Immunological Aspects of Fulminant Type 1 Diabetes in Chinese

Fulminant type 1 diabetes: Focusing on triggering factors

Fulminant type 1 diabetes (FT1D) is a novel type of type 1 diabetes that is caused by extremely rapid destruction of the pancreatic β cells. Early diagnosis or prediction of FT1D is critical for the prevention or timely treatment of diabetes ketoacidosis, which can be life-threatening. Understanding its triggers or promoting factors plays an important role in the prevention and treatment of FT1D. In this review, we summarised the various triggering factors of FT1D, including susceptibility genes, immunological factors (cellular and humoural immunity), immune checkpoint inhibitor therapies, drug reactions with eosinophilia and systemic symptoms or drug-induced hypersensitivity syndrome, pregnancy, viral infections, and vaccine inoculation. This review provides the basis for future research into the pathogenetic mechanisms that regulate FT1D development and progression to further improve the prognosis and clinical management of patients with FT1D.

Heterogeneity and endotypes in type 1 diabetes mellitus

Despite major advances over the past decade, prevention and treatment of type 1 diabetes mellitus (T1DM) remain suboptimal, with large and unexplained variations in individual responses to interventions. The current classification schema for diabetes mellitus does not capture the complexity of this disease or guide clinical management effectively. One of the approaches to achieve the goal of applying precision medicine in diabetes mellitus is to identify endotypes (that is, well-defined subtypes) of the disease each of which has a distinct aetiopathogenesis that might be amenable to specific interventions. Here, we describe epidemiological, clinical, genetic, immunological, histological and metabolic differences within T1DM that, together, suggest heterogeneity in its aetiology and pathogenesis. We then present the emerging endotypes and their impact on T1DM prediction, prevention and treatment.

[Clinical Analysis of 17 Adult Patients With Fulminant Type 1 Diabetes Mellitus]

Objective

To explore the clinical characteristics of adult patients with fulminant type 1 diabetes mellitus (FT1DM), a specific subtype of type 1 diabetes mellitus (T1DM).

Methods

We collected the clinical data of patients who were admitted to West China Hospital, Sichuan University in 2010-2019 for FT1DM and type 1 diabetes mellitus (T1DM) presenting with diabetic ketoacidosis (DKA) at the onset. In addition, all the FT1DM patients were followed up.

Results

A total of 70 patients presenting with DKA at the onset of T1DM were admitted to and received treatment at West China Hospital in 2010-2019. Among them, 17 (24.3%) had FT1DM and 53 did not. The mean ages of the FT1DM patients and the non-FT1DM patients were (33.2±12.8) years and (27.5±11.2) years, and the mean body mass indices were (22.6±2.9) kg/m 2 and (19.2±2.9) kg/m 2, respectively. A total of 14 FT1DM cases had symptoms of upper respiratory tract infection or acute gastroenteritis before the onset of the disease and 4 cases were related to pregnancy. The median time from the onset of the disease to the first diagnosis of DKA of the FT1DM group (median [P 25-P 75]: 2 [1-4] days, P<0.001) was significantly shorter than that of the non-FT1DM group (median [P 25-P 75]: 30 [17-78] days). The mean maximum blood glucose levels at the time of the first visit to the doctor of the FT1DM patients ([39.9±11.4] mmol/L, P<0.001) were significantly higher than that of the non-FT1DM patients ([28.9±9.2] mmol/L), but the HbA1c (6.6%±0.6%, P<0.001) and glycosylated serum albumin (GA) (21.4%±3.0%, P=0.001) levels of the FT1DM patients were significantly lower than those of the non-FT1DM group (HbA1c: 12.8%±2.7%; GA: 44.8%±15.0%). The median serum amylase in the FT1DM group was significantly higher than that in the non-FT1DM group (101 [54-336] IU/L vs. 54 [42-166] IU/L, P=0.045) and the median serum lipase in the FT1DM group showed a trend of being higher than that in the T1DM group (81 [57-154] IU/L vs. 46 [28-195] IU/L, P=0.051). 8.7% of the non-FT1DM patients tested positive for anti-glutamic acid decarboxylase antibody (GAD-Ab), while the FT1DM patients all tested negative. At the time of discharge, the mean daily insulin dose of the FT1DM patients was (0.67±0.22) IU/kg, which was not significantly different from that of the non-FT1DM group ([0.74±0.29] IU/kg, P=0.349). After about 6.5 years of follow-up, the mean daily insulin dose of the FT1DM patients was (0.73±0.19) IU/kg, which was similar to the insulin dosage on discharge ( P=0.409).

Conclusion

Compared with the non-FT1DM patients presenting with DKA at the onset, FT1DM patients have fewer typical diabetic symptoms, lower fasting C-peptide levels, higher serum amylase levels, and increased incidence of vomiting or other symptoms of gastrointestinal infections, and are more likely to be misdiagnosed. Therefore, it is very important for clinicians to correctly identify FT1DM as early as possible and administer early and long-term insulin replacement therapy.

Type 1 diabetes in diverse ancestries and the use of genetic risk scores

Over 75 genetic loci within and outside of the HLA region influence type 1 diabetes risk. Genetic risk scores (GRS), which facilitate the integration of complex genetic information, have been developed in type 1 diabetes and incorporated into models and algorithms for classification, prognosis, and prediction of disease and response to preventive and therapeutic interventions. However, the development and validation of GRS across different ancestries is still emerging, as is knowledge on type 1 diabetes genetics in populations of diverse genetic ancestries. In this Review, we provide a summary of the current evidence on the evolutionary genetic variation in type 1 diabetes and the racial and ethnic differences in type 1 diabetes epidemiology, clinical characteristics, and preclinical course. We also discuss the influence of genetics on type 1 diabetes with differences across ancestries and the development and validation of GRS in various populations.

Diagnostic value of combined islet antigen-reactive T cells and autoantibodies assays for type 1 diabetes mellitus

AIMS/INTRODUCTION

Type 1 diabetes mellitus is a T cell-mediated autoimmune disease. However, the determination of the autoimmune status of type 1 diabetes mellitus relies on islet autoantibodies (Abs), as T-cell assay is not routinely carried out. This study aimed to investigate the diagnostic value of combined assay of islet antigen-specific T cells and Abs in type 1 diabetes mellitus patients.

MATERIALS AND METHODS

A total of 54 patients with type 1 diabetes mellitus and 56 healthy controls were enrolled. Abs against glutamic acid decarboxylase (GAD), islet antigen-2 and zinc transporter 8 were detected by radioligand assay. Interferon-γ-secreting T cells responding to glutamic acid decarboxylase 65 and C-peptide (CP) were measured by enzyme-linked immunospot.

RESULTS

The positive rate for T-cell responses was significantly higher in patients with type 1 diabetes mellitus than that in controls (P < 0.001). The combined positive rate of Abs and T-cell assay was significantly higher than that of Abs assay alone (85.2% vs 64.8%, P = 0.015). A significant difference in fasting CP level was found between the T+ and T- groups (0.07 ± 0.05 vs 0.11 ± 0.09 nmol/L, P = 0.033). Furthermore, levels of fasting CP and postprandial CP were both lower in the Ab- T+ group than the Ab- T- group (fasting CP 0.06 ± 0.05 vs 0.16 ± 0.12 nmol/L, P = 0.041; postprandial CP 0.12 ± 0.13 vs 0.27 ± 0.12 nmol/L, P = 0.024).

CONCLUSIONS

Enzyme-linked immunospot assays in combination with Abs detection could improve the diagnostic sensitivity of autoimmune diabetes.

Fulminant type 1 diabetes: A comprehensive review of an autoimmune condition

Fulminant type 1 diabetes (FT1D) is a subset of type 1 diabetes characterized by extremely rapid pancreatic β-cell destruction with aggressive progression of hyperglycaemia and ketoacidosis. It was initially classified as idiopathic type 1 diabetes due to the absence of autoimmune markers. However, subsequent studies provide evidences supporting the involvement of autoimmunity in rapid β-cell loss in FT1D pathogenesis, which are crucial for FT1D being an autoimmune disease. This article highlights the role of immunological aspects in FT1D according to the autoimmune-associated genetic background, viral infection, innate immunity, adaptive immunity, and pancreas histology.

Clinical Characteristics of Fulminant Type 1 Diabetes Compared with Typical Type 1 Diabetes: One-Year Follow-Up Study from the Guangdong T1DM Translational Medicine Study

BACKGROUND

Fulminant type l diabetes mellitus (FT1DM) is a subtype of type 1 diabetes mellitus (T1DM) with abrupt onset, but data on its progression was limited. This study was aimed at exploring the clinical features through one-year follow-up. Methods and Materials. Patients with T1DM finishing at least one-year follow-up from June 2011 to July 2018 were enrolled from Guangdong Type 1 Diabetes Translational Medicine Study. Patients who fulfilled the respective criteria were categorized as an FT1DM group and a typical T1DM group (TT1DM). The 1 : 4 propensity score matching based on onset age, duration, and gender was performed between the FT1DM and TT1DM groups. Characteristics at the onset and after one-year follow-up were compared between the two groups.

RESULTS

A total of 53 patients with FT1DM and 212 matched patients with TT1DM were included. At the onset, there was a shorter duration of symptomatic period before diagnosis observed in the FT1DM group than in the TT1DM group (2 [1, 7] vs. 30 [10, 60] days, P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (P < 0.001). FT1DM patients had higher plasma glucose levels and higher percentage of diabetes ketoacidosis (.

CONCLUSION

Patients with FT1DM had more severe metabolic derangement and deficiency of insulin secretion than patients with TT1DM at the onset, but glycaemic and metabolic control was not worse than that in TT1DM.

A Case of Fulminant Type 1 Diabetes with Gastric and Urinary Retention

Fulminant type 1 diabetes (fT1D) is a severe subtype of type 1 diabetes which progresses rapidly with islet cells destroyed almost completely within a short period of time. It is often characterized by flu-like or gastrointestinal symptoms at the onset with negative islet-associated autoantibodies, resulting in an absolute deficiency of endogenous insulin secretion. Poor prognosis can be caused by the significantly higher incidence of metabolic disorders (such as severe ion disorders and elevated serum pancreatic enzymes), acute and chronic complications if not diagnosed and treated in a timely manner. We herein describe an fT1D patient with gastric and urinary retention along with severe ion disturbance, whose laboratory tests revealed diabetic ketoacidosis, peripheral neuropathy, retinopathy, nephropathy, and hypoproteinemia.

Diagnosis and treatment of endocrinological complications of immunotherapy of oncological diseases

In this lecture, we discuss in detail the endocrinopathies associated with the use of immune-checkpoint inhibitors in oncology. The cases, terms and features of clinical manifestations of endocrine-related immune reactions are discussed, and practical recommendations for the treatment of patients are proposed.

Recent findings on fulminant type 1 diabetes

Fulminant type 1 diabetes (fT1D) is a new subtype of type 1 diabetes proposed by Imagawa in 2000. It is a clinical syndrome characterized by a markedly rapid and almost complete destruction of pancreatic β cells. Metabolic derangement is more severe in this subtype than in autoimmune type 1 diabetes. The incidence of fT1D is associated with HLA DRB1*04:05DQB1*04:01; both innate and acquired immune disorders might contribute to the development of fT1D. The presence of specific innate immune responses to enterovirus infection connected with enhanced adaptive immune pathways responsible for aggressive β cell toxicity in fT1D. The process of β cell destruction is extremely rapid in fT1D, and the insulin secretary capacity rarely recovers after the onset. The serum glycated albumin to glycated haemoglobin ratio is significantly higher in fT1D; a cut-off value of 3.2 for serum glycated albumin to glycated haemoglobin ratio yielded 97% sensitivity and 98% specificity for differentiating fT1D from type 2 diabetes. Fulminant type 1 diabetes is associated with pregnancy. This article also updates the diagnostic criteria for fT1D by the Japanese Diabetes Association in 2012.

Fulminant Type 1 Diabetes in Children: A Multicenter Study in China

BACKGROUND

To investigate the hospital-based incidence of FT1D in Chinese children and compare the clinical feature with classical T1DM.

METHODS

A cross-sectional study with sixteen hospitals involved. We obtained 23 FT1D cases as group 1, acute-onset T1DM as group 2, and typical T1DM as group 3.

RESULTS

The incidence of FT1D was 1.56% in 16 participating hospitals. The mean age at the onset of group 1 was 2.00 (1.08, 6.51) years old, much younger than that of group 2 (6.11 (3.92, 9.50)) and group 3 (6.92 (4.17, 10.03)). In addition, significant differences were found between three groups: mean BMI and flu-like symptoms with fever and abdominal pain. Follow-up comparison of three groups from Beijing Children's Hospital for at least one year showed that there is no significant difference between the three groups in terms of mean HbA1c levels and insulin injection dosages.

CONCLUSION

FT1D onset age is much younger than that of classical T1D patients. The hospital-based incidence of FT1D in Chinese children was 1.56% in all new-onset T1DM. For the diagnosis, making FT1D alone into a subtype within type 1 diabetes may be meaningful. However, for the treatment and prognosis, such classification should not be helpful to the clinic.

Genetic diagnosis and treatment of a Chinese ketosis-prone MODY 3 family with depression

BACKGROUND

To analyze the gene mutation and mental disorder of a Chinese ketosis-prone diabetes (KPD) family, and to make a precise diagnosis and give a treatment for them.

METHODS

We studied a Chinese family with a clinical diagnosis of maturity-onset diabetes of the young (MODY). The clinical data and the blood samples were collected. The promotor and coding regions inclusive intron exon boundaries of the HNF1A, HNF4A were detected by polymerase chain reaction (PCR) and direct sequencing. The missense mutation was also analyzed by bioinformatics. Genetic counseling was performed twice a month to relieve the mental disorder of the persons.

RESULTS

The missense mutation c.779 C>T (p.T260M) in exon4 of HNF1A gene was detected, and the symptom heterogenicity among persons in this family were found. All the members were retreated with Gliclazide and stopped to use other medicine, the blood glucose of them were well controlled. We also performed an active genetic counseling to them and the mental disorder of the proband's sister was relieved.

CONCLUSIONS

A missense mutation of HNF1A gene was first found in Chinese ketosis-prone MODY family with manifestations heterogenicity among the persons. Sulphonylureas medicine and genetic counseling are efficiency ways to treat MODY 3 and its' mental disorder respectively.