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Kubota-Mishra E, Huang X, Minard CG, Astudillo M, Refaey A, Montes G, Sisley S, Ram N, Winter WE, Naylor RN, Balasubramanyam A, Redondo MJ, Tosur M. High Prevalence of A-β+ Ketosis-Prone Diabetes in Children with Type 2 Diabetes and Diabetic Ketoacidosis at Diagnosis: Evidence from the Rare and Atypical Diabetes Network (RADIANT). Pediatr Diabetes 2024; 2024:5907924. [PMID: 38765897 PMCID: PMC11100136 DOI: 10.1155/2024/5907924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
Background A-β+ ketosis-prone diabetes (KPD) in adults is characterized by presentation with diabetic ketoacidosis (DKA), negative islet autoantibodies, and preserved β-cell function in persons with a phenotype of obesity-associated type 2 diabetes (T2D). The prevalence of KPD has not been evaluated in children. We investigated children with DKA at "T2D" onset and determined the prevalence and characteristics of pediatric A-β+ KPD within this cohort. Methods We reviewed the records of 716 children with T2D at a large academic hospital and compared clinical characteristics of those with and without DKA at onset. In the latter group, we identified patients with A-β+ KPD using criteria of the Rare and Atypical Diabetes Network (RADIANT) and defined its prevalence and characteristics. Results Mean age at diagnosis was 13.7 ± 2.4 years: 63% female; 59% Hispanic, 29% African American, 9% non-Hispanic White, and 3% other. Fifty-six (7.8%) presented with DKA at diagnosis and lacked islet autoantibodies. Children presenting with DKA were older and had lower C-peptide and higher glucose concentrations than those without DKA. Twenty-five children with DKA (45%) met RADIANT A-β+ KPD criteria. They were predominantly male (64%), African American or Hispanic (96%), with substantial C-peptide (1.3 ± 0.7 ng/mL) at presentation with DKA and excellent long-term glycemic control (HbA1c 6.6% ± 1.9% at follow-up (median 1.3 years postdiagnosis)). Conclusions In children with a clinical phenotype of T2D and DKA at diagnosis, approximately half meet criteria for A-β+ KPD. They manifest the key characteristics of obesity, preserved β-cell function, male predominance, and potential to discontinue insulin therapy, similar to adults with A-β+ KPD.
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Affiliation(s)
- Elizabeth Kubota-Mishra
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Xiaofan Huang
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Charles G. Minard
- Institute for Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
| | - Marcela Astudillo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | | | - Graciela Montes
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Stephanie Sisley
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - Nalini Ram
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - William E. Winter
- Department of Pathology, University of Florida, Gainesville, FL, USA
| | - Rochelle N. Naylor
- Section of Adult and Pediatric Endocrinology, Diabetes and Metabolism, Departments of Pediatric and Medicine, University of Chicago, Chicago, IL, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX, USA
| | - Maria J. Redondo
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
| | - Mustafa Tosur
- Department of Pediatrics, The Division of Diabetes and Endocrinology, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, USA
- USDA/ARS Children’s Nutrition Research Center, Houston, TX, USA
| | - RADIANT Study Group
- The RADIANT Data Coordinating Center, Health Informatics Institute, University of South Florida, Tampa, FL, USA
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Raubenheimer PJ, Skelton J, Peya B, Dave JA, Levitt NS. Phenotype and predictors of insulin independence in adults presenting with diabetic ketoacidosis: a prospective cohort study. Diabetologia 2024; 67:494-505. [PMID: 38240751 PMCID: PMC10844464 DOI: 10.1007/s00125-023-06067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 11/06/2023] [Indexed: 02/06/2024]
Abstract
AIMS/HYPOTHESIS The aim of this work was to describe the phenotype of adults presenting with a first episode of diabetic ketoacidosis (DKA) in Cape Town, South Africa, and identify predictors of insulin independence at 12 and 60 months after presentation. METHODS A prospective, descriptive cohort study of all individuals, 18 years or older, presenting for the first time with DKA to four public-sector hospitals of the Groote Schuur Academic Health Complex was performed. Clinical, biochemical and laboratory data including GAD antibody and C-peptide status were collected at baseline. Insulin was systematically weaned and stopped in individuals who achieved normoglycaemia within the months after DKA. Individuals were followed for 12 months and then annually until 5 years after initial presentation with ketoacidosis. RESULTS Eighty-eight individuals newly diagnosed with diabetes when presenting with DKA were included and followed for 5 years. The mean ± SD age was 35±10 years and the median (IQR) BMI at diagnosis was 28.5 (23.3-33.4) kg/m2. Overall, 46% were insulin independent 12 months after diagnosis and 26% remained insulin independent 5 years after presentation. Forty-one participants (47%) tested negative for anti-GAD and anti-IA-2 antibodies and had C-peptide levels >0.3 nmol/l; in this group, 68% were insulin independent at 12 months and 37% at 5 years after diagnosis. The presence of acanthosis nigricans was strongly associated with insulin independence (OR 27.1 [95% CI 7.2, 102.2]; p<0.001); a positive antibody status was associated with a lower likelihood of insulin independence at 12 months (OR 0.10 [95% CI 0.03, 0.36]; p<0.001). On multivariable analysis only acanthosis (OR 11.5 [95% CI 2.5, 53.2]; p=0.004) was predictive of insulin independence 5 years after diagnosis. CONCLUSIONS/INTERPRETATION The predominant phenotype of adults presenting with a first episode of DKA in Cape Town, South Africa, was that of ketosis-prone type 2 diabetes. These individuals presented with obesity, acanthosis nigricans, negative antibodies and normal C-peptide and could potentially be weaned off insulin at follow-up. Classic type 1 diabetes (lower weight, antibody positivity, low or unrecordable C-peptide levels and long-term insulin dependence) was less common. The simple clinical sign of acanthosis nigricans is a strong predictor of insulin independence at 12 months and 5 years after initial presentation.
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Affiliation(s)
- Peter J Raubenheimer
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
| | - Joanna Skelton
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Bukiwe Peya
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Joel A Dave
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Naomi S Levitt
- Division of Endocrinology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Hao S, Cossen K, Westbrook AL, Umpierrez GE, Vellanki P. Diabetic Ketoacidosis and Long-term Insulin Requirements in Youths with Newly Diagnosed Type 2 Diabetes During the SARS-CoV-2 Pandemic. Endocr Pract 2023; 29:754-761. [PMID: 37451650 PMCID: PMC10910395 DOI: 10.1016/j.eprac.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE SARS-CoV-2 infection increases the risk of diabetes and diabetic ketoacidosis (DKA) in both adults and children. We investigated the clinical course of new-onset type 2 diabetes in youth presenting with DKA during the COVID-19 pandemic. METHODS This single-center retrospective cohort study included 148 subjects with obesity aged 10 to 21 years, admitted with DKA from January 2018 to January 2022. Groups were defined by the presence of DKA precipitant: any infection (n = 38, 26%), which included the SARS-CoV-2 (n = 10, 7%) and other infection (n = 28, 19%) groups, and no infection (n = 110, 74%). The primary outcome was insulin discontinuation within a 12-month follow-up. RESULTS The mean age was 14.9 years (IQR, 13.8-16.5), and age-adjusted body mass index (%) was 99.1 (IQR, 98.0-99.5) with 85.8% identifying as Black or Hispanic. There were no differences in DKA severity among groups. The incidence of DKA was higher during the pandemic (March 2020-January 2022, n = 117) than in the prepandemic period (January 2018-February 2020, n = 31). Within the first year after the acute DKA episode, 46 patients discontinued all insulin within 9 months (IQR, 4-14). Sixteen subjects restarted insulin 10 months (IQR, 6.5-11.0) after insulin discontinuation. Infection with SARS-CoV-2 at diagnosis was not associated with the likelihood (P =.57) or timing (P =.27) of discontinuing all insulin within 1 year, nor was having any infection. CONCLUSION The incidence of DKA at the onset of type 2 diabetes was higher during the SARS-CoV-2 pandemic than in the prepandemic period. SARS-CoV-2 infection was not associated with DKA severity or insulin discontinuation within the first year of diagnosis in youth with new-onset type 2 diabetes and DKA.
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Affiliation(s)
- Shuai Hao
- Department of Pediatrics, Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta, Georgia
| | - Kristina Cossen
- Department of Pediatrics, Division of Pediatric Endocrinology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia.
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Hao S, Umpierrez GE, Daley T, Vellanki P. Intervention with Therapeutic Agents, Understanding the Path to Remission in Type 2 Diabetes: Part 1. Endocrinol Metab Clin North Am 2023; 52:27-38. [PMID: 36754495 DOI: 10.1016/j.ecl.2022.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Type 2 diabetes is characterized by progressive decline in pancreatic β-cell function. Studies in adult subjects with newly diagnosed type 2 diabetes have reported that intensive insulin therapy followed by various antihyperglycemic medications can delay β-cell decline. However, this improvement is lost after cessation of therapy. In contrast, youth with type 2 diabetes experience a more rapid loss in β-cell function compared with adults and have loss of β-cell function despite being on insulin and other antihyperglycemic medications. In part one of this two-part review, we discuss studies aiming to achieve diabetes remission with insulin and oral antidiabetic medications.
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Affiliation(s)
- Shuai Hao
- Division of Pediatric Endocrinology, Children's Healthcare of Atlanta, Emory University School of Medicine, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism & Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Glenn Building, Room 205, Suite 200, Atlanta, GA 30303, USA
| | - Tanicia Daley
- Division of Pediatric Endocrinology, Children's Healthcare of Atlanta, Emory University School of Medicine, 1400 Tullie Road Northeast, Atlanta, GA 30329, USA
| | - Priyathama Vellanki
- Division of Endocrinology, Metabolism & Lipids, Emory University School of Medicine, 69 Jesse Hill Jr Drive Southeast, Glenn Building, Room 205, Suite 200, Atlanta, GA 30303, USA.
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Moffett BS, Allen J, Khichi M, McCann-Crosby B. Impact of Body Habitus on the Outcomes of Pediatric Patients With Diabetic Ketoacidosis. J Pediatr Pharmacol Ther 2021; 26:194-199. [PMID: 33603584 DOI: 10.5863/1551-6776-26.2.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/06/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine whether obese and overweight pediatric patients with new onset diabetic ketoacidosis (DKA) treated with continuous infusion insulin have increased time to subcutaneous insulin initiation or adverse events as compared with patients with normal body habitus. METHODS A retrospective, cohort study was designed that included patients 2 to 18 years of age admitted with new onset DKA who received continuous infusion insulin from January 1, 2011, to December 31, 2017. Patients were stratified according to BMI percentile with the primary outcome of time to initiation of subcutaneous insulin. Secondary endpoints included time to minimum beta-hydroxybutyrate, and incidence of hypoglycemia or other adverse events. RESULTS A total of 337 patients (46.6% male, 9.6 ± 3.8 years of age) met study criteria. Patients were classified by body habitus as obese (7.7%, n = 26), overweight (7.1%, n = 24), normal body weight (58.8%, n = 198), or underweight (26.4%, n = 89), based on BMI percentile. Most patients were initiated on insulin at 0.1 unit/kg/hr (86.7%) for 16.7 ± 7.0 hours. Time from continuous infusion insulin initiation to subcutaneous insulin was not different between body habitus groups, nor was hypoglycemia or the use of mannitol (p > 0.05). Median time to lowest beta-hydroxybutyrate was greater for obese (26.4, IQR [13.9, 41.9]) and overweight (32.4, IQR [18.3, 47.0]) groups than for normal body habitus patients (16.5, IQR [12.3, 23.8]) (p < 0.05). CONCLUSIONS Time to subcutaneous insulin and adverse events was not associated with body habitus, but obese and overweight patients may have delayed beta-hydroxybutyrate clearance.
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Vellanki P, Umpierrez GE. DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES. Endocr Pract 2017; 23:971-978. [PMID: 28534682 DOI: 10.4158/ep161679.ra] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes. METHODS We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes. RESULTS In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy. CONCLUSION KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes. ABBREVIATIONS A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.
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Vellanki P, Smiley DD, Stefanovski D, Anzola I, Duan W, Hudson M, Peng L, Pasquel FJ, Umpierrez GE. Randomized Controlled Study of Metformin and Sitagliptin on Long-term Normoglycemia Remission in African American Patients With Hyperglycemic Crises. Diabetes Care 2016; 39:1948-1955. [PMID: 27573938 PMCID: PMC5079604 DOI: 10.2337/dc16-0406] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 08/09/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE After intensive insulin treatment, many obese African American patients with new-onset diabetic ketoacidosis (DKA) and severe hyperglycemia are able to achieve near-normoglycemia remission. The optimal treatment to prevent hyperglycemic relapses after remission is not known. RESEARCH DESIGN AND METHODS This prospective, 4-year, placebo-controlled study randomly assigned 48 African American subjects with DKA and severe hyperglycemia to metformin 1,000 mg daily (n = 17), sitagliptin 100 mg daily (n = 16), or placebo (n = 15) after normoglycemia remission. Hyperglycemic relapse was defined as fasting glucose >130 mg/dL (7.2 mmol/L) and HbA1c >7.0% (53 mmol/mol). Oral glucose tolerance tests were conducted at randomization and at 3 months and then every 6 months for a median of 331 days. Oral minimal model and incremental area under the curve for insulin (AUCi) were used to calculate insulin sensitivity (Si) and β-cell function, respectively. Disposition index (DI) was calculated as a product of Si and incremental AUCi. RESULTS Relapse-free survival was higher in sitagliptin and metformin (P = 0.015) compared with placebo, and mean time to relapse was significantly prolonged in the metformin and sitagliptin groups compared with the placebo group (480 vs. 305 days, P = 0.004). The probability of relapse was significantly lower for metformin (hazard ratio 0.28 [95% CI 0.10-0.81]) and sitagliptin (0.31 [0.10-0.98]) than for placebo. Subjects who remained in remission had a higher DI (P = 0.02) and incremental AUCi (P < 0.001) than those with hyperglycemia relapse without significant changes in Si. CONCLUSIONS This study shows that near-normoglycemia remission was similarly prolonged by treatment with sitagliptin and metformin. The prolongation of remission was due to improvement in β-cell function.
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Affiliation(s)
- Priyathama Vellanki
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Dawn D Smiley
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Darko Stefanovski
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA
| | - Isabel Anzola
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Wenlan Duan
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Megan Hudson
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Francisco J Pasquel
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, GA
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Xavier DJ, Takahashi P, Evangelista AF, Foss-Freitas MC, Foss MC, Donadi EA, Passos GA, Sakamoto-Hojo ET. Assessment of DNA damage and mRNA/miRNA transcriptional expression profiles in hyperglycemic versus non-hyperglycemic patients with type 2 diabetes mellitus. Mutat Res 2015; 776:98-110. [PMID: 26364207 DOI: 10.1016/j.mrfmmm.2015.01.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Revised: 01/28/2015] [Accepted: 01/30/2015] [Indexed: 06/05/2023]
Abstract
The development of type 2 diabetes mellitus (T2D) is associated with a number of genetic and environmental factors. Hyperglycemia, a T2D hallmark, is related to several metabolic complications, comorbidities and increased DNA damage. However, the molecular alterations of a proper glucose control are still unclarified. In this study, we aimed to evaluate DNA damage (comet assay), as well as to compare the transcriptional expression (mRNA and miRNA analyzed by the microarray technique) displayed by peripheral blood mononuclear cells (PBMCs) from three distinct groups: hyperglycemic T2D patients (T2D-H, n=14), non-hyperglycemic T2D patients (T2D-N, n=15), and healthy non-diabetic individuals (n=16). The comet assay revealed significantly (p<0.05) higher levels of DNA damage in T2D-H group compared to both T2D-N and control groups, while a significant difference was not observed between the control and T2D-N groups. After bioinformatics analysis, the differentially expressed mRNAs were subjected to functional enrichment analysis (DAVID) and inflammatory response was among the enriched terms found when comparing T2D-N with controls and T2D-H with T2D-N. Concerning the gene set enrichment and gene set analyses, among the differentially expressed gene sets, three were of interest: regulation of DNA repair (T2D-H versus T2D-N), superoxide response (T2D-H versus control group), and response to endoplasmic reticulum stress (T2D-H versus control group). We also identified miRNAs related with T2D and hyperglycemia not yet associated with these conditions in the literature. Some of the differentially expressed mRNAs were among the predicted targets of the differentially expressed miRNAs. Our results showed the association of hyperglycemia with increased DNA damage and aberrant expression of miRNAs and genes related to several biological processes, such as inflammation, DNA repair, ROS production and antioxidant defense, highlighting the importance of proper glycemic control. Moreover, the transcriptional expression of miRNAs provided novel information for understanding the regulatory mechanisms involved in the T2D progression.
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Affiliation(s)
- Danilo J Xavier
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil
| | - Paula Takahashi
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil
| | - Adriane F Evangelista
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil
| | - Maria C Foss-Freitas
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14048-900 Ribeirão Preto, SP, Brazil
| | - Milton C Foss
- Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14048-900 Ribeirão Preto, SP, Brazil
| | - Eduardo A Donadi
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil; Department of Internal Medicine, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14048-900 Ribeirão Preto, SP, Brazil
| | - Geraldo A Passos
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil; Disciplines of Genetics and Molecular Biology, Department of Morphology, Faculty of Dentistry of Ribeirão Preto, University of São Paulo - USP, Av. Do Café, s/n, Monte Alegre, 14040-904 Ribeirão Preto, SP, Brazil
| | - Elza T Sakamoto-Hojo
- Department of Genetics, Ribeirão Preto Medical School, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14049-900 Ribeirão Preto, SP, Brazil; Department of Biology, Faculty of Philosophy, Sciences and Letters at Ribeirão Preto, University of São Paulo - USP, Av. Bandeirantes, 3900 - Monte Alegre, 14040-901 Ribeirão Preto, SP, Brazil.
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Abstract
PURPOSE OF REVIEW This review focuses on recent literature on insulin resistance in youth with type 2 diabetes mellitus (T2DM). Insulin resistance is associated with a variety of cardiometabolic problems leading to increased morbidity and mortality across the lifespan. RECENT FINDINGS Functional pancreatic β-cell changes play a role in the transition from obesity to impaired glucose tolerance (IGT). Insulin resistance drives islet cell upregulation, manifested by elevated glucagon and c-peptide levels, early in the transition to IGT. Surrogate measurements of insulin resistance and insulin secretion exist but their accuracy compared to clamp data is imperfect. Recent large longitudinal studies provide detailed information on the progression from normoglycemia to T2DM and on the phenotype of T2DM youth. Defining prediabetes and T2DM remains a challenge in youth. Lifestyle interventions do not appear as effective in children as in adults. Metformin remains the only oral hypoglycemic agent approved for T2DM in youth. SUMMARY New insights exist regarding the conversion from insulin resistance to T2DM, measurement of insulin resistance and phenotypes of insulin resistance youth, but more information is needed. Surrogate measurements of insulin resistance, additional treatment options for insulin resistance and individualization of treatment options for T2DM adolescents in particular require further investigation.
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Affiliation(s)
- Kara Mizokami-Stout
- Division of Endocrinology, Department of Pediatrics, University of Colorado Denver and the Children's Hospital Colorado, Denver, Colorado, USA
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Kruger DF. Managing diabetes from first diagnosis: choosing well-tolerated therapies with durability. DIABETES EDUCATOR 2012; 38:4S-11S; quiz 12S. [PMID: 22713263 DOI: 10.1177/0145721712450619] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE A review of the pathophysiologic features of early type 2 diabetes mellitus, the benefits of early glycemic control, the concerns of patients that may influence treatment adherence, and how the use of newer treatment options are addressed. CONCLUSION Given the multifactorial nature of diabetes pathophysiology, early combination therapy incorporating agents with different mechanisms of action is advocated. Medication side effects and risks influence patients' treatment choices. These concerns include hypoglycemia, weight gain, and fears of treatment failure. With the increasing complexity of therapy regimens for diabetes, the role of diabetes educators includes recommending therapy, counseling about adverse effects, monitoring for contraindications, identifying therapeutic duplication, as well as discussion of new agents to optimize patient outcomes. A case study is used to describe the process of choosing well-tolerated therapies at first diagnosis.
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Affiliation(s)
- Davida F Kruger
- Henry Ford Health System, Divsion of Endocrinology, Diabetes, Bone and Mineral Disease, New Center One, 3031 West Grand Blvd, Suite 800, Detroit, MI 48202 3031, USA.
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Cizza G, Brown R, Rothe K. Rising incidence and challenges of childhood diabetes. A mini review. J Endocrinol Invest 2012; 35:541-6. [PMID: 22572768 PMCID: PMC3485685 DOI: 10.3275/8411] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Approximately 215,000 people younger than 20 yr of age, or 1 in 500 children and adolescents, had diabetes in the United States in 2010--and the incidence is rising. We still have insufficient knowledge about the precise mechanisms leading to the autoimmune mediated β-cell destruction in Type 1 diabetes, and the β-cell failure associated with insulin resistance in Type 2 diabetes. Long-term complications are similar: micro- and macrovascular disease occurs prematurely and presents an enormous burden on affected individuals, often as early as in middle age. In Type 1 diabetes, technological advances have clearly improved blood glucose management, but chronic peripheral over-insulinization remains a problem even with the most advanced systems. Thus, in Type 1 diabetes our research must focus on 1) finding the stimulus that ignites the immune response and 2) developing treatments that avoid hyperinsulinemia. In Type 2 diabetes in youth, the challenges start much earlier: most young patients do not even benefit from existing therapies due to non-compliance. Therefore, prevention of Type 2 diabetes and improvement of compliance, especially with non-pharmacological interventions, are the greatest challenges.
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Affiliation(s)
- G. Cizza
- Section of Neuroendocrinology of Obesity, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - R.J. Brown
- Section of Pediatric Diabetes and Metabolism, Diabetes, Endocrinology and Diabetes Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - K.I. Rothe
- Section of Pediatric Diabetes and Metabolism, Diabetes, Endocrinology and Diabetes Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland, USA
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