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Ikeda N, Wada Y, Izumi T, Munakata Y, Katagiri H, Kure S. Stealthy progression of type 2 diabetes mellitus due to impaired ketone production in an adult patient with multiple acyl-CoA dehydrogenase deficiency. Mol Genet Metab Rep 2024; 38:101061. [PMID: 38469101 PMCID: PMC10926221 DOI: 10.1016/j.ymgmr.2024.101061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 03/13/2024] Open
Abstract
Background Multiple acyl-CoA dehydrogenase deficiency (MADD) is an inherited metabolic disorder caused by biallelic pathogenic variants in genes related to the flavoprotein complex. Dysfunction of the complex leads to impaired fatty acid oxidation and ketone body production which can cause hypoketotic hypoglycemia with prolonged fasting. Patients with fatty acid oxidation disorders (FAODs) such as MADD are treated primarily with a dietary regimen consisting of high-carbohydrate foods and avoidance of prolonged fasting. However, information on the long-term sequelae associated with this diet have not been accumulated. In general, high-carbohydrate diets can induce diseases such as type 2 diabetes mellitus (T2DM), although few patients with both MADD and T2DM have been reported. Case We present the case of a 32-year-old man with MADD who was on a high-carbohydrate diet for >30 years and exhibited symptoms resembling diabetic ketoacidosis. He presented with polydipsia, polyuria, and weight loss with a decrease in body mass index from 31 to 25 kg/m2 over 2 months. Laboratory tests revealed a HbA1c level of 13.9%; however, the patient did not show metabolic acidosis but only mild ketosis. Discussion/conclusion This report emphasizes the potential association between long-term adherence to high-carbohydrate dietary therapy and T2DM development. Moreover, this case underscores the difficulty of detecting diabetic ketosis in patients with FAODs such as MADD due to their inability to produce ketone bodies. These findings warrant further research of the long-term complications associated with this diet as well as warning of the potential progression of diabetes in patients with FAODs such as MADD.
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Affiliation(s)
- Nodoka Ikeda
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Yoichi Wada
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
| | - Tomohito Izumi
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Yuichiro Munakata
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Hideki Katagiri
- Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai 980-8575, Japan
| | - Shigeo Kure
- Department of Pediatrics, Tohoku University School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi 980-8574, Japan
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Takahashi K, Uenishi N, Sanui M, Uchino S, Yonezawa N, Takei T, Nishioka N, Kobayashi H, Otaka S, Yamamoto K, Yasuda H, Kosaka S, Tokunaga H, Fujiwara N, Kondo T, Ishida T, Komatsu T, Endo K, Moriyama T, Oyasu T, Hayakawa M, Hoshino A, Matsuyama T, Miyamoto Y, Yanagisawa A, Wakabayashi T, Ueda T, Komuro T, Sugimoto T, Lefor AK. Clinical profile of patients with diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome in Japan: a multicenter retrospective cohort study. Acta Diabetol 2024; 61:117-126. [PMID: 37728831 DOI: 10.1007/s00592-023-02181-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 09/03/2023] [Indexed: 09/21/2023]
Abstract
INTRODUCTION Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar syndrome (HHS) are life-threatening complications of diabetes mellitus. Their clinical profiles have not been fully investigated. METHODS A multicenter retrospective cohort study was conducted in 21 acute care hospitals in Japan. Patients included were adults aged 18 or older who had been hospitalized from January 1, 2012, to December 31, 2016 due to DKA or HHS. The data were extracted from patient medical records. A four-group comparison (mild DKA, moderate DKA, severe DKA, and HHS) was performed to evaluate outcomes. RESULTS A total of 771 patients including 545 patients with DKA and 226 patients with HHS were identified during the study period. The major precipitating factors of disease episodes were poor medication compliance, infectious diseases, and excessive drinking of sugar-sweetened beverages. The median hospital stay was 16 days [IQR 10-26 days]. The intensive care unit (ICU) admission rate was 44.4% (mean) and the rate at each hospital ranged from 0 to 100%. The in-hospital mortality rate was 2.8% in patients with DKA and 7.1% in the HHS group. No significant difference in mortality was seen among the three DKA groups. CONCLUSIONS The mortality rate of patients with DKA in Japan is similar to other studies, while that of HHS was lower. The ICU admission rate varied among institutions. There was no significant association between the severity of DKA and mortality in the study population. TRIAL REGISTRATION This study is registered in the UMIN clinical Trial Registration System (UMIN000025393, Registered 23th December 2016).
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Affiliation(s)
- Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-Ku, Saitama City, Saitama Prefecture, 330-0834, Japan.
| | - Norimichi Uenishi
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-Ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Shigehiko Uchino
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, 1-847 Amanumacho, Omiya-Ku, Saitama City, Saitama Prefecture, 330-0834, Japan
| | - Naoki Yonezawa
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care Medicine, Yokohama City Minato Red Cross Hospital, Yokohama, Kanagawa, Japan
| | - Norihiro Nishioka
- Department of Preventive Services, Kyoto University Graduate School of Medicine, Sakyo, Kyoto, Japan
- Division of Nephrology, Department of Internal Medicine, Okinawa Prefectural Chubu Hospital, Uruma, Okinawa, Japan
| | - Hirotada Kobayashi
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Intensive Care Medicine, Kameda Medical Center, Kamogawa, Chiba, Japan
| | - Shunichi Otaka
- Department of Emergency Medicine, International University of Health and Welfare Narita Hospital, Narita, Chiba, Japan
- Department of Emergency Medicine, Kumamoto Red Cross Hospital, Higashi, Kumamoto, Japan
| | - Kotaro Yamamoto
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
| | - Hideto Yasuda
- Department of Emergency Medicine, Musashino Red Cross Hospital, Musashino, Tokyo, Japan
- Department of Emergency Medicine, Jichi Medical University Saitama Medical Center, Omiya, Saitama, Japan
| | - Shintaro Kosaka
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Hidehiko Tokunaga
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
| | - Naoki Fujiwara
- Department of Medicine, Nerima Hikarigaoka Hospital, Nerima, Tokyo, Japan
- Department of Medicine, Taito Municipal Taito Hospital, Taito, Tokyo, Japan
| | - Takashiro Kondo
- Department of Emergency and Critical Care Medicine, National Hospital Organization Nagoya Medical Center, Nagoya, Aichi, Japan
| | - Tomoki Ishida
- Nanohana Clinic, Ikuno, Osaka, Japan
- Department of Emergency Medicine, Yodogawa Christian Hospital, Higashi Yodogawa, Osaka, Japan
| | - Takayuki Komatsu
- Department of Sports Medicine, Faculty of Medicine, Juntendo University, Bunkyo, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Juntendo University Nerima Hospital, Nerima, Tokyo, Japan
| | - Koji Endo
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Sakyo, Kyoto, Japan
- Department of General Internal Medicine, Tottori Prefectural Central Hospital, Tottori, Tottori, Japan
| | - Taiki Moriyama
- Department of Emergency Medicine, Hyogo Emergency Medical Center, Kobe, Hyogo, Japan
- Department of Emergency Medicine, Saiseikai Senri Hospital, Suita, Osaka, Japan
| | - Takayoshi Oyasu
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Mineji Hayakawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Hokkaido, Japan
| | - Atsumi Hoshino
- Department of Intensive Care Medicine, Tokyo Women's Medical University Hospital, Shinjuku, Tokyo, Japan
- Department of Emergency and Critical Care Medicine, Toyooka Public Hospital, Toyooka, Hyogo, Japan
| | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Yuki Miyamoto
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kamigyo, Kyoto, Japan
| | - Akihiro Yanagisawa
- Department of Anesthesia, Gyoda General Hospital, Gyoda, Saitama, Japan
- Department of Anesthesiology and Intensive Care, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Tadamasa Wakabayashi
- Department of Medicine, Suwa Central Hospital, Chino, Nagano, Japan
- Department of Cardiology, Suwa Central Hospital, Chino, Nagano, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Nakagyo, Kyoto, Japan
| | - Tetsuya Komuro
- Department of Medicine, TMG Muneoka Central Hospital, Shiki, Saitama, Japan
- Department of Critical Care, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
| | - Toshiro Sugimoto
- Department of Medicine, Shiga University of Medical Science, Otsu, Shiga, Japan
- Department of Medicine, National Hospital Organization Higashiohmi General Medical Center, Higashiohmi, Shiga, Japan
| | - Alan Kawarai Lefor
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
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Tsujimoto Y, Nakamura T, Onishi J, Ishimaru N, Iwata N, Fujisawa H, Suzuki A, Sugimura Y, Chihara K. Ketoacidosis, Hypertriglyceridemia and Acute Pancreatitis Induced by Soft Drink Polydipsia in a Patient with Occult Central Diabetes Insipidus. Intern Med 2022; 61:365-371. [PMID: 34373377 PMCID: PMC8866797 DOI: 10.2169/internalmedicine.7663-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 21-year-old Japanese man without known diabetes mellitus had abdominal pain. The diagnosis was ketoacidosis and hypertriglyceridemia-induced acute pancreatitis. He had polydipsia and polyuria and had habitually drunk several soft drinks every day for two years. After hospitalization, despite adequate liquid intake, dehydration remained with hypotonic polyuria. Further examinations revealed the coexistence of central diabetes insipidus (CDI), possibly caused by lymphocytic infundibulo-neurohypophysitis, based on anti-rabphilin-3A antibody positivity. Although CDI had been undiagnosed for two years, over-consumption of sugar-rich soft drinks to ease thirst caused ketoacidosis, hypertriglyceridemia, and acute pancreatitis. There are no previous reports of this three-part combination of symptoms caused by CDI.
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Affiliation(s)
- Yasutaka Tsujimoto
- Department of Diabetes and Endocrinology, Akashi Medical Center Hospital, Japan
| | - Tomoaki Nakamura
- Department of Diabetes and Endocrinology, Akashi Medical Center Hospital, Japan
| | - Jun Onishi
- Department of General Internal Medicine, Akashi Medical Center Hospital, Japan
| | - Naoto Ishimaru
- Department of General Internal Medicine, Akashi Medical Center Hospital, Japan
| | - Naoko Iwata
- Department of Endocrinology and Diabetes, Daido Hospital, Japan
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Japan
| | - Haruki Fujisawa
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Japan
| | - Atsushi Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Japan
| | - Yoshihisa Sugimura
- Department of Endocrinology, Diabetes and Metabolism, Fujita Health University, Japan
| | - Kazuo Chihara
- Department of Diabetes and Endocrinology, Akashi Medical Center Hospital, Japan
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Masuda S, Ota K, Okazaki R, Ishii R, Cho K, Hiramatsu Y, Adachi Y, Koseki S, Ueda E, Minami I, Yamada T, Watanabe T. Clinical Characteristics Associated with the Development of Diabetic Ketoacidosis in Patients with Type 2 Diabetes. Intern Med 2022; 61:1125-1132. [PMID: 35431303 PMCID: PMC9107989 DOI: 10.2169/internalmedicine.7266-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objective This study analyzed the clinical and laboratory parameters that might influence the clinical outcomes of patients with type 2 diabetes who develop diabetic ketoacidosis (DKA), which has not been well investigated. Methods We reviewed the clinical and laboratory data of 158 patients who were hospitalized due to DKA between January 2006 and June 2019 and compared the data of patients stratified by the type of diabetes. In addition, the patients with type 2 diabetes were subdivided according to age, and their clinical and laboratory findings were evaluated. Results Patients with type 2 diabetes had a longer symptom duration associated with DKA, higher body mass index (BMI), and higher C-peptide levels than those with type 1 diabetes (p<0.05). Among patients with type 2 diabetes, elderly patients (≥65 years old) had a longer duration of diabetes, higher frequency of DKA onset under diabetes treatment, higher effective osmolarity, lower BMI, and lower urinary C-peptide levels than nonelderly patients (<65 years old) (p<0.05). A correlation analysis showed that age was significantly negatively correlated with the index of insulin secretory capacity. Conclusion Patients with DKA and type 2 diabetes had a higher BMI and insulin secretion capacity than those with type 1 diabetes. However, elderly patients with type 2 diabetes, unlike younger patients, were characterized by a lean body, impaired insulin secretion, and more frequent DKA development while undergoing treatment for diabetes.
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Affiliation(s)
- Seizaburo Masuda
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Kazuki Ota
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Rei Okazaki
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Ryoko Ishii
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Keiho Cho
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Yuki Hiramatsu
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Yuko Adachi
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Sayo Koseki
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Eri Ueda
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Isao Minami
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Japan
| | - Takayuki Watanabe
- Department of Diabetes and Endocrinology, Yokohama City Minato Red Cross Hospital, Japan
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Haimoto H, Watanabe S, Maeda K, Murase T, Wakai K. Reducing Carbohydrate from Individual Sources Has Differential Effects on Glycosylated Hemoglobin in Type 2 Diabetes Mellitus Patients on Moderate Low-Carbohydrate Diets. Diabetes Metab J 2021; 45:390-403. [PMID: 32794380 PMCID: PMC8164948 DOI: 10.4093/dmj.2020.0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/21/2020] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND We evaluated decreases in glycosylated hemoglobin (HbA1c) achieved by reducing carbohydrate from various sources in type 2 diabetes mellitus patients. METHODS We followed up 138 male and 107 female outpatients on a moderate low-carbohydrate diet without diabetic medication for 6 months. Changes in carbohydrate sources (Δcarbohydrate) were assessed from 3-day dietary records at baseline and 6 months, and associations with changes in HbA1c (ΔHbA1c) were examined with Spearman's correlation coefficients (rs) and multiple regression analysis. RESULTS ΔHbA1c was -1.5%±1.6% in men and -0.9%±1.3% in women, while Δtotal carbohydrate was -115.3±103.7 g/day in men and -63.6±71.1 g/day in women. Positive associations with ΔHbA1c were found for Δtotal carbohydrate (rs=0.584), Δcarbohydrate from soft drinks (0.368), confectionery (0.361), rice (0.325), bread (0.221), Chinese soup noodles (0.199) in men, and Δtotal carbohydrate (0.547) and Δcarbohydrate from rice (0.376) and confectionery (0.195) in women. Reducing carbohydrate sources by 50 g achieved decreases in HbA1c of 0.43% for total carbohydrate, 1.33% for soft drinks, 0.88% for confectionery, 0.63% for bread, 0.82% for Chinese soup noodles and 0.34% for rice in men and 0.45% for total carbohydrate, 0.67% for confectionery and 0.34% for rice in women, although mean reductions in carbohydrate from these sources were much smaller than that from rice. CONCLUSION Decreases in HbA1c achieved by reducing carbohydrate from soft drinks, confectionery, bread and Chinese soup noodles were 2- to 4-fold greater than that for rice. Our results will enable patients to decrease HbA1c efficiently (UMIN000009866).
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Affiliation(s)
- Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, Kasugai, Japan
| | - Shiho Watanabe
- Division of Clinical Nutrition, Haimoto Clinic, Kasugai, Japan
| | - Keiko Maeda
- Department of Health and Nutritional Sciences, Faculty of Health and Sciences, Aichi Shukutoku University, Nagakute, Japan
| | - Takashi Murase
- Division of Endocrinology and Diabetes, Libra Sasashima Medical Clinic, Nagoya, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Vitelli A, Apuzzi V, Calderaro F, Fattoruso O, Bassi V. A Triad of Ketoacidosis, Hypertriglyceridemia, and Acute Pancreatitis Associated With Sugar-Sweetened Soft Drinks Abuse in a Caucasian Patient With Undiagnosed Type 2 Diabetes Mellitus. Cureus 2020; 12:e8299. [PMID: 32607288 PMCID: PMC7320639 DOI: 10.7759/cureus.8299] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
A 24-year-old obese Caucasian male, without relevant anamnesis, who was admitted to the ER presented with abdominal pain, nausea and vomiting, hyperglycemia, and diabetic ketoacidosis (DKA). The diagnosis of acute pancreatitis (AP) was supported by increased serum levels of triglycerides and lipase associated with abdominal CT scans. The patient was treated for five days with IV regular insulin, hydration, electrolytes replacement, and statin/fibrate therapy with clinical improvement. Some 10% hemoglobin A1c value, normal C-peptide level and negative glutamic acid decarboxylase (GAD-65), and islet cell autoantibodies suggested the diagnosis of a new-onset type 2 diabetes mellitus (DM) presenting with an uncommon triad of DKA and hypertriglyceridemia (HTG)-induced AP. Anamnestic history suggested that DKA was dependent on sugar-sweetened soft drinks abuse (soft drink ketosis), a clinical association more frequent in Asian than in Western patients.
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Affiliation(s)
- Alessandra Vitelli
- U.O.C. Medicina Generale E Lungodegenza, San Giovanni Bosco, Asl Napoli 1 Centro, Naples, ITA
| | - Valentina Apuzzi
- U.O.C. Medicina Generale E Lungodegenza, San Giovanni Bosco, Asl Napoli 1 Centro, Naples, ITA
| | - Francesco Calderaro
- U.O.C. Medicina Genereale E Lungodegenza, San Giovanni Bosco, Asl Napoli 1 Centro, Naples, ITA
| | - Olimpia Fattoruso
- Pathology, San Giovanni Bosco Hospital, ASL Napoli 1 Centro, Naples, ITA
| | - Vincenzo Bassi
- U. O. C. Di Medicina Generale E Lungodegenza, San Giovanni Bosco Hospital, Asl Napoli 1 Centro, Naples, ITA
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Tsuchiya S, Sawada S, Takeda K, Takahashi K, Nakajima T, Kohata M, Kurosawa S, Satake C, Imai J, Kikuchi K, Aiba S, Katagiri H. Eruptive xanthomas in a patient with soft-drink diabetic ketosis and apolipoprotein E4/2. Endocr J 2019; 66:107-114. [PMID: 30393272 DOI: 10.1507/endocrj.ej18-0356] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Soft-drink diabetic ketosis, characterized by acute onset ketosis induced by excessive ingestion of sugar-containing drinks, is often seen in obese, young patients, even with undiagnosed type 2 diabetes. We herein report a 15-year-old obese patient with the apolipoprotein E4/2 phenotype, in whom eruptive xanthomas lead to a diagnosis of soft-drink diabetic ketosis. He developed multiple asymptomatic yellowish papules on the auricles, back, buttocks and the extensor surfaces of the elbows and knees. He initially visited a dermatology clinic and his blood triglyceride and HbA1c levels were found to be 6,490 mg/dL and 16.5%, respectively. He was referred to our hospital for treatment of hyperglycemia and hypertyriglyceridemia. On admission, he had ketonuria and increased blood levels of 3-hydroxybutylate and acetoacetate. He habitually drank 1-3 litters of sweet beverages daily to quench his thirst. Therefore, "soft-drink diabetic ketosis" was diagnosed. Severe hypertriglyceridemia was considered to have been a consequence of impaired insulin action and his apolipoprotein E4/2 phenotype. We treated the diabetic ketosis and hypertriglyceridemia with intensive insulin therapy and a fat-restricted diet. At discharge, he no longer required insulin therapy and his blood glucose levels were controlled with metformin and voglibose. Along with amelioration of the hyperglycemia, triglyceride levels decreased to 247 mg/dL without administration of anti-hyperlipidemia agents. The eruptive xanthoma lesions gradually diminished in size and number and eventually disappeared by 12 months. This case provides an instructive example of eruptive xanthomas serving as a sign of severe dysregulation, not only of lipid, but also glucose, metabolism.
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Affiliation(s)
- Satoko Tsuchiya
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Shojiro Sawada
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Kana Takeda
- Department of Dermatology, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Kenji Takahashi
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Takeko Nakajima
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Masato Kohata
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Satoko Kurosawa
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Chihiro Satake
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Junta Imai
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Katsuko Kikuchi
- Department of Dermatology, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Setsuya Aiba
- Department of Dermatology, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
| | - Hideki Katagiri
- Department of Diabetes and Metabolism, Tohoku University Hospital, Sendai, Miyagi 980-8575, Japan
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Haimoto H, Watanabe S, Komeda M, Wakai K. The impact of carbohydrate intake and its sources on hemoglobin A1c levels in Japanese patients with type 2 diabetes not taking anti-diabetic medication. Diabetes Metab Syndr Obes 2018; 11:53-64. [PMID: 29563823 PMCID: PMC5849919 DOI: 10.2147/dmso.s154839] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Although postprandial glucose levels largely depend on carbohydrate intake, the impact of carbohydrate and its sources on hemoglobin A1c (HbA1c) levels has not been demonstrated in patients with type 2 diabetes (T2DM) probably because, in previous studies, more than 50% of patients were taking anti-diabetic medication, and the researchers used energy percent of carbohydrate as an indicator of carbohydrate intake. PATIENTS AND METHODS We recruited 125 Japanese men (mean age 58±12 years) and 104 women (mean age 62±10 years) with T2DM who were not taking anti-diabetic medication and dietary therapy. We used 3-day dietary records to assess total carbohydrate intake and its sources, computed Spearman's correlation coefficients, and conducted multiple regression analyses for associations of carbohydrate sources with HbA1c by sex. RESULTS Mean HbA1c and total carbohydrate intake were 8.2%±1.9% and 272.0±84.6 g/day in men and 7.6%±1.3% and 226.7±61.5 g/day in women, respectively. We observed positive correlation of total carbohydrate intake (g/day) with HbA1c in men (rs=0.384) and women (rs=0.251), but no correlation for % carbohydrate in either sex. Regarding carbohydrate sources, we found positive correlations of carbohydrate from noodles (rs=0.231) and drinks (rs=0.325), but not from rice, with HbA1c in men. In women, carbohydrate from rice had a positive correlation (rs=0.317), but there were no correlations for carbohydrate from noodles and drinks. The association of total carbohydrate intake (g/day) and carbohydrate from soft drinks with HbA1c in men remained significant even after adjustment for total energy by multiple regression analyses. CONCLUSION Our findings warrant interventional studies for moderate low-carbohydrate diets that focus on carbohydrate sources and sex differences in order to efficiently decrease HbA1c in patients with T2DM.
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Affiliation(s)
- Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, Kasugai, Aichi, Japan
- Correspondence: Hajime Haimoto, Department of Internal Medicine, Haimoto Clinic, 1-80 Yayoi, Kasugai, Aichi 486-0838, Japan, Tel +81 56 885 8226, Fax +81 56 885 8315, Email
| | - Shiho Watanabe
- Department of Clinical Nutrition, Haimoto Clinic, Kasugai, Aichi, Japan
| | - Masashi Komeda
- Department of Cardiovascular Surgery, Jinsenkai Hospital, Morofuku, Osaka, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
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Hayami T, Kato Y, Kamiya H, Kondo M, Naito E, Sugiura Y, Kojima C, Sato S, Yamada Y, Kasagi R, Ando T, Noda S, Nakai H, Takada E, Asano E, Motegi M, Watarai A, Kato K, Nakamura J. Case of ketoacidosis by a sodium-glucose cotransporter 2 inhibitor in a diabetic patient with a low-carbohydrate diet. J Diabetes Investig 2015; 6:587-90. [PMID: 26417418 PMCID: PMC4578500 DOI: 10.1111/jdi.12330] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 12/04/2014] [Accepted: 01/08/2015] [Indexed: 12/19/2022] Open
Abstract
We present a case of a 32-year-old diabetic woman with Prader-Willi syndrome who developed severe ketoacidosis caused by a sodium-glucose cotransporter 2 (SGLT2) inhibitor, a novel class of antihyperglycemic agents, during a strict low-carbohydrate diet. At admission, a serum glucose level of 191 mg/dL was relatively low, though laboratory evaluations showed severe ketoacidosis. This is the first report of ketoacidosis caused by a SGLT2 inhibitor. It is necessary to not only pay attention when using a SGLT2 inhibitor in patients following a low-carbohydrate diet, but also to start a low-carbohydrate diet in patients treated with a SGLT2 inhibitor because of a high risk for developing ketoacidosis.
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Affiliation(s)
- Tomohide Hayami
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Yoshiro Kato
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Hideki Kamiya
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Masaki Kondo
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Ena Naito
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Yukako Sugiura
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Chika Kojima
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Sami Sato
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Yuichiro Yamada
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Rina Kasagi
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Toshihito Ando
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Saeko Noda
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Hiromi Nakai
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Eriko Takada
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Emi Asano
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Mikio Motegi
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
| | - Atsuko Watarai
- Center for Preventive Medicine, Chubu Rosai Hospital Nagoya, Aichi, Japan
| | - Koichi Kato
- Laboratory of Medicine, Aichi Gakuin University School of Pharmacy Nagoya, Aichi, Japan
| | - Jiro Nakamura
- Division of Diabetes, Department of Internal Medicine, Aichi Medical University School of Medicine Nagakute, Japan
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Abstract
This article highlights the difficulties in creating a definitive classification of diabetes mellitus in the absence of a complete understanding of the pathogenesis of the major forms. This brief review shows the evolving nature of the classification of diabetes mellitus. No classification scheme is ideal, and all have some overlap and inconsistencies. The only diabetes in which it is possible to accurately diagnose by DNA sequencing, monogenic diabetes, remains undiagnosed in more than 90% of the individuals who have diabetes caused by one of the known gene mutations. The point of classification, or taxonomy, of disease, should be to give insight into both pathogenesis and treatment. It remains a source of frustration that all schemes of diabetes mellitus continue to fall short of this goal.
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Affiliation(s)
- Celeste C Thomas
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA.
| | - Louis H Philipson
- Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 5841 South Maryland Avenue, MC 1027, Chicago, IL 60637, USA; Department of Pediatrics, Section of Endocrinology, Diabetes and Metabolism, The University of Chicago, 900 East 57th Street, Chicago, IL 60637, USA
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Haimoto H, Sasakabe T, Kawamura T, Umegaki H, Komeda M, Wakai K. Three-graded stratification of carbohydrate restriction by level of baseline hemoglobin A1c for type 2 diabetes patients with a moderate low-carbohydrate diet. Nutr Metab (Lond) 2014; 11:33. [PMID: 25114711 PMCID: PMC4128548 DOI: 10.1186/1743-7075-11-33] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 07/21/2014] [Indexed: 01/09/2023] Open
Abstract
Background A moderate low-carbohydrate diet has been receiving attention in the dietary management of type 2 diabetes (T2DM). A fundamental issue has still to be addressed; how much carbohydrate delta-reduction (Δcarbohydrate) from baseline would be necessary to achieve a certain decrease in hemoglobin A1c (HbA1c) levels. Objective We investigated the effects of three-graded stratification of carbohydrate restriction by patient baseline HbA1c levels on glycemic control and effects of Δcarbohydrate on decreases in HbA1c levels (ΔHbA1c) in each group. Research design and methods We treated 122 outpatients with T2DM by three-graded carbohydrate restriction according to baseline HbA1c levels (≤ 7.4% for Group 1, 7.5%-8.9% for Group 2 and ≥ 9.0% for Group 3) and assessed their HbA1c levels, doses of anti-diabetic drugs and macronutrient intakes over 6 months. Results At baseline, the mean HbA1c level and carbohydrate intake were 6.9 ± 0.4% and 252 ± 59 g/day for Group 1 (n = 55), 8.1 ± 0.4% and 282 ± 85 g/day for Group 2 (n = 41) and 10.6 ± 1.4% and 309 ± 88 g/day for Group 3 (n = 26). Following three-graded carbohydrate restriction for 6 months significantly decreased mean carbohydrate intake (g/day) and HbA1c levels for all patients, from 274 ± 78 to 168 ± 52 g and from 8.1 ± 1.6 to 7.1 ± 0.9% (n = 122, P < 0.001 for both) and anti-diabetic drugs could be tapered. ΔHbA1c and Δcarbohydrate were -0.4 ± 0.4% and -74 ± 69 g/day for Group 1, -0.6 ± 0.9% and -117 ± 78 g/day for Group 2 and -3.1 ± 1.4% and -156 ± 74 g/day for Group 3. Linear regression analysis showed that the greater the carbohydrate intake, the greater the HbA1c levels at baseline (P = 0.001). Also, the greater the reduction in carbohydrate intake (g/day), the greater the decrease in HbA1c levels (P < 0.001), but ΔHbA1c was not significantly influenced by changes in other macronutrient intakes (g/day). Conclusions Three-graded stratification of carbohydrate restriction according to baseline HbA1c levels may provide T2DM patients with optimal objectives for carbohydrate restriction and prevent restriction from being unnecessarily strict.
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Affiliation(s)
- Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, 1-80 Yayoi, Kasugai, Aichi 486-0838, Japan
| | - Tae Sasakabe
- Department of Clinical Nutrition, Haimoto Clinic, 1-80 Yayoi-cho, Kasugai, Aichi 486-0838, Japan
| | - Takahiko Kawamura
- Department of Diabetes and Endocrine Internal Medicine, Chubu Rosai Hospital, 10-6-1, Komei-cho, Minato-ku, Nagoya, Aichi 455-8530, Japan
| | - Hiroyuki Umegaki
- Department of Geriatrics, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
| | - Masashi Komeda
- Department of Cardiac Surgery, Kansai Heart Center, Nara 1-3-3 Ukyo Nara-city, 631-0805, Japan
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, 65 Tsuruma-cho, Showa-ku, Nagoya, Aichi 466-8550, Japan
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Yoshida N, Goto H, Suzuki H, Nagasawa K, Takeshita A, Okubo M, Miyakawa M, Mori Y, Fukuhara N, Nishioka H, Yamada S, Takeuchi Y. Ketoacidosis as the initial clinical condition in nine patients with acromegaly: a review of 860 cases at a single institute. Eur J Endocrinol 2013; 169:127-32. [PMID: 23828957 DOI: 10.1530/eje-13-0060] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Excess GH causes insulin resistance and impaired glucose metabolism. The objective of this study was to clarify the prevalence of ketoacidosis as the initial presenting symptom of acromegaly. DESIGN AND METHODS Data were collected from 860 patients with acromegaly who underwent pituitary surgery at Toranomon Hospital over the last 32 years, between 1980 and 2011. RESULTS Nine cases had ketoacidosis before being diagnosed with acromegaly, including seven males and two females with a mean +/- S.D. age of 38.8 +/- 14.2 years. Serum GH and IGF1 levels were 155 +/- 203 ng/ml and 9.86 +/- 0.68 SDS before pituitary surgery and 3.6 +/- 1.7 ng/ml and 3.72 +/- 3.40 SDS after surgery respectively. The maximum tumor diameter was 28.2 +/- 11.6 mm (ranging from 15 to 47 mm, n=8). None of the patients were diagnosed with diabetes mellitus (DM) nor were they positive for antibodies related to type 1 DM. A possible precipitating factor for ketoacidosis in six cases was excessive ingestion of sugar-containing soft drinks. All the cases had invasive pituitary adenomas. After pituitary surgery, plasma glucose levels were under control without requiring insulin in all cases. Furthermore, six patients did not need oral hypoglycemic agents. CONCLUSIONS Approximately 1% of patients with acromegaly presented with diabetic ketoacidosis as their first clinical condition.
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Affiliation(s)
- Naohiro Yoshida
- Division of Endocrinology and Metabolism, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
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14
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Li LX, Zhao CC, Ren Y, Tu YF, Lu JX, Wu X, Zhang WX, Zhu JA, Li MF, Yu LB, Bao YQ, Jia WP. Prevalence and clinical characteristics of carotid atherosclerosis in newly diagnosed patients with ketosis-onset diabetes: a cross-sectional study. Cardiovasc Diabetol 2013; 12:18. [PMID: 23324539 PMCID: PMC3583071 DOI: 10.1186/1475-2840-12-18] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2012] [Accepted: 01/11/2013] [Indexed: 11/10/2022] Open
Abstract
Background The features of carotid atherosclerosis in ketosis-onset diabetes have not been investigated. Our aim was to evaluate the prevalence and clinical characteristics of carotid atherosclerosis in newly diagnosed Chinese diabetic patients with ketosis but without islet-associated autoantibodies. Methods In total, 423 newly diagnosed Chinese patients with diabetes including 208 ketosis-onset diabetics without islet-associated autoantibodies, 215 non-ketotic type 2 diabetics and 79 control subjects without diabetes were studied. Carotid atherosclerosis was defined as the presence of atherosclerotic plaques in any of the carotid vessel segments. Carotid intima-media thickness (CIMT), carotid atherosclerotic plaque formation and stenosis were assessed and compared among the three groups based on Doppler ultrasound examination. The clinical features of carotid atherosclerotic lesions were analysed, and the risk factors associated with carotid atherosclerosis were evaluated using binary logistic regression in patients with diabetes. Results The prevalence of carotid atherosclerosis was significantly higher in the ketosis-onset diabetic group (30.80%) than in the control group (15.2%, p=0.020) after adjusting for age- and sex-related differences, but no significant difference was observed in comparison to the non-ketotic diabetic group (35.8%, p=0.487). The mean CIMT of the ketosis-onset diabetics (0.70±0.20 mm) was markedly higher than that of the control subjects (0.57±0.08 mm, p<0.001), but no significant difference was found compared with the non-ketotic type 2 diabetics (0.73±0.19 mm, p=0.582) after controlling for differences in age and sex. In both the ketosis-onset and the non-ketotic diabetes, the prevalence of carotid atherosclerosis was markedly increased with age (both p<0.001) after controlling for sex, but no sex difference was observed (p=0.479 and p=0.707, respectively) after controlling for age. In the ketosis-onset diabetics, the presence of carotid atherosclerosis was significantly associated with age, hypertension, low-density lipoprotein cholesterol and mean CIMT. Conclusions The prevalence and risk of carotid atherosclerosis were significantly higher in the ketosis-onset diabetics than in the control subjects but similar to that in the non-ketotic type 2 diabetics. The characteristics of carotid atherosclerotic lesions in the ketosis-onset diabetics resembled those in the non-ketotic type 2 diabetics. Our findings support the classification of ketosis-onset diabetes as a subtype of type 2 diabetes.
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Affiliation(s)
- Lian-Xi Li
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, China.
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15
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Liu B, Yu C, Li Q, Li L. Ketosis-onset diabetes and ketosis-prone diabetes: same or not? Int J Endocrinol 2013; 2013:821403. [PMID: 23710177 PMCID: PMC3655588 DOI: 10.1155/2013/821403] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 04/03/2013] [Accepted: 04/03/2013] [Indexed: 11/17/2022] Open
Abstract
Objective. To compare clinical characteristics, immunological markers, and β -cell functions of 4 subgroups ("A β " classification system) of ketosis-onset diabetes and ketosis prone diabetes patients without known diabetes, presenting with ketosis or diabetic ketoacidosis (DKA) and admitted to our department from March 2011 to December 2011 in China, with 50 healthy persons as control group. Results. β -cell functional reserve was preserved in 63.52% of patients. In almost each subgroup (except A- β - subgroup of ketosis prone group), male patients were more than female ones. The age of the majority of patients in ketosis prone group was older than that of ketosis-onset group, except A- β - subgroup of ketosis prone group. The durations from the patient first time ketosis or DKA onset to admitting to the hospital have significant difference, which were much longer for the ketosis prone group except the A+ β + subgroup. BMI has no significant difference among subgroups. FPG of ketosis prone group was lower than that of A- β + subgroup and A+ β + subgroup in ketosis-onset group. A- β - subgroup and A+ β + subgroup of ketosis prone group have lower HbA1c than ketosis-onset group. Conclusions. Ketosis-onset diabetes and ketosis prone diabetes do not absolutely have the same clinical characteristics. Each subgroup shows different specialty.
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Affiliation(s)
- Beiyan Liu
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
| | - Changhua Yu
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
| | - Qiang Li
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
- *Qiang Li:
| | - Lin Li
- Endocrinology and Metabolism Department of the Second Hospital Affiliated to Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang Province 150086, China
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Haimoto H, Sasakabe T, Umegaki H, Wakai K. Reduction in urinary albumin excretion with a moderate low-carbohydrate diet in patients with type 2 diabetes: a 12-month intervention. Diabetes Metab Syndr Obes 2012; 5:283-91. [PMID: 22924004 PMCID: PMC3422909 DOI: 10.2147/dmso.s34306] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
INTRODUCTION Urinary albumin excretion (UAE) is a marker of the early phase of diabetic nephropathy. Although a low-carbohydrate diet (LCD) has been shown to effectively improve glycemic control in patients with type 2 diabetes (T2DM), its effects on UAE remain unknown. PATIENTS AND METHODS A total of 124 patients (mean age ± standard deviation, 61.6 ± 9.2 years) with T2DM were instructed to consume a moderate LCD (1734 ± 416 kcal/d; % carbohydrate:fat:protein = 38:37:19) for 12 months. We measured the levels of UAE, hemoglobin A(1c), fasting plasma glucose, fasting serum insulin (IRI), and the serum lipid profiles in the patients and recorded their dosages of antidiabetic drugs during this 12-month period. RESULTS Of the 124 patients, 68 were normoalbuminuric, 50 were microalbuminuric, and six were macroalbuminuric at baseline. The patients had relatively good compliance with the moderate LCD diet. After 12 months, the mean levels of hemoglobin A(1c), fasting plasma glucose, IRI, homeostasis model assessment-estimated insulin resistance, and the body mass index of all participants significantly decreased (P = 0.003 for IRI and P < 0.001 for the other parameters). Among the microalbuminuric patients (n = 50), remission to normoalbuminuria was frequently achieved (52%) and the geometric mean UAE significantly decreased by 53% (95% confidence interval: 43, 62) over 12 months (P < 0.001). After patients taking an angiotensin 2 receptor blocker were excluded, the UAE significantly decreased by 41% (n = 26, 95% confidence interval: 25, 54; P < 0.001). Moreover, the reduction in UAE was significantly and positively correlated with a reduction in homeostasis model assessment-estimated insulin resistance levels (r(s) = 0.308; P = 0.031). CONCLUSION A moderate LCD (38% carbohydrate diet) achieved a remarkable reduction in UAE over 12 months in microalbuminuric patients with T2DM.
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Affiliation(s)
- Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, Kasugai
- Correspondence: Hajime Haimoto, Haimoto Clinic, 1-80 Yayoi, Kasugai, Aichi 486-0838, Japan, Tel +81 568 858 226, Fax +81 568 858 315, Email
| | - Tae Sasakabe
- Department of Clinical Nutrition, Haimoto Clinic, Kasugai
| | - Hiroyuki Umegaki
- Department of Geriatrics, Nagoya University Graduate School of Medicine, Nagoya
| | - Kenji Wakai
- Department of Preventive Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Smiley D, Chandra P, Umpierrez GE. Update on diagnosis, pathogenesis and management of ketosis-prone Type 2 diabetes mellitus. ACTA ACUST UNITED AC 2011; 1:589-600. [PMID: 22611441 DOI: 10.2217/dmt.11.57] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diabetic ketoacidosis (DKA) has been considered a key clinical feature of Type 1 diabetes mellitus; however, increasing evidence indicates that DKA is also a common feature of Type 2 diabetes (T2DM). Many cases of DKA develop under stressful conditions such as trauma or infection but an increasing number of cases without precipitating cause have been reported in children and adults with T2DM. Such patients present with severe hyperglycemia and ketosis as in Type 1 diabetes mellitus but can discontinue insulin after a few months and maintain acceptable glycemic control on diet or oral agents. This subtype of diabetes has been referred to as ketosis-prone T2DM. In this article, we reviewed the literature on ketosis-prone T2DM and summarized the epidemiology, putative pathophysiology and approaches to management.
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Affiliation(s)
- Dawn Smiley
- Emory University School of Medicine, Division of Endocrinology & Metabolism, Atlanta, GA 30303, USA
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Iwasaki Y, Hamamoto Y, Kawasaki Y, Ikeda H, Honjo S, Wada Y, Koshiyama H. Japanese cases of acute onset diabetic ketosis without acidosis in the absence of glutamic acid decarboxylase autoantibody. Endocrine 2010; 37:286-8. [PMID: 20960264 DOI: 10.1007/s12020-009-9301-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Accepted: 12/20/2009] [Indexed: 11/29/2022]
Abstract
We report consecutive Japanese patients presented with acute onset diabetic ketosis who had negative glutamic acid decarboxylase autoantibody (GADAb) to clarify the clinical characteristics of them. A total of consecutive 1,296 in-patients with newly diagnosed diabetes mellitus, who were admitted to our center from April 2003 to October 2008, were analyzed. Among them, 17 patients who presented with acute onset diabetic ketosis without acidosis, and found to be negative for GADAb, were included. They showed male preponderance (n = 15). Ten patients had history of excessive ingestion of sugar-containing soft drink. Patients who successfully withdrew insulin therapy by 6 months (n = 7) showed significantly higher insulin secretion capacity and higher body mass index at the time of diagnosis than those who continued insulin therapy at least for 6 months (n = 10). These findings suggest that some of Japanese patients who presented with acute onset diabetic ketosis and negative for GADAb share several clinical characteristics with atypical type 2 diabetes such as ketosis-prone diabetes and "soft-drink ketosis," but others do not.
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Affiliation(s)
- Yorihiro Iwasaki
- Center for Diabetes and Endocrinology, Tazuke Kofukai Medical Research Institute Kitano Hospital, Kita-ku, Osaka, 530-8480, Japan
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Sugimoto K, Hosotani T, Kawasaki T, Nakagawa K, Hayashi S, Nakano Y, Inui H, Yamanouchi T. Eucalyptus leaf extract suppresses the postprandial elevation of portal, cardiac and peripheral fructose concentrations after sucrose ingestion in rats. J Clin Biochem Nutr 2010; 46:205-11. [PMID: 20490315 PMCID: PMC2872225 DOI: 10.3164/jcbn.09-93] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Accepted: 12/05/2009] [Indexed: 12/14/2022] Open
Abstract
Overintake of sucrose or fructose induces adiposity. Fructose undergoes a strong Maillard reaction, which worsens diabetic complications. To determine whether Eucalyptus globulus leaf extract (ELE) suppresses the postprandial elevation of serum fructose concentrations (SFCs) in the portal, cardiac, and peripheral blood after sucrose ingestion, we performed gas chromatography/mass spectrometry (GC/MS) and measured SFC without any interference by contaminating glucose in the samples. Fasting Wistar rats were orally administered water (control group) or ELE (ELE group) before sucrose ingestion. Blood was collected from the portal vein, heart, and tail. The increase in the SFCs in the portal and cardiac samples 30 min after sucrose ingestion was lower in the ELE group than in the control group. The coefficient of correlation between the SFCs in the portal and cardiac samples was 0.825. The peripheral SFC in the control group progressively increased and was 146 micromol/L at 60 min. This increase was significantly lower in the ELE group. In contrast, the serum glucose concentrations in the 2 groups were similar. ELE suppressed postprandial hyperfructosemia in the portal, cardiac, and peripheral circulations. ELE may counteract glycation caused by high blood fructose concentrations induced by the consumption of fructose-containing foods or drinks.
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Affiliation(s)
- Keiichiro Sugimoto
- Research and Development Center, Nagaoka Perfumery Co. Ltd., 1-3-30 Itsukaichi, Ibaraki, Osaka 567-0005, Japan
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Arai K, Hirao K, Yamauchi M, Takagi H, Kobayashi M. Influence of BMI, Age and Duration of Diabetes Mellitus on Glycaemic Control with Twice-Daily Injections of Biphasic Insulin Aspart 30 versus Multiple Daily Injections of Insulin Aspart (JDDM 18). Clin Drug Investig 2010; 30:35-40. [DOI: 10.2165/11530920-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Haimoto H, Sasakabe T, Wakai K, Umegaki H. Effects of a low-carbohydrate diet on glycemic control in outpatients with severe type 2 diabetes. Nutr Metab (Lond) 2009; 6:21. [PMID: 19419563 PMCID: PMC2690585 DOI: 10.1186/1743-7075-6-21] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Accepted: 05/06/2009] [Indexed: 11/30/2022] Open
Abstract
We previously demonstrated that a loosely restricted 45%-carbohydrate diet led to greater reduction in hemoglobin A1c (HbA1c) compared to high-carbohydrate diets in outpatients with mild type 2 diabetes (mean HbA1c level: 7.4%) over 2 years. To determine whether good glycemic control can be achieved with a 30%-carbohydrate diet in severe type 2 diabetes, 33 outpatients (15 males, 18 females, mean age: 59 yrs) with HbA1c levels of 9.0% or above were instructed to follow a low-carbohydrate diet (1852 kcal; %CHO:fat:protein = 30:44:20) for 6 months in an outpatient clinic and were followed to assess their HbA1c levels, body mass index and doses of antidiabetic drugs. HbA1c levels decreased sharply from a baseline of 10.9 ± 1.6% to 7.8 ± 1.5% at 3 months and to 7.4 ± 1.4% at 6 months. Body mass index decreased slightly from baseline (23.8 ± 3.3) to 6 months (23.5 ± 3.4). Only two patients dropped out. No adverse effects were observed except for mild constipation. The number of patients on sulfonylureas decreased from 7 at baseline to 2 at 6 months. No patient required inpatient care or insulin therapy. In summary, the 30%-carbohydrate diet over 6 months led to a remarkable reduction in HbA1c levels, even among outpatients with severe type 2 diabetes, without any insulin therapy, hospital care or increase in sulfonylureas. The effectiveness of the diet may be comparable to that of insulin therapy.
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Affiliation(s)
- Hajime Haimoto
- Department of Internal Medicine, Haimoto Clinic, 1-80 Yayoi, Kasugai, Aichi 486-0838, Japan.
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Makino S, Hamada S, Iwata M, Fujiwara M. A case of abrupt onset autoimmune type 1 diabetes mimicking fulminant type 1 diabetes. Endocr J 2009; 56:1113-7. [PMID: 19680007 DOI: 10.1507/endocrj.k09e-074] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 63-year-old male was admitted to our hospital with diabetic ketoacidosis. He had flu-like symptoms 10 days before admission and developed thirst, polyuria and anorexia with 9 kg of body weight loss in a week. Plasma glucose level on admission was 983 mg/dL and HbA1c was 7.5%. Despite high levels of serum pancreatic enzymes, lack of severe abdominal pain and no morphological change of pancreas in the abdominal CT scan eliminated the complication of classical acute pancreatitis. These findings suggested the diagnosis of fulminant type 1 diabetes. However, urinary and plasma C-peptide levels showed that insulin secretion was not completely depleted at onset. Furthermore, an examination of islet-related antibodies revealed the presence of high titer anti-GAD antibody. His HLA typing showed that DRB1*0901-DQB1*0303 and A24 were present. He has been doing well with continuation of insulin therapy. Over two years after onset, his plasma C-peptide level was gradually lowered, and anti-GAD antibody was still positive. Taken together, this is a rare case of abrupt onset autoimmune type 1 diabetes with transient but apparent exocrine pancreatic impairment at onset. Similar cases should be accumulated to clarify pathophysiological similarities and/or differences between fulminant type 1 diabetes and abrupt onset autoimmune type 1 diabetes.
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Affiliation(s)
- Shinya Makino
- Department of Internal Medicine, Osaka Gyomeikan Hospital, Osaka, Japan.
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Dib SA. [Heterogeneity of type 1 diabetes mellitus]. ARQUIVOS BRASILEIROS DE ENDOCRINOLOGIA E METABOLOGIA 2008; 52:205-18. [PMID: 18438531 DOI: 10.1590/s0004-27302008000200008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 02/01/2008] [Indexed: 11/22/2022]
Abstract
Type 1 diabetes (T1D) comprises all forms of autoimmune-mediated and idiopathic beta-cell destruction leading to absolute insulin deficiency. The etiological heterogeneity of T1D has been recognized for the last decades, but it has been divided into only two subtypes so far: autoimmune (T1D)A and non-autoimmune (T1D)B mediated. Polygenic T1DA (isolated or associated to other autoimmune diseases) is the most prevalent type of T1D. T1DA might be part of rare monogenic syndromes related to mutations in the autoimmune regulator gene (AIRE) and FOXp3. Non-autoimmune forms of T1D correspond to approximately 4 to 7% of newly diagnosed T1D and include T1DB, as well as other types of atypical diabetes, for example fulminant type 1 diabetes and adult ketosis-prone diabetes. A new expression of diabetes in young with insulin resistance and obesity, along with the presence of pancreatic autoimmunity markers, namely auto-antibodies to islet cell antigens, is called double diabetes (DD), T1DA plus type 2 diabetes. Evidence has been collected concerning the potential effect of obesity-linked cytokines in amplifying the autoimmune response in DD. Therefore all these issues are presented and discussed in this review as the concept of heterogeneity of Type 1 Diabetes.
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Affiliation(s)
- Sergio Atala Dib
- Centro de Diabetes, Departamento de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo SP, Brasil. sergio.dib@unifes
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Fujimoto S, Nabe K, Takehiro M, Shimodahira M, Kajikawa M, Takeda T, Mukai E, Inagaki N, Seino Y. Impaired metabolism-secretion coupling in pancreatic beta-cells: role of determinants of mitochondrial ATP production. Diabetes Res Clin Pract 2007; 77 Suppl 1:S2-10. [PMID: 17449130 DOI: 10.1016/j.diabres.2007.01.026] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2007] [Indexed: 12/21/2022]
Abstract
Glucose-induced insulin secretion from beta-cells is often impaired in diabetic condition and by exposure to diabetogenic pharmacological agents. In pancreatic beta-cells, intracellular glucose metabolism regulates exocytosis of insulin granules, according to metabolism-secretion coupling in which glucose-induced mitochondrial ATP production plays an essential role. Impaired glucose-induced insulin secretion often results from impaired glucose-induced ATP elevation in beta-cells. Mitochondrial ATP production is driven by the proton-motive force including mitochondrial membrane potential (DeltaPsi(m)) generated by the electron transport chain. These electrons are derived from reducing equivalents, generated in the Krebs cycle and transferred from cytosol by the shuttles. Here, roles of the determinants of mitochondrial ATP production in impaired glucose-induced insulin secretion are discussed. Cytosolic alkalization, H(+) leak in the inner membrane by uncoupler (e.g. free fatty acid exposure), decrease in the supply of electron donors including NADH and FADH(2) to the respiratory chain, and endogenous mitochondrial ROS (e.g. Na(+)/K(+)-ATPase inhibition) all reduce hyperpolarlization of DeltaPsi(m) and ATP production, causing decresed glucose-induced insulin release. The decrease in the supply of NADH and FADH(2) to the respiratory chain derives from impairments in glucose metabolism including glycolysis (e.g. MODY2 and exposure to NO) and the shuttles (e.g. diabetic state and exposure to ketone body).
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Affiliation(s)
- Shimpei Fujimoto
- Department of Diabetes and Clinical Nutrition, Graduate School of Medicine, Kyoto University, Kyoto 606-8507, Japan.
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Ramos-Román MA, Piñero-Piloña A, Adams-Huet B, Raskin P. Comparison of type 1, type 2, and atypical ketosis-prone diabetes at 4 years of diabetes duration. J Diabetes Complications 2006; 20:137-44. [PMID: 16632232 DOI: 10.1016/j.jdiacomp.2006.01.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 01/11/2006] [Indexed: 10/24/2022]
Abstract
CONTEXT Atypical ketosis-prone diabetes (KPD) is frequently detected in obese individuals at diagnosis of diabetes, yet its precise pathophysiology is not understood. AIM The hypothesis tested in this study states that while individuals with atypical KPD are phenotypically similar to those with type 2 diabetes, metabolically, they behave more like individuals with autoimmune type 1 diabetes. METHODS Thirty-seven individuals of Black, Hispanic, or White background and a diagnosis of diabetes mellitus for an average duration of 4 years participated in this cross-sectional study. Ten, 12, and 15 subjects had type 1, atypical, and type 2 diabetes, respectively. Insulin secretion was evaluated by a mixed-meal test. Insulin sensitivity and fuel oxidation were assessed by simultaneous euglycemic hyperinsulinemic clamp and indirect calorimetry. Lastly, a 12-h insulin withdrawal test was performed. RESULTS Insulin secretion, insulin sensitivity, and the insulin withdrawal tests yielded significant differences for type 1 vs. atypical diabetes and type 1 vs. type 2 diabetes, while there were no significant differences between atypical vs. type 2 diabetes. The indirect calorimetry showed higher-than-normal basal nonprotein respiratory quotients (RQs) and lower-than-normal insulin-stimulated nonprotein RQs across the three study groups. CONCLUSIONS After 4 years from diabetes diagnosis and while far from optimal glycemic control, atypical KPD resembles type 2 diabetes phenotypically and metabolically as well. Therefore, this study supports the classification of atypical KPD as ketosis-prone type 2 diabetes, and the concept that metabolic inflexibility occurs in the presence of insulin resistance in type 1 and type 2 diabetes.
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Affiliation(s)
- María A Ramos-Román
- Department of Internal Medicine at the University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390-8858, USA.
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Matsui J, Tamasawa N, Tanabe J, Kasai N, Murakami H, Matsuki K, Suda T. Clinical characteristics of Japanese youth-onset type 2 diabetes with ketonuria. Diabetes Res Clin Pract 2005; 70:235-8. [PMID: 15946760 DOI: 10.1016/j.diabres.2005.03.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2004] [Revised: 09/30/2004] [Accepted: 03/31/2005] [Indexed: 10/25/2022]
Abstract
The study analyzed the clinical background and eating habits of Japanese youth-onset type 2 diabetes. Thirty-six patients with type 2 diabetes (22 males, 14 females) with onset in less than 20-year-old were studied. All patients were negative for anti-glutamic acid decarboxylase (GAD) antibody and islet cell antibody. Cases diagnosed as having abnormalities in the mitochondrial gene, maturity onset diabetes of the young (MODY), and apparent type 1 diabetes were excluded from the study. Urinary ketone was detected positive in 11 cases among 36 patients at the onset of diabetes. We compared the clinical characteristics and food compositions between the patients with ketonuria and those without ketonuria. Age and urinary C-peptide secretion did not show any significant difference between both groups. In the patients with ketonuria, male to female ratio was remarkably high (10:1) compared with the group without ketonuria (12:13). Positive diabetic family history was predominantly higher in the group with ketonuria (11/11) than that in the group without ketonuria (17/25). All these were identical to previously reported characteristics of soft-drink ketosis. However, we in this study, revealed the difference of total calorie intake and dietary composition between youth-onset type 2 diabetes with and without ketonuria. As a result dietary contents such as carbohydrate, fat and confectionery in the former group were also 1.5, 1.4-2.4 times higher, respectively, than those in the latter group.
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Affiliation(s)
- Jun Matsui
- Third Department of Internal Medicine, Hirosaki University School of Medicine, 5 Zaifu-cho, Hirosaki, Aomori-ken 036-8562, Japan.
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Kazlauskaite R, Evans AT, Mazzone T, Fogelfeld LA. Ethnic differences predicting ketonuria in patients with Type 2 diabetes. J Diabetes Complications 2005; 19:284-90. [PMID: 16112504 DOI: 10.1016/j.jdiacomp.2005.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Revised: 12/10/2004] [Accepted: 01/19/2005] [Indexed: 11/18/2022]
Abstract
UNLABELLED Ketonuria occurs more frequently than ketoacidosis does in patients with Type 2 diabetes and may portend serious future events. We studied the correlates of ketonuria among African American and Hispanic/Latino patients with Type 2 diabetes who did not have ketoacidosis. METHODS We performed a retrospective cross-sectional study of patients referred for diabetes education from the emergency department or the urgent care clinic of a large, public, urban hospital from 2001 until 2003. Eligible patients had newly diagnosed Type 2 diabetes or diabetes diagnosed within 15 years but without treatment for the previous 2 months. Using logistic regression analysis, we analyzed the predictors of ketonuria and assessed whether they varied by ethnic group. RESULTS Of 228 adult African American and Hispanic/Latino patients, 112 (49%) had ketonuria. Independent predictors of ketonuria were younger age (OR: 2.3), higher hemoglobin A(1c) (OR: 3.0), and a history of substance abuse (OR: 1.9) (for all: P<.05). Among Hispanic/Latino patients, ketonuria was also independently associated with low HDL-cholesterol (adjusted OR: 6.6; 95% CI: 2-20), but this relationship was not seen in African American patients. CONCLUSIONS Ketonuria is common among newly diagnosed or untreated patients with Type 2 diabetes in a public hospital serving a predominantly minority population. Some correlates of ketonuria differ among ethnic groups, suggesting potential ethnic differences in ketogenesis. Prospective identification and study of patients with ketonuria may have important implications for appropriate therapy, especially if it is shown that ketonuria is a predictor of symptomatic ketoacidosis.
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Affiliation(s)
- Rasa Kazlauskaite
- John H. Stroger, Jr. Hospital of Cook County, 1900 W. Polk Street, Chicago, IL 60612, USA; Rush University, Chicago, IL 60612, USA.
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Sapru A, Gitelman SE, Bhatia S, Dubin RF, Newman TB, Flori H. Prevalence and characteristics of type 2 diabetes mellitus in 9-18 year-old children with diabetic ketoacidosis. J Pediatr Endocrinol Metab 2005; 18:865-72. [PMID: 16279364 DOI: 10.1515/jpem.2005.18.9.865] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To estimate the prevalence of type 2 diabetes mellitus (DM2) in 9-18 year-old children with diabetic ketoacidosis (DKA) and to describe the presenting biochemical characteristics and response to standardized DKA treatment. METHODS Data were collected from a consecutive sample of 9-18 year-old children presenting with DKA. DKA was defined as hyperglycemia and ketosis with an initial pH <7.3, or bicarbonate <15 mmol/l. Patients were classified as having DM2 if they had negative autoantibody status and normal or elevated fasting C-peptide. RESULTS The prevalence of DM2 in patients with DKA was 13.0% (6.1-23.3%). There was no significant difference in the presenting pH (7.14 vs 7.15), but blood glucose was higher (735 vs 587 mg/dl) in patients with DM2, than in patients with type 1 DM (DM1). The duration of insulin infusion until resolution of acidosis (17.3 vs 13.2 h) and intensive care unit stay (2.4 vs 1.6 days) were longer in patients with DM2. Seven of the nine patients with DM2 did not require insulin at 1-year follow-up. CONCLUSIONS Children with DM2 can present with DKA and constitute a significant percentage in the above 9-year age group. The need for insulin must be carefully re-evaluated as DKA resolves in these patients. Adolescents with DM2 and their families need to be educated about DKA.
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Affiliation(s)
- Anil Sapru
- Pediatric Critical Care Medicine, University of California, San Francisco, CA 94143, USA.
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29
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Takehiro M, Fujimoto S, Shimodahira M, Shimono D, Mukai E, Nabe K, Radu RG, Kominato R, Aramaki Y, Seino Y, Yamada Y. Chronic exposure to beta-hydroxybutyrate inhibits glucose-induced insulin release from pancreatic islets by decreasing NADH contents. Am J Physiol Endocrinol Metab 2005; 288:E372-80. [PMID: 15479955 DOI: 10.1152/ajpendo.00157.2004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To investigate the effects of chronic exposure to ketone bodies on glucose-induced insulin secretion, we evaluated insulin release, intracellular Ca2+ and metabolism, and Ca2+ efficacy of the exocytotic system in rat pancreatic islets. Fifteen-hour exposure to 5 mM d-beta-hydroxybutyrate (HB) reduced high glucose-induced insulin secretion and augmented basal insulin secretion. Augmentation of basal release was derived from promoting the Ca2+-independent and ATP-independent component of insulin release, which was suppressed by the GDP analog. Chronic exposure to HB affected mostly the second phase of glucose-induced biphasic secretion. Dynamic experiments showed that insulin release and NAD(P)H fluorescence were lower, although the intracellular Ca2+ concentration ([Ca2+](i)) was not affected 10 min after exposure to high glucose. Additionally, [Ca2+](i) efficacy in exocytotic system at clamped concentrations of ATP was not affected. NADH content, ATP content, and ATP-to-ADP ratio in the HB-cultured islets in the presence of high glucose were lower, whereas glucose utilization and oxidation were not affected. Mitochondrial ATP production shows that the respiratory chain downstream of complex II is not affected by chronic exposure to HB, and that the decrease in ATP production is due to decreased NADH content in the mitochondrial matrix. Chronic exposure to HB suppresses glucose-induced insulin secretion by lowering the ATP level, at least partly by inhibiting ATP production by reducing the supply of NADH to the respiratory chain. Glucose-induced insulin release in the presence of aminooxyacetate was not reduced, which implies that chronic exposure to HB affects the malate/aspartate shuttle and thus reduces NADH supply to mitochondria.
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Affiliation(s)
- Mihoko Takehiro
- Dept. of Diabetes and Clinical Nutrition, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto 606-8507, Japan
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Rasouli N, Elbein SC. Improved glycemic control in subjects with atypical diabetes results from restored insulin secretion, but not improved insulin sensitivity. J Clin Endocrinol Metab 2004; 89:6331-5. [PMID: 15579799 DOI: 10.1210/jc.2004-1016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
African-American subjects often present with hyperglycemic crisis (diabetic ketoacidosis or severe hyperglycemia), yet subsequently are treated without insulin. The pathophysiology of this unique condition is unknown. We hypothesized that recovery from atypical diabetes with intensive insulin therapy resulted from a reversal of a defect in beta-cell function and improved insulin sensitivity. We studied eight newly diagnosed, antibody-negative African-American subjects (age, 34-56 yr) who presented with hyperglycemic crisis. Subjects were studied at baseline after overnight glycemic control and again after 3 wk and 3 months of intensive insulin therapy. Insulin sensitivity (SI) was determined from an insulin-modified, frequently sampled i.v. glucose tolerance test, and insulin secretion was measured as the acute insulin response to glucose and to a glucagon stimulation test. Fructosamine and hemoglobin A1c declined significantly with intensive insulin therapy, and insulin requirements decreased over time. Both acute insulin response to glucose and the C peptide response to glucagon stimulation test improved by 3 wk (P = 0.02 vs. baseline), and improvements were maintained at 3 months (P = 0.02 vs. baseline). In contrast, the SI remained low throughout the study. We demonstrate that improved glycemic control correlates with a remarkable recovery of beta-cell function, but no change in SI.
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Affiliation(s)
- Neda Rasouli
- University of Arkansas for Medical Sciences, and Central Arkansas Veterans Healthcare System, Little Rock, Arkansas 72205, USA.
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Mauvais-Jarvis F, Sobngwi E, Porcher R, Riveline JP, Kevorkian JP, Vaisse C, Charpentier G, Guillausseau PJ, Vexiau P, Gautier JF. Ketosis-prone type 2 diabetes in patients of sub-Saharan African origin: clinical pathophysiology and natural history of beta-cell dysfunction and insulin resistance. Diabetes 2004; 53:645-53. [PMID: 14988248 DOI: 10.2337/diabetes.53.3.645] [Citation(s) in RCA: 205] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Nonautoimmune ketosis-prone diabetic syndromes are increasingly frequent in nonwhite populations. We have characterized a cohort of patients of sub-Saharan African origin who had ketosis-prone type 2 diabetes (n = 111), type 1 diabetes (n = 21), and type 2 diabetes (n = 88) and were admitted to a hospital for management of uncontrolled diabetes. We compared epidemiological, clinical, and metabolic features at diabetes onset and measured insulin secretion (glucagon-stimulated C-peptide) and insulin action (short intravenous insulin tolerance test) during a 10-year follow-up. Ketosis-prone type 2 diabetes shows a strong male predominance, stronger family history, higher age and BMI, and more severe metabolic decompensation than type 1 diabetes. In ketosis-prone type 2 diabetes, discontinuation of insulin therapy with development of remission of insulin dependence is achieved in 76% of patients (non-insulin dependent), whereas only 24% of patients remain insulin dependent. During evolution, ketosis-prone type 2 diabetes exhibit specific beta-cell dysfunction features that distinguish it from type 1 and type 2 diabetes. The clinical course of non-insulin-dependent ketosis-prone type 2 diabetes is characterized by ketotic relapses followed or not by a new remission. Progressive hyperglycemia precedes and is a strong risk factor for ketotic relapses (hazard ratio 38). The probability for non-insulin-dependent ketosis-prone type 2 diabetes to relapse is 90% within 10 years, of whom approximately 50% will become definitively insulin dependent. Insulin sensitivity is decreased in equal proportion in both ketosis-prone type 2 diabetes and type 2 diabetes, but improves significantly in non-insulin-dependent ketosis-prone type 2 diabetes, only after correction of hyperglycemia. In conclusion, ketosis-prone type 2 diabetes can be distinguished from type 1 diabetes and classical type 2 diabetes by specific features of clinical pathophysiology and also by the natural history of beta-cell dysfunction and insulin resistance reflecting a propensity to glucose toxicity.
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Affiliation(s)
- Franck Mauvais-Jarvis
- Department of Endocrinology & Diabetes, Saint-Louis Hospital and University of Paris VII School of Medicine, Paris, France.
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Abstract
Hyperglycemic crises in type 2 diabetes are not rare and are becoming increasingly recognized as part of the spectrum of the presentation of previously undiagnosed diabetes mellitus and the decompensation of established diabetes mellitus. Contributing factors and associations are being elucidated but remain far from clear, particularly in DKA states. Medications commonly used in the treatment of many comorbid illnesses in patients with diabetes can themselves predispose to HHS. Endocrinopathies can contribute to insulin resistance and directly increase the glycemic load, leading to hyperglycemia. Medications such as the protease inhibitors may in the future lead to a better understanding of the pathophysiology of the metabolic derangements seen in the development of type 2 diabetes mellitus.
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Affiliation(s)
- D L Trence
- Division of Metabolism, Endocrinology, and Nutrition, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA.
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