liver disease and hypertriglyceridemia

Insulin detemir is commonly used in obese patients with diabetes mellitus as it is considered hepatoselective and causes less weight gain. We describe a relative lack of effectiveness of detemir in patients with significant NAFLD and hypertriglyceridemia, compared to isophane insulin. This may affect how such patients are managed with insulin.

A study of the role of GATA4 polymorphism in cardiovascular metabolic disorders

BACKGROUND

The study was designed to evaluate the association of GATA4 gene polymorphism with coronary artery disease (CAD) and its metabolic risk factors, including dyslipidaemic disorders, obesity, type 2 diabetes and hypertension, following a preliminary study linking early onset of CAD in heterozygous familial hypercholesterolaemia to chromosome 8, which harbours the GATA4 gene.

RESULTS

We first sequenced the whole GATA4 gene in 250 individuals to identify variants of interest and then investigated the association of 12 single-nucleotide polymorphisms (SNPs) with the disease traits using Taqman chemistry in 4,278 angiographed Saudi individuals. Of the studied SNPs, rs804280 (1.14 (1.03 to 1.27); p = 0.009) was associated with CAD (2,274 cases vs 2,004 controls), hypercholesterolaemia (1,590 vs 2,487) (1.61 (1.03-2.52); p = 0.037) and elevated low-density lipoprotein-cholesterol (hLDLC) (575 vs 3,404) (1.87 (1.10-3.15); p = 0.020). Additionally, rs3729855_T (1.52 (1.09-2.11; p = 0.013)) and rs17153743 (AG + GG) (2.30 (1.30-4.26); p = 0.005) were implicated in hypertension (3,312 vs 966), following adjustments for confounders. Furthermore, haplotypes CCCGTGCC (χ2 = 4.71; p = 0.041) and GACCCGTG (χ2 = 3.84; p = 0.050) constructed from the SNPs were associated with CAD and ACCCACGC (χ2 = 6.58; p = 0.010) with myocardial infarction, while hypercholesterolaemia (χ2 = 3.86; p = 0.050) and hLDLC (χ2 = 4.94; p = 0.026) shared the AACCCATGT, and AACCCATGTC was associated with hLDLC (χ2 = 4.83; p = 0.028). A 10-mer GACCCGCGCC (χ2 = 7.59; p = 0.006) was associated with obesity (1,631 vs 2,362), and the GACACACCC (χ2 = 4.05; p = 0.044) was implicated in type 2 diabetes mellitus 2,378 vs 1,900).

CONCLUSION

Our study implicates GATA4 in CAD and its metabolic risk traits. The finding also points to the possible involvement of yet undefined entities related to GATA4 transcription activity or gene regulatory pathways in events leading to these cardiovascular disorders.

Acute Pancreatitis Due to Hypertriglyceridaemia in Pregnancy

Acute pancreatitis due to hypertriglyceridaemia during pregnancy is a rare but severe clinical condition that may cause fatal results for both the mother and the foetus. Acute pancreatitis developed in a 37-year-old pregnant woman with familial hypertriglyceridaemia and diabetes mellitus in the 31(st) week of pregnancy. As intrauterine foetal death developed, the pregnancy of the patient was terminated. Additionally, insulin, octreotide and plasmapheresis with "double membrane filtration" were applied, and triglycerides rapidly decreased. After 24 hours, the level of triglycerides decreased from 9742 mg dL(-1) to 432 mg dL(-1). The patient was discharged from the intensive care unit at the end of 5 days and was discharged from the hospital after 32 days. The current article presents the successful treatment of severe hypertriglyceridaemia in a pregnant case.

Hypertriglyceridaemia predicts subsequent long-term risk of cardiovascular events in Chinese adults: 23-year follow-up of the Daqing Diabetes Study

BACKGROUND

Limited information is available on the long-term risk of cardiovascular disease (CVD) associated with hypertriglyceridaemia (HTG) in the Chinese population. We estimated this risk over a 23-year period in participants recruited from among those included in the Da Qing Diabetes Study.

METHODS

A total of 833 Chinese adults including 379 with normal glucose levels and 454 with hyperglycaemia were identified by their oral glucose tolerance in 1986 in Da Qing, China. CVD outcomes were monitored until 2009. Thirty-four percent (280/833) of the participants had HTG, which was defined as a fasting plasma triglyceride (TG) level ≥ 1.7 mmol/L, at the baseline time point.

RESULTS

Over the 23-yearfollow-up period, 149 subjects in the HTG group and 190 subjects in the non-HTG group (NTG group) experienced their first CVD event, including fatal or nonfatal myocardial infarction (MI) and stroke. The age and sex-adjusted annual incidence of the first CVD event per 1000 person-years was 30.23 for the HTG group vs 18.68 for the NTG group. The corresponding rates for MI and stroke were 7.71 vs 3.89 and 19.55 vs 13.98, respectively. After adjusting for confounders, the HTG group had a 28% higher risk of the first CVD event than the NTG group. This association was significant among only the subjects with a serum cholesterol level > 5.7 mmol/L and those with diabetes or impaired glucose tolerance (IGT).

CONCLUSION

HGT predicted a substantially higher subsequent long-term risk of the first CVD event in Chinese adults, especially in those with hypercholesterolaemia and hyperglycaemia.

Serum uric acid and risk of incident hypercholesterolaemia and hypertriglyceridaemia in middle-aged and older Chinese: a 4-year prospective cohort study

PURPOSE

The aim was to investigate whether serum uric acid (SUA) was associated with incident hypercholesterolaemia and hypertriglyceridaemia in middle-aged and older Chinese.

METHODS

This prospective cohort study used data from the China Health and Retirement Longitudinal Study. A total of 6,063 participants were included, who were free of hypercholesterolaemia and hypertriglyceridaemia at baseline (2011) and were followed until 2015. Natural cubic spline models were conducted to investigate the dose-response association of SUA with incident hypercholesterolaemia and hypertriglyceridaemia. Moreover, SUA was categorized into four groups according to gender-specific quartiles. Log-binomial regression was performed to explore the association of SUA with hypercholesterolaemia and hypertriglyceridaemia, with the quartile 1 as a reference.

RESULTS

After full adjustment, we observed a positive linear dose-response relationship between SUA and hypercholesterolaemia and hypertriglyceridaemia. Compared with the quartile 1 of SUA, the adjusted risk ratios (95% confidence interval) of hypertriglyceridaemia were 1.15 (0.95-1.39), 1.23 (1.02-1.49) and 1.31 (1.08-1.59) for quartile 2-4 (p-value for trend = .004), respectively. Whereas, we failed to find SUA significantly associated with hypercholesterolaemia. Sex-stratified analyses indicated that the association of SUA with hypertriglyceridaemia was more evident in the female.

CONCLUSIONS

These findings suggest that SUA may be positively associated with incident hypertriglyceridaemia. KEY MESSAGES The natural cubic spline model showed a positive linear dose-response relationship between serum uric acid levels and hypertriglyceridaemia. Compared with the quartile 1 of SUA, the adjusted risk ratios (95% confidence interval) of hypertriglyceridaemia were 1.15 (0.95-1.39), 1.23 (1.02-1.49) and 1.31 (1.08-1.59) for quartile 2-4 (p-value for trend = .004), respectively. Sex-stratified analyses indicated that the association of serum uric acid with hypertriglyceridaemia was more evident in the female.

Impaired secretion of active GLP-1 in patients with hypertriglyceridaemia: A novel lipotoxicity paradigm?

BACKGROUND

Lipotoxicity plays an important role in the pathogenesis of β-cell dysfunction. Glucagon-like peptide-1 (GLP-1) is an incretin hormone that exerts beneficial effects on the number and function of islet β cells. However, the effect of lipotoxicity on GLP-1 secretion is still unknown.

METHODS

Twenty-five patients who were newly diagnosed with diabetes were recruited from 400 subjects based on 75-g Oral Glucose Tolerance Test. Patients were divided into diabetes (DM) and DM combined with hypertriglyceridaemia (DM + HTG) groups according to their serum triglyceride (TG) levels. Seventy-one normal controls and 17 patients with isolated hypertriglyceridaemia were matched by age and gender.

RESULTS

Total and active fasting GLP-1 and 2-hour GLP-1 levels were not significantly altered among the 4 groups. However, total and active ΔGLP-1 levels (the difference between 2-hour GLP-1 and fasting GLP-1 levels) were significantly reduced in the isolated HTG, DM, and DM + HTG groups, particularly the DM + HTG group. The ratio of serum active GLP-1 (AGLP-1) to total GLP-1 (TGLP-1) levels was also decreased in patients with isolated HTG, suggesting that active GLP-1 secretion may be more seriously impaired. Both ΔTGLP-1 and ΔAGLP-1 levels were negatively correlated with serum TG levels, body mass index and fasting plasma glucose (FPG) levels and positively correlated with HDL-C levels. According to the multivariate linear regression analysis, only TG and FPG levels were independently associated with ΔTGLP-1 and ΔAGLP-1 levels.

CONCLUSION

Impaired GLP-1 secretion was associated with hypertriglyceridaemia and diabetes, and a more obvious association was noted in hypertriglyceridaemic patients with diabetes.

Impact of acute pancreatitis during pregnancy in Chinese women: a meta-analysis

A random-effects meta-analysis was performed in English and Chinese databases since its inception to August 2020 to assess the incidence, causes and severity of acute pancreatitis (AP) at various stages of pregnancy, maternal and foetal mortality. A total of 154 articles representing 4034 patients with AP during pregnancy in China were included for the analysis. The incidence of AP during pregnancy was 0.0469 (95% confidence interval [CI], 0.0349; 0.0627) in the first trimester, whereas it was 0.2518 (95% CI, 0.2210; 0.2854) and 0.6323 (95% CI, 0.5870; 0.6753) in the second and third trimester, respectively. The major causes of AP were hypertriglyceridaemia (0.351 [95% CI, 0.3202; 0.3834]) and biliary pancreatitis (0.424 [95% CI, 0.4094; 0.5002]). The severity of AP was mild in majority of the patients. The incidence of AP at maternal mortality was 0.0184 (95% CI, 0.0126; 0.0269) and foetal mortality was 0.1018 (95% CI, 0.0867; 0.1192). Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Foetal mortality requires further investigation. IMPACT STATEMENTWhat is already known on this subject? Acute pancreatitis (AP) in pregnant women is characterised by acute onset and delay in understanding the interaction of the metabolic changes with pancreatic pathophysiology, and thus becomes difficult to diagnose the disease and provide timely treatment to the patients. This poses a greater health risk among women and their foetus by increasing their chances of mortality.What the results of this study add? We performed an exhaustive, random-effects meta-analysis involving 154 articles representing 4034 patients to assess the incidence of AP at various stages of pregnancy, the causes of AP and the severity of AP during pregnancy, maternal and foetal mortality.What are the implications of these findings for clinical practice and/or further research? Our meta-analysis revealed that hypertriglyceridaemia and biliary pancreatitis remain the major causes of AP during pregnancy. Although the rates of maternal mortality have decreased in the recent years, foetal mortality still remains high and requires further investigation.

Tamoxifen-induced acute pancreatitis - a case report

Tamoxifen is a selective estrogen receptor modulator used for the treatment of oestrogen/progesterone receptor positive breast cancer. It has antagonistic or agonistic activity depending on the tissue location. Generally it causes mild and reversible side effects, however more serious ones including cardiovascular and thromboembolic adverse events, uterine cancer or acute pancreatitis can also occur. Tamoxifen, like oestrogens, increases the plasma level of TG and liver secretion of VLDL. Moreover, it inhibits the key enzymes of triglyceride metabolism. In this report we present a case of a 55-year-old woman with a history of a poorly controlled hypertriglyceridaemia diagnosed with breast cancer. She was treated with surgery and adjuvant chemotherapy, radiotherapy and hormonotherapy with tamoxifen. About three months after hormonal treatment, her triglyceride level increased. Five months later she developed an acute necrotic pancreatitis that required hospitalization. Her serum samples on admission were highly lipemic. An abdominal ultrasound showed no evidence of gallstones or dilation of the bile ducts. There was no history of alcohol abuse or abdominal trauma. Tamoxifen was suspected as a trigger factor for pancreatitis. After the drug withdrawal and administration of the conservative management the patient's medical condition improved. Due to a postmenopausal status of the patient and no harmful effect on serum lipids, an adjuvant hormonotherapy with aromatase inhibitor was started.

Natural history and comorbidities of generalised and partial lipodystrophy syndromes in Spain

The rarity of lipodystrophies implies that they are not well-known, leading to delays in diagnosis/misdiagnosis. The aim of this study was to assess the natural course and comorbidities of generalised and partial lipodystrophy in Spain to contribute to their understanding. Thus, a total of 140 patients were evaluated (77.1% with partial lipodystrophy and 22.9% with generalised lipodystrophy). Clinical data were collected in a longitudinal setting with a median follow-up of 4.7 (0.5-17.6) years. Anthropometry and body composition studies were carried out and analytical parameters were also recorded. The estimated prevalence of all lipodystrophies in Spain, excluding Köbberling syndrome, was 2.78 cases/million. The onset of phenotype occurred during childhood in generalised lipodystrophy and during adolescence-adulthood in partial lipodystrophy, with the delay in diagnosis being considerable for both cohorts. There are specific clinical findings that should be highlighted as useful features to take into account when making the differential diagnosis of these disorders. Patients with generalised lipodystrophy were found to develop their first metabolic abnormalities sooner and a different lipid profile has also been observed. Mean time to death was 83.8 ± 2.5 years, being shorter among patients with generalised lipodystrophy. These results provide an initial point of comparison for ongoing prospective studies such as the ECLip Registry study.

Transient hypertriglyceridaemia associated with propranolol for treatment of infantile hemangioma

We present a case of a one-month-old female patient with severe hypertriglyceridaemia as a side effect of treating an ulcerating infantile hemangioma with systemic propranolol. The remarkedly rapid increase in triglyceride returned to normal 96 hours after the discontinuation of the medication, and further follow-up revealed normalisation of the lipid profile. Further research is necessary to unveil the association of systemic propranolol with hypertriglyceridaemia.