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Marcovecchio ML, Hendriks AEJ, Delfin C, Battelino T, Danne T, Evans ML, Johannesen J, Kaur S, Knip M, Overbergh L, Pociot F, Todd JA, Van der Schueren B, Wicker LS, Peakman M, Mathieu C. The INNODIA Type 1 Diabetes Natural History Study: a European cohort of newly diagnosed children, adolescents and adults. Diabetologia 2024; 67:995-1008. [PMID: 38517484 PMCID: PMC11058619 DOI: 10.1007/s00125-024-06124-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/24/2024] [Indexed: 03/24/2024]
Abstract
AIMS/HYPOTHESIS Type 1 diabetes is an heterogenous condition. Characterising factors explaining differences in an individual's clinical course and treatment response will have important clinical and research implications. Our aim was to explore type 1 diabetes heterogeneity, as assessed by clinical characteristics, autoantibodies, beta cell function and glycaemic outcomes, during the first 12 months from diagnosis, and how it relates to age at diagnosis. METHODS Data were collected from the large INNODIA cohort of individuals (aged 1.0-45.0 years) newly diagnosed with type 1 diabetes, followed 3 monthly, to assess clinical characteristics, C-peptide, HbA1c and diabetes-associated antibodies, and their changes, during the first 12 months from diagnosis, across three age groups: <10 years; 10-17 years; and ≥18 years. RESULTS The study population included 649 individuals (57.3% male; age 12.1±8.3 years), 96.9% of whom were positive for one or more diabetes-related antibodies. Baseline (IQR) fasting C-peptide was 242.0 (139.0-382.0) pmol/l (AUC 749.3 [466.2-1106.1] pmol/l × min), with levels increasing with age (p<0.001). Over time, C-peptide remained lower in participants aged <10 years but it declined in all age groups. In parallel, glucose levels progressively increased. Lower baseline fasting C-peptide, BMI SD score and presence of diabetic ketoacidosis at diagnosis were associated with lower stimulated C-peptide over time. HbA1c decreased during the first 3 months (p<0.001), whereas insulin requirement increased from 3 months post diagnosis (p<0.001). CONCLUSIONS/INTERPRETATION In this large cohort with newly diagnosed type 1 diabetes, we identified age-related differences in clinical and biochemical variables. Of note, C-peptide was lower in younger children but there were no main age differences in its rate of decline.
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Affiliation(s)
- M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
- Department of Paediatric Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - A Emile J Hendriks
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Department of Paediatric Diabetes and Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Carl Delfin
- Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolism, University Children's Hospital, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Thomas Danne
- Centre for Paediatric Endocrinology, Diabetology, and Clinical Research, Auf Der Bult Children's Hospital, Hannover, Germany
| | - Mark L Evans
- Wellcome MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Jesper Johannesen
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - Simranjeet Kaur
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - Mikael Knip
- Research Program for Clinical and Molecular Metabolism, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Pediatric Research Center, New Children's Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Lut Overbergh
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Flemming Pociot
- Translational Type 1 Diabetes Research, Clinical Research, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Paediatrics, Copenhagen University Hospital, Herlev, Denmark; Institute of Health and Medical Sciences, University of Copenhagen, Herlev, Denmark
| | - John A Todd
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bart Van der Schueren
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Linda S Wicker
- Centre for Human Genetics, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mark Peakman
- Immunology & Inflammation Research Therapeutic Area, Sanofi, MA, USA
| | - Chantal Mathieu
- Clinical and Experimental Endocrinology, Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
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2
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Leão IS, Dantas JR, Araújo DB, Ramos MEN, Silva KR, Batista LS, Pereira MDFC, Luiz RR, da Silva CC, Maiolino A, Rebelatto CLK, Daga DR, Senegaglia AC, Brofman PRS, de Oliveira JEP, Zajdenverg L, Rodacki M. Evaluation of type 1 diabetes' partial clinical remission after three years of heterologous adipose tissue derived stromal/stem cells transplantation associated with vitamin D supplementation. Diabetol Metab Syndr 2024; 16:114. [PMID: 38790009 PMCID: PMC11127374 DOI: 10.1186/s13098-024-01302-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/04/2024] [Indexed: 05/26/2024] Open
Abstract
BACKGROUND Mesenchymal stem cell infusion and vitamin D supplementation may have immunomodulatory actions that could prolong the preservation of residual insulin secretion in patients with type 1 diabetes (T1D). Intervention with these agents after onset of T1D could favor the development of a remission phase, with potential clinical impact. We aimed to compare the presence of clinical remission (CR), glycemic control and daily insulin requirement at 6, 12, 18, 24 and 36 months after the diagnosis of T1D using IDAA1c in patients who received therapy with adipose tissue-derived mesenchymal stem cell (ASC) infusion and vitamin D supplementation and a control group. METHODS This retrospective cohort study analyzed data from the medical records of patients with T1D diagnosed between 15 and 40 years. Partial CR was defined as an IDAA1c index < 9. Patients in the intervention group received an infusion of adipose tissued-derived mesenchymal stem cells (ASCs) within 3 months after diagnosis and supplementation with 2000 IU of cholecalciferol for 1 year, started on the day following the infusion. Partial CR was also determined using the ISPAD criteria, to assess its agreement with IDAA1c. RESULTS A total of 28 patients were evaluated: 7 in the intervention group (group 1) and 21 in the control group (group 2). All patients in group 1 evolved with partial CR while only 46.7% of patients in group 2 had this outcome. Group 1 had a higher frequency of CR when evaluated with IDAA1c and ISPAD criteria. The mean duration of CR varied between the two criteria. Although HbA1c was similar between groups during follow-up, group 1 had a lower total daily insulin requirement (p < 0.005) at all time points. At 36 months, group 1 used 49% of the total daily insulin dose used by group 2 with similar glycemic control. CONCLUSION The intervention with infusion of ASC + vitamin D supplementation was associated with partial CR at 6 months. Although there were no differences in CR established by the IDAA1c and ISPAD criteria after three years of follow-up, patients who underwent intervention had nearly the half insulin requirement of controls with conventional treatment, with similar glycemic control. TRIAL REGISTRATION 37001514.0.0000.5257.
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Affiliation(s)
- Isabella Sued Leão
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil.
| | - Joana Rodrigues Dantas
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Débora Baptista Araújo
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Maria Eduarda Nascimento Ramos
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Karina Ribeiro Silva
- Laboratory of Tissue Bioengineering, Instituto Nacional de Metrologia Qualidade e Tecnologia Campus de Xerem, Duque de Caxias, Brazil
- Histology and Embryology Departament, Universidade Estadual do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leandra S Batista
- Laboratory of Tissue Bioengineering, Instituto Nacional de Metrologia Qualidade e Tecnologia Campus de Xerem, Duque de Caxias, Brazil
- Center for Biological Research (Numpex-Bio), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Maria de Fátima Carvalho Pereira
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Ronir Raggio Luiz
- Institute of Public Health Studies, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Angelo Maiolino
- Hematology Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Débora Regina Daga
- Core Cell Technology, Pontifical Catholic University of Parana, Curitiba, Brazil
| | | | | | - José Egídio Paulo de Oliveira
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Lenita Zajdenverg
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
| | - Melanie Rodacki
- Department of Internal Medicine, Nutrology Section, Universidade Federal do Rio de Janeiro (UFRJ), Av Professor Rodolpho Paulo Rocco 255, 22440035, Rio de Janeiro, RJ, Brazil
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Piemonti L, Melzi R, Aleotti F, Capretti G, Nano R, Mercalli A, Magistretti P, Caldara R, Pecorelli N, Catarinella D, Gremizzi C, Gavazzi F, De Cobelli F, Poretti D, Falconi M, Zerbi A, Balzano G. Autologous Pancreatic Islet Cell Transplantation Following Pancreatectomy for Pancreas Diseases Other Than Chronic Pancreatitis: A 15-Y Study of the Milan Protocol. Transplantation 2024:00007890-990000000-00735. [PMID: 38637923 DOI: 10.1097/tp.0000000000005037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Pancreatogenic diabetes, a consequence of pancreatic tissue loss following pancreatectomy, poses a significant challenge for patients undergoing pancreatic surgery. Islet autotransplantation (IAT) offers a promising approach to prevent or alleviate pancreatogenic diabetes, but its application has been limited to individuals with painful chronic pancreatitis. METHODS This study presents a 15-y clinical experience with the Milan Protocol, which expands IAT after pancreatectomy to a broader spectrum of patients with malignant and nonmalignant pancreatic diseases. The analysis evaluates feasibility, efficacy, and safety of IAT. Modified Igls criteria validated through the arginine test and mixed meal tolerance tests were used to assess long-term metabolic outcomes. RESULTS Between November 2008 and June 2023, IAT procedures were performed on 114 of 147 candidates. IAT-related complications occurred in 19 of 114 patients (16.7%), with 5 being potentially serious. Patients exhibited sustained C-peptide secretion over the 10-y follow-up period, demonstrating a prevalence of optimal and good beta-cell function. Individuals who underwent partial pancreatectomy demonstrated superior metabolic outcomes, including sustained C-peptide secretion and a reduced risk of developing diabetes or insulin dependence compared with those who underwent total pancreatectomy. For patients who had total pancreatectomy, the quantity of infused islets and tissue volume were identified as critical factors influencing metabolic outcomes. An increased risk of recurrence or progression of baseline diseases was not observed in subjects with neoplasms. CONCLUSIONS These findings provide valuable insights into the benefits and applications of IAT as a therapeutic option for pancreatogenic diabetes after pancreatic surgery, expanding its potential beyond painful chronic pancreatitis.
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Affiliation(s)
- Lorenzo Piemonti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
| | - Raffella Melzi
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Aleotti
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Giovanni Capretti
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Rita Nano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessia Mercalli
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Paola Magistretti
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Rossana Caldara
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Nicolò Pecorelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Davide Catarinella
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Chiara Gremizzi
- Clinic Unit of Regenerative Medicine and Organ Transplants, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Francesca Gavazzi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Francesco De Cobelli
- Università Vita-Salute San Raffaele, Milan, Italy
- Department of Radiology, Experimental Imaging Center, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dario Poretti
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Massimo Falconi
- Università Vita-Salute San Raffaele, Milan, Italy
- Pancreatic Surgery, Pancreas Translational and Clinical Research Center, IRCCS Ospedale San Raffaele, Milan, Italy
| | - Alessandro Zerbi
- Department of Pancreatic Surgery, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gianpaolo Balzano
- Diabetes Research Institute, IRCCS Ospedale San Raffaele, Milan, Italy
- Università Vita-Salute San Raffaele, Milan, Italy
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Hatle H, Skrivarhaug T, Bjørgaas MR, Åsvold BO, Rø TB. Prevalence and associations of impaired awareness of hypoglycemia in a pediatric type 1 diabetes population - The Norwegian Childhood Diabetes Registry. Diabetes Res Clin Pract 2024; 209:111093. [PMID: 38224875 DOI: 10.1016/j.diabres.2024.111093] [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: 11/10/2023] [Revised: 01/04/2024] [Accepted: 01/09/2024] [Indexed: 01/17/2024]
Abstract
AIMS To determine the prevalence and associations of impaired awareness of hypoglycemia (IAH) in pediatric type 1 diabetes. METHODS Nationwide, population-based cross-sectional study with 51 % participation. Participants (n = 1329; 53 % males) aged 2-19 years (median 13.3) with type 1 diabetes ≥ 6 months (median 4.6 years) self-assessed hypoglycemia awareness with a validated questionnaire ('Clarke'). Parents responded for children aged < 9 years (n = 235). We estimated associations between IAH and clinical data in the Norwegian Childhood Diabetes Registry. RESULTS The overall prevalence of IAH was 22 %, but gradually decreased from 53 % in preschoolers to 12 % in adolescents aged ≥ 16 years. IAH was associated (adjusted OR; 95 %CI) with episodes of severe hypoglycemia (6.0; 3.04, 11.8) and diabetic ketoacidosis (3.45; 1.37, 8.68) the preceding year, increased fear of hypoglycemia (highest quartile vs. lowest: 2.27; 1.51, 3.40), female sex (1.41; 1.05, 1.90), and HbA1c ≥ 8.5 % (69 mmol/mol) vs. 7.5-8.4 % (58-68 mmol/mol) (1.48; 1.01, 2.18), but not with disease duration, use of insulin pump or continuous glucose monitoring, or HbA1c < 7.5 % (58 mmol/mol). CONCLUSIONS IAH is prevalent in pediatric diabetes and more likely reported in young children. IAH is associated with severe hypoglycemia and fear of hypoglycemia, but good metabolic control seems achievable without increased risk of IAH.
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Affiliation(s)
- Håvard Hatle
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Torild Skrivarhaug
- Division of Paediatric and Adolescence Medicine, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Oslo Diabetes Research Centre, Oslo University Hospital, Oslo, Norway
| | - Marit R Bjørgaas
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Bjørn O Åsvold
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway; K.G. Jebsen Center for Genetic Epidemiology, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torstein B Rø
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, NTNU, Norwegian University of Science and Technology, Trondheim, Norway; Children's Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
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Liu W, Fang Y, Cai X, Zhu Y, Zhang M, Han X, Li J, Yin S, Cai D, Chen J, Wang L, Shi D, Ji L. Preserved C-peptide is common and associated with higher time in range in Chinese type 1 diabetes. Front Endocrinol (Lausanne) 2024; 15:1335913. [PMID: 38405156 PMCID: PMC10884320 DOI: 10.3389/fendo.2024.1335913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/23/2024] [Indexed: 02/27/2024] Open
Abstract
Objective The aim of this study is to determine the residual C-peptide level and to explore the clinical significance of preserved C-peptide secretion in glycemic control in Chinese individuals with type 1 diabetes (T1D). Research design and methods A total of 534 participants with T1D were enrolled and divided into two groups, low-C-peptide group (fasting C-peptide ≤10 pmol/L) and preserved-C-peptide group (fasting C-peptide >10 pmol/L), and clinical factors were compared between the two groups. In 174 participants who were followed, factors associated with C-peptide loss were also identified by Cox regression. In addition, glucose metrics derived from intermittently scanned continuous glucose monitoring were compared between individuals with low C-peptide and those with preserved C-peptide in 178 participants. Results The lack of preserved C-peptide was associated with longer diabetes duration, glutamic acid decarboxylase autoantibody, and higher daily insulin doses, after adjustment {OR, 1.10 [interquartile range (IQR), 1.06-1.14]; OR, 0.46 (IQR, 0.27-0.77); OR, 1.04 (IQR, 1.02-1.06)}. In the longitudinal analysis, the percentages of individuals with preserved C-peptide were 71.4%, 56.8%, 71.7%, 62.5%, and 22.2% over 5 years of follow-up. Preserved C-peptide was also associated with higher time in range after adjustment of diabetes duration [62.4 (IQR, 47.3-76.6) vs. 50.3 (IQR, 36.2-63.0) %, adjusted P = 0.003]. Conclusions Our results indicate that a high proportion of Chinese patients with T1D had preserved C-peptide secretion. Meanwhile, residual C-peptide was associated with favorable glycemic control, suggesting the importance of research on adjunctive therapy to maintain β-cell function in T1D.
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Affiliation(s)
- Wei Liu
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Yayu Fang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Xiaoling Cai
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Yu Zhu
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Mingxia Zhang
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Juan Li
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Sai Yin
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
| | - Deheng Cai
- School of Automation, Beijing Institute of Technology, Beijing, ;China
| | - Jing Chen
- School of Automation, Beijing Institute of Technology, Beijing, ;China
| | - Lei Wang
- School of Automation, Beijing Institute of Technology, Beijing, ;China
| | - Dawei Shi
- School of Automation, Beijing Institute of Technology, Beijing, ;China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People’s Hospital, Beijing, ;China
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Kennedy EC, Hawkes CP. Approaches to Measuring Beta Cell Reserve and Defining Partial Clinical Remission in Paediatric Type 1 Diabetes. CHILDREN (BASEL, SWITZERLAND) 2024; 11:186. [PMID: 38397298 PMCID: PMC10887271 DOI: 10.3390/children11020186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/26/2024] [Accepted: 02/01/2024] [Indexed: 02/25/2024]
Abstract
CONTEXT Type 1 diabetes (T1D) results from the autoimmune T-cell mediated destruction of pancreatic beta cells leading to insufficient insulin secretion. At the time of diagnosis of T1D, there is residual beta cell function that declines over the subsequent months to years. Recent interventions have been approved to preserve beta cell function in evolving T1D. OBJECTIVE The aim of this review is to summarise the approaches used to assess residual beta cell function in evolving T1D, and to highlight potential future directions. METHODS Studies including subjects aged 0 to 18 years were included in this review. The following search terms were used; "(type 1 diabetes) and (partial remission)" and "(type 1 diabetes) and (honeymoon)". References of included studies were reviewed to determine if additional relevant studies were eligible. RESULTS There are numerous approaches to quantifying beta cell reserve in evolving T1D. These include c-peptide measurement after a mixed meal or glucagon stimuli, fasting c-peptide, the urinary c-peptide/creatinine ratio, insulin dose-adjusted haemoglobin A1c, and other clinical models to estimate beta cell function. Other biomarkers may have a role, including the proinsulin/c-peptide ratio, cytokines, and microRNA. Studies using thresholds to determine if residual beta cell function is present often differ in values used to define remission. CONCLUSIONS As interventions are approved to preserve beta cell function, it will become increasingly necessary to quantify residual beta cell function in research and clinical contexts. In this report, we have highlighted the strengths and limitations of the current approaches.
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Affiliation(s)
- Elaine C Kennedy
- Department of Paediatrics and Child Health, University College Cork, T12 DC4A Cork, Ireland
- INFANT Research Centre, University College Cork, T12 DC4A Cork, Ireland
| | - Colin P Hawkes
- Department of Paediatrics and Child Health, University College Cork, T12 DC4A Cork, Ireland
- INFANT Research Centre, University College Cork, T12 DC4A Cork, Ireland
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA
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Al-Hasani K, Marikar SN, Kaipananickal H, Maxwell S, Okabe J, Khurana I, Karagiannis T, Liang JJ, Mariana L, Loudovaris T, Kay T, El-Osta A. EZH2 inhibitors promote β-like cell regeneration in young and adult type 1 diabetes donors. Signal Transduct Target Ther 2024; 9:2. [PMID: 38161208 PMCID: PMC10757994 DOI: 10.1038/s41392-023-01707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 10/16/2023] [Accepted: 11/15/2023] [Indexed: 01/03/2024] Open
Abstract
β-cells are a type of endocrine cell found in pancreatic islets that synthesize, store and release insulin. In type 1 diabetes (T1D), T-cells of the immune system selectively destroy the insulin-producing β-cells. Destruction of these cells leads to a lifelong dependence on exogenous insulin administration for survival. Consequently, there is an urgent need to identify novel therapies that stimulate β-cell growth and induce β-cell function. We and others have shown that pancreatic ductal progenitor cells are a promising source for regenerating β-cells for T1D owing to their inherent differentiation capacity. Default transcriptional suppression is refractory to exocrine reaction and tightly controls the regenerative potential by the EZH2 methyltransferase. In the present study, we show that transient stimulation of exocrine cells, derived from juvenile and adult T1D donors to the FDA-approved EZH2 inhibitors GSK126 and Tazemetostat (Taz) influence a phenotypic shift towards a β-like cell identity. The transition from repressed to permissive chromatin states are dependent on bivalent H3K27me3 and H3K4me3 chromatin modification. Targeting EZH2 is fundamental to β-cell regenerative potential. Reprogrammed pancreatic ductal cells exhibit insulin production and secretion in response to a physiological glucose challenge ex vivo. These pre-clinical studies underscore the potential of small molecule inhibitors as novel modulators of ductal progenitor differentiation and a promising new approach for the restoration of β-like cell function.
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Affiliation(s)
- Keith Al-Hasani
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Safiya Naina Marikar
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Harikrishnan Kaipananickal
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Scott Maxwell
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Jun Okabe
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Ishant Khurana
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Thomas Karagiannis
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia
| | - Julia J Liang
- School of Science, STEM College, RMIT University, Melbourne, 3001, VIC, Australia
| | - Lina Mariana
- Immunology and Diabetes Unit, St Vincent's Institute of Medical Research, Fitzroy, 3065, VIC, Australia
| | - Thomas Loudovaris
- Immunology and Diabetes Unit, St Vincent's Institute of Medical Research, Fitzroy, 3065, VIC, Australia
| | - Thomas Kay
- Immunology and Diabetes Unit, St Vincent's Institute of Medical Research, Fitzroy, 3065, VIC, Australia
| | - Assam El-Osta
- Epigenetics in Human Health and Disease Program, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, 3004, VIC, Australia.
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia.
- Epigenetics in Human Health and Disease Laboratory, Central Clinical School, Monash University, Melbourne, 3004, VIC, Australia.
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Sha Tin, Hong Kong SAR.
- Hong Kong Institute of Diabetes and Obesity, Prince of Wales Hospital, The Chinese University of Hong Kong, 3/F Lui Che Woo Clinical Sciences Building, 30-32- Ngan Shing Street, Sha Tin, Hong Kong SAR.
- Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Sha Tin, Hong Kong SAR.
- Biomedical Laboratory Science, Department of Technology, Faculty of Health, University College Copenhagen, Copenhagen, Denmark.
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8
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Ramos EL, Dayan CM, Chatenoud L, Sumnik Z, Simmons KM, Szypowska A, Gitelman SE, Knecht LA, Niemoeller E, Tian W, Herold KC. Teplizumab and β-Cell Function in Newly Diagnosed Type 1 Diabetes. N Engl J Med 2023; 389:2151-2161. [PMID: 37861217 DOI: 10.1056/nejmoa2308743] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
BACKGROUND Teplizumab, a humanized monoclonal antibody to CD3 on T cells, is approved by the Food and Drug Administration to delay the onset of clinical type 1 diabetes (stage 3) in patients 8 years of age or older with preclinical (stage 2) disease. Whether treatment with intravenous teplizumab in patients with newly diagnosed type 1 diabetes can prevent disease progression is unknown. METHODS In this phase 3, randomized, placebo-controlled trial, we assessed β-cell preservation, clinical end points, and safety in children and adolescents who were assigned to receive teplizumab or placebo for two 12-day courses. The primary end point was the change from baseline in β-cell function, as measured by stimulated C-peptide levels at week 78. The key secondary end points were the insulin doses that were required to meet glycemic goals, glycated hemoglobin levels, time in the target glucose range, and clinically important hypoglycemic events. RESULTS Patients treated with teplizumab (217 patients) had significantly higher stimulated C-peptide levels than patients receiving placebo (111 patients) at week 78 (least-squares mean difference, 0.13 pmol per milliliter; 95% confidence interval [CI], 0.09 to 0.17; P<0.001), and 94.9% (95% CI, 89.5 to 97.6) of patients treated with teplizumab maintained a clinically meaningful peak C-peptide level of 0.2 pmol per milliliter or greater, as compared with 79.2% (95% CI, 67.7 to 87.4) of those receiving placebo. The groups did not differ significantly with regard to the key secondary end points. Adverse events occurred primarily in association with administration of teplizumab or placebo and included headache, gastrointestinal symptoms, rash, lymphopenia, and mild cytokine release syndrome. CONCLUSIONS Two 12-day courses of teplizumab in children and adolescents with newly diagnosed type 1 diabetes showed benefit with respect to the primary end point of preservation of β-cell function, but no significant differences between the groups were observed with respect to the secondary end points. (Funded by Provention Bio and Sanofi; PROTECT ClinicalTrials.gov number, NCT03875729.).
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Affiliation(s)
- Eleanor L Ramos
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Colin M Dayan
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Lucienne Chatenoud
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Zdenek Sumnik
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Kimber M Simmons
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Agnieszka Szypowska
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Stephen E Gitelman
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Laura A Knecht
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Elisabeth Niemoeller
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Wei Tian
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
| | - Kevan C Herold
- From Provention Bio, a Sanofi company, Red Bank, NJ (E.L.R., L.A.K., W.T.); Cardiff University, Cardiff, United Kingdom (C.M.D.); Université Paris Cité, CNRS, INSERM, Institut Necker Enfants Malades-INEM, Paris (L.C.); the Department of Pediatrics, Motol University Hospital, Second Faculty of Medicine-Charles University, Prague, Czech Republic (Z.S.); the Barbara Davis Center for Diabetes/University of Colorado School of Medicine, Aurora (K.M.S.); the Medical University of Warsaw, Warsaw, Poland (A.S.); the University of California, San Francisco, San Francisco (S.E.G.); Sanofi, Frankfurt, Germany (E.N.); and the Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT (K.C.H.)
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Hjelholt AJ, Bergh C, Bhatt DL, Fröbert O, Kjolby MF. Pleiotropic Effects of Influenza Vaccination. Vaccines (Basel) 2023; 11:1419. [PMID: 37766096 PMCID: PMC10536538 DOI: 10.3390/vaccines11091419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/20/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
Influenza vaccines are designed to mimic natural influenza virus exposure and stimulate a long-lasting immune response to future infections. The evolving nature of the influenza virus makes vaccination an important and efficacious strategy to reduce healthcare-related complications of influenza. Several lines of evidence indicate that influenza vaccination may induce nonspecific effects, also referred to as heterologous or pleiotropic effects, that go beyond protection against infection. Different explanations are proposed, including the upregulation and downregulation of cytokines and epigenetic reprogramming in monocytes and natural killer cells, imprinting an immunological memory in the innate immune system, a phenomenon termed "trained immunity". Also, cross-reactivity between related stimuli and bystander activation, which entails activation of B and T lymphocytes without specific recognition of antigens, may play a role. In this review, we will discuss the possible nonspecific effects of influenza vaccination in cardiovascular disease, type 1 diabetes, cancer, and Alzheimer's disease, future research questions, and potential implications. A discussion of the potential effects on infections by other pathogens is beyond the scope of this review.
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Affiliation(s)
- Astrid Johannesson Hjelholt
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark; (O.F.); (M.F.K.)
- Department of Biomedicine, Aarhus University, Høegh-Guldbergs Gade 10, 8000 Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
| | - Cecilia Bergh
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Örebro University, S-701 82 Örebro, Sweden;
| | - Deepak L. Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, One Gustave L. Levi Place, P.O. Box 1030, New York, NY 10029-6574, USA;
| | - Ole Fröbert
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark; (O.F.); (M.F.K.)
- Department of Clinical Pharmacology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
- Faculty of Health, Department of Cardiology, Örebro University, SE-701 82 Örebro, Sweden
| | - Mads Fuglsang Kjolby
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark; (O.F.); (M.F.K.)
- Department of Biomedicine, Aarhus University, Høegh-Guldbergs Gade 10, 8000 Aarhus, Denmark
- Department of Clinical Pharmacology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark
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10
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Qureshi FM, Panzer JK, Põder J, Malek TR, Caicedo A. Immunotherapy With Low-Dose IL-2/CD25 Prevents β-Cell Dysfunction and Dysglycemia in Prediabetic NOD Mice. Diabetes 2023; 72:769-780. [PMID: 36939730 PMCID: PMC10202767 DOI: 10.2337/db22-0482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 03/15/2023] [Indexed: 03/21/2023]
Abstract
Low-dose IL-2 is a promising immunotherapy in clinical trials for treating type 1 diabetes. A new IL-2 analog, IL-2/CD25 fusion protein, has been shown to more efficiently delay or prevent diabetes in NOD mice by expanding the population of activated regulatory T cells. This therapy is intended for use before clinical diagnosis, in the early stages of type 1 diabetes progression. During this prediabetic period, there is a chronic decline in β-cell function that has long-term implications for disease pathogenesis. Yet, to date, the effects of IL-2/CD25 on β-cell function have not been evaluated. In this study, we treated prediabetic NOD mice with low-dose mouse IL-2/CD25 over 5 weeks and determined its impact on β-cell function. This treatment limited the progressive impairment of glucose tolerance and insulin secretion typical of the later stages of prediabetes. Intracellular Ca2+ responses to glucose in β-cells became more robust and synchronous, indicating that changing the local immune cell infiltrate with IL-2/CD25 preserved β-cell function even after treatment cessation. Our study thus provides mechanistic insight and serves as a steppingstone for future research using low-dose IL-2/CD25 immunotherapy in patients. ARTICLE HIGHLIGHTS Immunotherapies such as IL-2/CD25 are known to prevent or delay diabetes. However, their impact on individual β-cell function is not yet understood. Female NOD mice progress from stage 1 to 2 pre-type 1 diabetes between 12 and 17 weeks. Treatment with mouse IL-2 (mIL-2)/CD25 prevents this progression even after treatment cessation. Individual β-cell function (measured via intracellular Ca2+ responses to glucose) declines during the pathogenesis of type 1 diabetes. Treatment with mIL-2/CD25 therapy limits β-cell dysfunction, and function continues to improve after treatment cessation. Insulin secretion is improved with mIL-2/CD25 therapy.
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Affiliation(s)
- Farhan M. Qureshi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Department of Molecular, Cell and Developmental Biology, University of Miami Miller School of Medicine, Miami, FL
- Medical Scientist Training Program, University of Miami Miller School of Medicine, Miami, FL
| | - Julia K. Panzer
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - Janika Põder
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL
| | - Thomas R. Malek
- Department of Microbiology and Immunology, University of Miami Miller School of Medicine, Miami, FL
| | - Alejandro Caicedo
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
- Department of Molecular, Cell and Developmental Biology, University of Miami Miller School of Medicine, Miami, FL
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11
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Pinheiro MM, Pinheiro FMM, de Arruda MM, Beato GM, Verde GACL, Bianchini G, Casalenuovo PRM, Argolo AAA, de Souza LT, Pessoa FG, Hirose TS, Senra EF, Ricordi C, Fabbri A, Infante M, Diniz SN. Association between sitagliptin plus vitamin D3 (VIDPP-4i) use and clinical remission in patients with new-onset type 1 diabetes: a retrospective case-control study. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 67:e000652. [PMID: 37249465 PMCID: PMC10665061 DOI: 10.20945/2359-3997000000652] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 03/15/2023] [Indexed: 05/31/2023]
Abstract
Objective The occurrence of partial remission (honeymoon phase) in type 1 diabetes (T1D) has been associated with a reduced risk of chronic microvascular complications of diabetes. We have published case reports showing that a combination therapy with the DPP-4 inhibitor sitagliptin plus vitamin D3 (VIDPP-4i) can prolong the honeymoon phase in patients with new-onset T1D. In the present case-control study, we investigated the frequency of occurrence of clinical remission (CR) in patients with new-onset T1D after VIDPP-4i treatment. Subjects and methods In this case-control study, we collected data spanning 10 years from medical records of 46 patients (23 females) recently diagnosed with T1D. Overall, 27 participants with CR (insulin dose-adjusted glycated hemoglobin [IDAA1c] ≤ 9) at 12 or 24 months composed the case group, and 19 participants without CR served as the control group. Chi-square with Yates correction was used to analyze the association between VIDPP-4i use and CR, and odds ratio (OR) was used to determine the chance of CR due to VIDPP-4i treatment exposure. Results In all, 37 patients (80.4%) experienced CR at some time over 24 months. The mean CR duration was 13.15 ± 9.91 months. Treatment with VIDPP-4i was significantly associated with CR. At 24 months, the OR of CR after VIDPP-4i exposure was 9.0 (95% confidence interval [CI] 2.21-30.18, p = 0.0036). Additionally, 9 (33.6%) and 4 (14.8%) patients in the VIDPP-4i group experienced insulin-free CR at 12 and 24 months, respectively. Conclusion Therapy with VIDPP-4i was associated with a higher frequency and duration of the honeymoon phase. Randomized controlled trials are needed to confirm these findings.
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Affiliation(s)
- Marcelo Maia Pinheiro
- Univag Centro Universitário, Várzea Grande, MT, Brasil,
- Universidade Anhanguera, São Paulo, SP, Brasil
- Beta Cell Center Diabetes & Endocrinologia, Cuiabá, MT, Brasil
| | - Felipe Moura Maia Pinheiro
- Hospital das Clínicas, Faculdade de Medicina de São Paulo, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | | | | | | | | | | | | | | | | | | | - Camillo Ricordi
- Diabetes Research Institute (DRI) and Cell Transplant Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Andrea Fabbri
- Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Marco Infante
- Diabetes Research Institute (DRI) and Cell Transplant Center, University of Miami Miller School of Medicine, Miami, FL, USA
- Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN), Rome, Italy
- UniCamillus, Saint Camillus International University of Health Sciences, Rome, Italy
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12
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Xia Z, You W, Li Y, Li F, Hao S, Sun Y, Li N, Lin L, Dou J, Su X, Zhai Q, Zuo Y, Zhang Y, Gaisano HY, Zheng D, He Y, Jiang J. Association between residual islet beta-cell function and achieving the target of time in range in inpatients with type 2 diabetes undergoing antidiabetic treatment: An observation study. Diabetes Obes Metab 2023; 25:1714-1722. [PMID: 36811214 DOI: 10.1111/dom.15026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Revised: 02/06/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023]
Abstract
AIM To assess whether the beta-cell function of inpatients undergoing antidiabetic treatment influences achieving time in range (TIR) and time above range (TAR) targets. MATERIALS AND METHODS This cross-sectional study included 180 inpatients with type 2 diabetes. TIR and TAR were assessed by a continuous glucose monitoring system, with target achievement defined as TIR more than 70% and TAR less than 25%. Beta-cell function was assessed by the insulin secretion-sensitivity index-2 (ISSI2). RESULTS Following antidiabetic treatment, logistic regression analysis showed that lower ISSI2 was associated with a decreased number of inpatients achieving TIR (OR = 3.10, 95% CI: 1.19-8.06) and TAR (OR = 3.40, 95% CI: 1.35-8.55) targets after adjusting for potential confounders. Similar associations still existed in those participants treated with insulin secretagogues (TIR: OR = 2.91, 95% CI: 0.90-9.36, P = .07; TAR, OR = 3.14, 95% CI: 1.01-9.80) or adequate insulin therapy (TIR: OR = 2.84, 95% CI: 0.91-8.81, P = .07; TAR, OR = 3.24, 95% CI: 1.08-9.67). Furthermore, receiver operating characteristic curves showed that the diagnostic value of the ISSI2 for achieving TIR and TAR targets was 0.73 (95% CI: 0.66-0.80) and 0.71 (95% CI: 0.63-0.79), respectively. CONCLUSIONS Beta-cell function was associated with achieving TIR and TAR targets. Stimulating insulin secretion or exogenous insulin treatment could not overcome the disadvantage of lower beta-cell function on glycaemic control.
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Affiliation(s)
- Zhang Xia
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Wenjun You
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
| | - Yuhao Li
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Feng Li
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
- Institute for Chronic Disease Management, Jining No.1 People's Hospital, Jining, China
| | - Shuai Hao
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
| | - Yihan Sun
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
| | - Na Li
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
| | - Lu Lin
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Jingtao Dou
- Department of Endocrinology, The First Medical Center, Chinese PLA General Hospital, Beijing, China
| | - Xin Su
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Qi Zhai
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yingting Zuo
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Yibo Zhang
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Herbert Y Gaisano
- Departments of Medication and Physiology, University of Toronto, Toronto, Ontario, Canada
| | - Deqiang Zheng
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Yan He
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
- Beijing Municipal Key Laboratory of Clinical Epidemiology, Beijing, China
| | - Jiajia Jiang
- Department of Endocrinology, Jining No.1 People's Hospital, Jining, China
- Institute for Chronic Disease Management, Jining No.1 People's Hospital, Jining, China
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13
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Reddy R, Dayal D, Sachdeva N, Attri SV, Gupta VK. Combination therapy with lansoprazole and cholecalciferol is associated with a slower decline in residual beta-cell function and lower insulin requirements in children with recent onset type 1 diabetes: results of a pilot study. EINSTEIN-SAO PAULO 2022; 20:eAO0149. [DOI: 10.31744/einstein_journal/2022ao0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/05/2022] [Indexed: 11/13/2022] Open
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14
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Grönberg A, Espes D, Carlsson PO, Ludvigsson J. Higher risk of severe hypoglycemia in children and adolescents with a rapid loss of C-peptide during the first 6 years after type 1 diabetes diagnosis. BMJ Open Diabetes Res Care 2022; 10:10/6/e002991. [PMID: 36384886 PMCID: PMC9670837 DOI: 10.1136/bmjdrc-2022-002991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The progression to insulin deficiency in type 1 diabetes is heterogenous. This study aimed to identify early characteristics associated with rapid or slow decline of beta-cell function and how it affects the clinical course. RESEARCH DESIGN AND METHODS Stimulated C-peptide was assessed by mixed meal tolerance test in 50 children (<18 years) during 2004-2017, at regular intervals for 6 years from type 1 diabetes diagnosis. 40% of the children had a rapid decline of stimulated C-peptide defined as no measurable C-peptide (<0.03 nmol/L) 30 months after diagnosis. RESULTS At diagnosis, higher frequencies of detectable glutamic acid decarboxylase antibodies (GADA) and IA-2A (p=0.027) were associated with rapid loss of beta-cell function. C-peptide was predicted positively by age at 18 months (p=0.017) and 30 months duration (p=0.038). BMI SD scores (BMISDS) at diagnosis predicted higher C-peptide at diagnosis (p=0.006), 3 months (p=0.002), 9 months (p=0.005), 30 months (p=0.022), 3 years (p=0.009), 4 years (p=0.016) and 6 years (p=0.026), whereas high HbA1c and blood glucose at diagnosis predicted a lower C-peptide at diagnosis (p=<0.001) for both comparisons. Both GADA and IA-2A were negative predictors of C-peptide at 9 months (p=0.011), 18 months (p=0.008) and 30 months (p<0.001). Ten children had 22 events of severe hypoglycemia, and they had lower mean C-peptide at 18 months (p=0.025), 30 months (p=0.008) and 6 years (p=0.018) compared with others. Seven of them had a rapid decline of C-peptide (p=0.030), and the odds to experience a severe hypoglycemia were nearly fivefold increased (OR=4.846, p=0.04). CONCLUSIONS Low age and presence of multiple autoantibodies at diagnosis predicts a rapid loss of beta-cell function in children with type 1 diabetes. Low C-peptide is associated with an increased risk of severe hypoglycemia and higher Hemoglobin A1C. A high BMISDS at diagnosis is predictive of remaining beta-cell function during the 6 years of follow-up.
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Affiliation(s)
- Annika Grönberg
- Department of Women's and Children's Health, Uppsala Universitet Institutionen for kvinnors och barns halsa, Uppsala, Sweden
| | - Daniel Espes
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Science for Life Laboratory, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Per-Ola Carlsson
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- Science for Life Laboratory, Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden
| | - Johnny Ludvigsson
- Department of Biomedical and Clinical Scienses, Linkopings Universitet, Linkoping, Sweden
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15
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Li GH, Huang K, Dong GP, Zhang JW, Gong CX, Luo FH, Luo XP, Wang CL, Zhu M, Li P, Wang L, Fu JF. Clinical Incidence and Characteristics of Newly Diagnosed Type 1 Diabetes in Chinese Children and Adolescents: A Nationwide Registry Study of 34 Medical Centers. Front Pediatr 2022; 10:888370. [PMID: 35783304 PMCID: PMC9242427 DOI: 10.3389/fped.2022.888370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/19/2022] [Indexed: 12/01/2022] Open
Abstract
Objective To investigate the clinical incidence and characteristics of type 1 diabetes mellitus (T1DM) of children and adolescents at the time of initial diagnosis in China. Methods Data on all pediatric patients with newly diagnosed T1DM were retrospectively collected from 34 medical centers in 25 major cities in China from January 2015 to January 2020. Patients were classified into three age groups: <5 years, 5 to <10 years, and ≥10 years of age. The same patient population was also categorized into diabetic ketoacidosis (DKA) and non-DKA groups based on clinical criteria. Results The mean annual clinical incidence of T1DM was 3.16/100,000 from the years 2015 to 2019. A total of 6,544 patients with newly diagnosed T1DM aged 0-16 years (median 7.84 ± 3.8) were studied [ages <5 years (29.3%), 5 to <10 years (38.7%), and ≥10 years (32%)], 52.4% of them were women. In total, 90.5% of the cases were occurred in individuals without a family history. Patients had lower C-peptide (CP) and body mass index (BMI) z scores when compared with healthy children, 41.8% of them had measurable T1DM-related antibodies and 52.7% had DKA. Among all three age groups, the <5 years group had the lowest BMI z score, CP, and glycated hemoglobin (HbA1c) on average, while it had the highest incidence rate of DKA (56.9%). Compared to the non-DKA group, the DKA group was significantly younger, with a lower BMI z score and CP, higher antibody positive rate, HbA1c, and the rate of insulin pump therapy. Conclusion The clinical incidence of T1DM in children and adolescents in China was 3.16/100,000. Patients with DKA at the first diagnosis of T1DM have a worse β-cell function. Public health measures for the prevention and treatment of T1DM should focus on preschoolers (aged <5 years) in particular, considering the severity and the highest frequency of DKA in this age group. More efforts should be dedicated to early screening and diagnosis of the T1DM.
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Affiliation(s)
- Guo-Hua Li
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Ke Huang
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guan-Ping Dong
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Jian-Wei Zhang
- Department of Pediatrics, Shaoxing Maternal and Child Health Care Hospital, Hangzhou, China
| | - Chun-Xiu Gong
- Endocrinology, Genetics, and Metabolism, Beijing Diabetes Center for Children and Adolescents, Medical Genetics Department, Beijing Children's Hospital, Beijing, China
| | - Fei-Hong Luo
- Department of Pediatric Endocrinology and Inherited Metabolic Diseases, Children's Hospital of Fudan University, Shanghai, China
| | - Xiao-Ping Luo
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun-Lin Wang
- Department of Pediatric, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zhu
- Department of Endocrinology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Pin Li
- Department of Endocrinology, Shanghai Children's Hospital of Shanghai Jiao Tong University, Shanghai, China
| | - Ling Wang
- Laboratory for Translational Genetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - Jun-Fen Fu
- The Children's Hospital of the Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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16
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Liu YF, Powrie J, Arif S, Yang JH, Williams E, Khatri L, Joshi M, Lhuillier L, Fountoulakis N, Smith E, Beam C, Lorenc A, Peakman M, Tree T. Immune and Metabolic Effects of Antigen-Specific Immunotherapy Using Multiple β-Cell Peptides in Type 1 Diabetes. Diabetes 2022; 71:722-732. [PMID: 35073398 PMCID: PMC8965665 DOI: 10.2337/db21-0728] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 01/15/2022] [Indexed: 01/11/2023]
Abstract
Type 1 diabetes is characterized by a loss of tolerance to pancreatic β-cell autoantigens and defects in regulatory T-cell (Treg) function. In preclinical models, immunotherapy with MHC-selective, autoantigenic peptides restores immune tolerance, prevents diabetes, and shows greater potency when multiple peptides are used. To translate this strategy into the clinical setting, we administered a mixture of six HLA-DRB1*0401-selective, β-cell peptides intradermally to patients with recent-onset type 1 diabetes possessing this genotype in a randomized placebo-controlled study at monthly doses of 10, 100, and 500 μg for 24 weeks. Stimulated C-peptide (measuring insulin functional reserve) had declined in all placebo subjects at 24 weeks but was maintained at ≥100% baseline levels in one-half of the treated group. Treatment was accompanied by significant changes in islet-specific immune responses and a dose-dependent increase in Treg expression of the canonical transcription factor FOXP3 and changes in Treg gene expression. In this first-in-human study, multiple-peptide immunotherapy shows promise as a strategy to correct immune regulatory defects fundamental to the pathobiology of autoimmune diabetes.
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Affiliation(s)
- Yuk-Fun Liu
- Department of Diabetes, School of Life Course Sciences, King’s College London, London, U.K
- Department of Diabetes and Endocrinology, Guy’s and St. Thomas’ NHS Foundation Trust, London, U.K
- Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London, U.K
| | - Jake Powrie
- Department of Diabetes and Endocrinology, Guy’s and St. Thomas’ NHS Foundation Trust, London, U.K
| | - Sefina Arif
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
| | - Jennie H.M. Yang
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
- National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust and Kings College London, London, U.K
| | - Evangelia Williams
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
- National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust and Kings College London, London, U.K
| | - Leena Khatri
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
- National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust and Kings College London, London, U.K
| | - Mamta Joshi
- Department of Diabetes and Endocrinology, Guy’s and St. Thomas’ NHS Foundation Trust, London, U.K
| | - Loic Lhuillier
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
| | - Nikolaos Fountoulakis
- Department of Diabetes and Endocrinology, Guy’s and St. Thomas’ NHS Foundation Trust, London, U.K
| | | | - Craig Beam
- Department of Biomedical Sciences, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, MI
| | - Anna Lorenc
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
| | - Mark Peakman
- Department of Diabetes, School of Life Course Sciences, King’s College London, London, U.K
- Department of Diabetes and Endocrinology, Guy’s and St. Thomas’ NHS Foundation Trust, London, U.K
- Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London, U.K
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
- Corresponding authors: Mark Peakman, , and Timothy Tree,
| | - Timothy Tree
- Department of Immunobiology, School of Immunology and Microbial Sciences, King’s College London, London, U.K
- National Institute for Health Research Biomedical Research Centre, Guy’s and St. Thomas’ NHS Foundation Trust and Kings College London, London, U.K
- Corresponding authors: Mark Peakman, , and Timothy Tree,
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17
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Nwosu BU. The Theory of Hyperlipidemic Memory of Type 1 Diabetes. Front Endocrinol (Lausanne) 2022; 13:819544. [PMID: 35432186 PMCID: PMC9009047 DOI: 10.3389/fendo.2022.819544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
A literature search was conducted to identify publications addressing the early phases of lipid phenotypes in children and adults with either type 1 diabetes or type 2 diabetes. Medline, EMBASE, and Ovid were searched using the following search terms: clinical remission, partial remission, partial clinical remission, honeymoon phase, C-peptide, type 1 or 2 diabetes, children, pediatric type 1 or 2 diabetes, and paediatrics type 1 or 2 diabetes, adults, adult type 1 or type 2 diabetes. Partial clinical remission (PR) of type 1 diabetes (T1D) is characterized by continued endogenous production of insulin and C-peptide following the diagnosis and the introduction of exogenous insulin therapy. PR is associated with improved glycemic control and reduced prevalence of diabetes complications. The theory of hyperglycemic memory was proposed to explain this concept of improved glycemic outcomes in remitters (those who experienced PR) versus non-remitters (those who did not experience PR). However, this theory is incomplete as it does not explain the dichotomy in early lipid phenotypes in T1D based on PR status, which is an understudied area in diabetology and lipidology. To fill this knowledge gap, we propose the Theory of Hyperlipidemic Memory of T1D. This theory is premised on our 5-year research on early post-diagnostic dichotomy in lipid phenotypes between remitters and non-remitters across the lifespan. It provides a more rigorous explanation for the differences in lifelong atherosclerotic cardiovascular disease (ASCVD) risk between remitters and non-remitters. We conducted 4 clinical studies in pediatric and adult subjects with diabetes mellitus to characterize the particulars of the hyperlipidemic memory. In the first investigation, we explored the impact of the presence or absence of PR on lipid parameters in children and adolescents with T1D. In the second, we investigated whether pubertal maturation influenced our findings in T1D; and whether these findings could be replicated in healthy, non-diabetic children and adolescents. In the third, we leveraged our findings from T1D and controls to investigate the mechanisms of early lipid changes in T2D by comparing the earliest lipid phenotype of subjects with type 2 diabetes (T2D) to those of remitters, non-remitters, and controls. In the fourth, we investigated the impact of PR on the earliest lipid phenotypes in adults with T1D and compared these early lipid data to those of T2D subjects and controls. This body of work across the lifespan in children, adolescents, and adults supports the Theory of Hyperlipidemic Memory. This new theory clarifies why PR largely determines the risks for early-phase dyslipidemia, mid-term microvascular disease risk, and long-term ASCVD risk in subjects with T1D.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Division of Endocrinology, Department of Pediatrics, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, United States
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA, United States
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18
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Suh J, Lee HI, Lee M, Song K, Choi HS, Kwon A, Kim HS, Chae HW. Insulin Requirement and Complications Associated With Serum C-Peptide Decline in Patients With Type 1 Diabetes Mellitus During 15 Years After Diagnosis. Front Endocrinol (Lausanne) 2022; 13:869204. [PMID: 35518934 PMCID: PMC9061978 DOI: 10.3389/fendo.2022.869204] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/22/2022] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE C-peptide is conventionally used in assessing pancreatic function in patients with diabetes mellitus. The clinical significance of this molecule during the course of type 1 diabetes mellitus (T1DM) has been recently revisited. This study aimed to investigate the natural course of C-peptide in T1DM patients over the period of 15 years and analyze the association between the residual C-peptide and diabetes complications. METHODS This retrospective study included a total of 234 children and adolescents with T1DM. Patient data including sex, age at diagnosis, anthropometric measures, daily insulin dose, serum HbA1c, post-prandial serum C-peptide levels, lipid profiles, and diabetic complications at the time of diagnosis and 1, 3, 5, 10, and 15 years after diagnosis were retrospectively collected. RESULTS Among the 234 patients, 101 were men and 133 were women, and the mean patient age at initial diagnosis was 8.3 years. Serum C-peptide decreased constantly since the initial diagnosis, and showed a significant decline at 3 years after diagnosis. At 15 years after diagnosis, only 26.2% of patients had detectable serum C-peptide levels. The subgroup with older patients and patients with higher BMI standard deviation score showed higher mean serum C-peptide, but the group-by-time results were not significant, respectively. Patients with higher serum C-peptide required lower doses of insulin and had fewer events of diabetic ketoacidosis. CONCLUSION Serum C-peptide decreased consistently since diagnosis of T1DM, showing a significant decline after 3 years. Patients with residual C-peptide required a lower dose of insulin and had a lower risk for diabetic ketoacidosis.
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19
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Abstract
INTRODUCTION Despite advances in technology including the development of more sophisticated methods of monitoring blood glucose and delivering insulin, many individuals with type 1 diabetes continue to experience significant challenges in optimizing glycaemic control. Alternative treatment approaches to insulin are required. Increasing efforts have focused on developing treatments aimed at targeting the underlying disease process to modulate the immune system, maximize beta cell function and enhance endogenous insulin production and action. SOURCES OF DATA Literature searches with keywords 'Type 1 diabetes and immunotherapy', publications relating to clinical trials of immunotherapy in type 1 diabetes. AREAS OF AGREEMENT Insulin therapy is insufficient to achieve optimal glycaemic control in many individuals with type 1 diabetes, and new treatment approaches are required. Studies have showed promising results for the use of immunotherapy as a means of delaying disease onset and progression. AREAS OF CONTROVERSY The optimal way of identifying individuals most likely to benefit from immunotherapies. GROWING POINTS A better understanding of the natural history of type 1 diabetes has made it possible to identify individuals who have developed autoimmunity but have not yet progressed to clinical diabetes, offering opportunities not only to develop treatments that delay disease progression, but prevent its development in the first place. A consensus on how to identify individuals who may benefit from immunotherapy to prevent disease onset is needed. AREAS TIMELY FOR DEVELOPING RESEARCH The development of optimal strategies for preventing and delaying progression of type 1 diabetes, and monitoring the response to immunointervention.
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Affiliation(s)
- L A Allen
- Diabetes Research Group, Cardiff University, Cardiff, UK
| | - C M Dayan
- Diabetes Research Group, Cardiff University, Cardiff, UK
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20
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Tatovic D, Dayan CM. Replacing insulin with immunotherapy: Time for a paradigm change in Type 1 diabetes. Diabet Med 2021; 38:e14696. [PMID: 34555209 DOI: 10.1111/dme.14696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/22/2021] [Indexed: 12/17/2022]
Abstract
For almost a hundred years, the management of Type 1 diabetes has not advanced beyond insulin replacement. However, insulin does not provide satisfactory glycaemic control in the majority of individuals and there remains a major unmet need for novel treatments for Type 1 diabetes. Immunomodulation to preserve beta-cell function offers the prospect of making treatment with insulin easier and/or preventing the need for insulin, particularly when it comes to novel low-risk immunotherapies. Led by the concept that the best insulin-producing cell is a patient's own beta-cell, the Type 1 diabetes scientific community has a challenging task ahead-to fundamentally change the management of this devastating disease by using low-risk immunotherapy to preserve endogenous beta-cell function and make metabolic control substantially easier. In that way, insulin and/or beta-cell replacement (stem cell or transplantation) should in the future be considered rescue therapies reserved for delayed presentations.
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Affiliation(s)
- Danijela Tatovic
- Diabetes and Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Diabetes and Autoimmunity Research Group, Cardiff University School of Medicine, Cardiff, UK
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21
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Gregory JW, Carter K, Cheung WY, Holland G, Bowen-Morris J, Luzio S, Dunseath G, Tree T, Yang JHM, Marwaha A, Ali MA, Bashir N, Hutchings HA, Fegan GW, Stenson R, Hiles S, Marques-Jones S, Brown A, Tatovic D, Dayan C. Phase II multicentre, double-blind, randomised trial of ustekinumab in adolescents with new-onset type 1 diabetes (USTEK1D): trial protocol. BMJ Open 2021; 11:e049595. [PMID: 34663658 PMCID: PMC8524290 DOI: 10.1136/bmjopen-2021-049595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Most individuals newly diagnosed with type 1 diabetes (T1D) have 10%-20% of beta-cell function remaining at the time of diagnosis. Preservation of residual beta-cell function at diagnosis may improve glycaemic control and reduce longer-term complications.Immunotherapy has the potential to preserve endogenous beta-cell function and thereby improve metabolic control even in poorly compliant individuals. We propose to test ustekinumab (STELARA), a targeted and well-tolerated therapy that may halt T-cell and cytokine-mediated destruction of beta-cells in the pancreas at the time of diagnosis. METHODS AND ANALYSIS This is a double-blind phase II study to assess the safety and efficacy of ustekinumab in 72 children and adolescents aged 12-18 with new-onset T1D.Participants should have evidence of residual functioning beta-cells (serum C-peptide level >0.2nmol/L in the mixed-meal tolerance test (MMTT) and be positive for at least one islet autoantibody (GAD, IA-2, ZnT8) to be eligible.Participants will be given ustekinumab/placebo subcutaneously at weeks 0, 4 and 12, 20, 28, 36 and 44 in a dose depending on the body weight and will be followed for 12 months after dose 1.MMTTs will be used to measure the efficacy of ustekinumab for preserving C-peptide area under the curve at week 52 compared with placebo. Secondary objectives include further investigations into the efficacy and safety of ustekinumab, patient and parent questionnaires, alternative methods for measuring insulin production and exploratory mechanistic work. ETHICS AND DISSEMINATION This trial received research ethics approval from the Wales Research Ethics Committee 3 in September 2018 and began recruiting in December 2018.The results will be disseminated using highly accessed, peer-reviewed medical journals and presented at conferences. TRIAL REGISTRATION NUMBER ISRCTN14274380.
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Affiliation(s)
- John W Gregory
- Division of Population Medicine, Cardiff University, Cardiff, South Glamorgan, UK
| | - Kymberley Carter
- Swansea Trials Unit (STU), Swansea University, Swansea, West Glamorgan, UK
| | - Wai Yee Cheung
- Diabetes Research Unit Cymru (DRUC), Swansea University, Swansea, West Glamorgan, UK
| | - Gail Holland
- Swansea Trials Unit (STU), Swansea University, Swansea, West Glamorgan, UK
| | - Jane Bowen-Morris
- Diabetes Research Group, Cardiff University, Cardiff, South Glamorgan, UK
| | - Stephen Luzio
- Diabetes Research Unit Cymru (DRUC), Swansea University, Swansea, West Glamorgan, UK
| | - Gareth Dunseath
- Diabetes Research Unit Cymru (DRUC), Swansea University, Swansea, West Glamorgan, UK
| | - Timothy Tree
- Peter Gorer Department of Immunobiology, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Center (BRC), Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Jennie Hsiu Mien Yang
- Peter Gorer Department of Immunobiology, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Center (BRC), Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Ashish Marwaha
- Department of Molecular Genetics, Cumming School of Medicine, The University of Calgary, Calgary, Alberta, Canada
| | | | - Nadim Bashir
- Swansea Trials Unit (STU), Swansea University, Swansea, West Glamorgan, UK
| | | | - Greg W Fegan
- Swansea Trials Unit (STU), Swansea University, Swansea, West Glamorgan, UK
| | - Rachel Stenson
- Diabetes Research Group, Cardiff University, Cardiff, South Glamorgan, UK
| | - Stephen Hiles
- Swansea Trials Unit (STU), Swansea University, Swansea, West Glamorgan, UK
| | | | - Amy Brown
- Patient and Public Representative, Cardiff, UK
| | - Danijela Tatovic
- Diabetes Research Group, Cardiff University, Cardiff, South Glamorgan, UK
| | - Colin Dayan
- Diabetes Research Group, Cardiff University, Cardiff, South Glamorgan, UK
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22
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Januszewski AS, Cho YH, Joglekar MV, Farr RJ, Scott ES, Wong WKM, Carroll LM, Loh YW, Benitez-Aguirre PZ, Keech AC, O'Neal DN, Craig ME, Hardikar AA, Donaghue KC, Jenkins AJ. Insulin micro-secretion in Type 1 diabetes and related microRNA profiles. Sci Rep 2021; 11:11727. [PMID: 34083567 PMCID: PMC8175359 DOI: 10.1038/s41598-021-90856-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 05/13/2021] [Indexed: 12/22/2022] Open
Abstract
The aim of this cross-sectional study was to compare plasma C-peptide presence and levels in people without diabetes (CON) and with Type 1 diabetes and relate C-peptide status to clinical factors. In a subset we evaluated 50 microRNAs (miRs) previously implicated in beta-cell death and associations with clinical status and C-peptide levels. Diabetes age of onset was stratified as adult (≥ 18 y.o) or childhood (< 18 y.o.), and diabetes duration was stratified as ≤ 10 years, 10–20 years and > 20 years. Plasma C-peptide was measured by ultrasensitive ELISA. Plasma miRs were quantified using TaqMan probe-primer mix on an OpenArray platform. C-peptide was detectable in 55.3% of (n = 349) people with diabetes, including 64.1% of adults and 34.0% of youth with diabetes, p < 0.0001 and in all (n = 253) participants without diabetes (CON). C-peptide levels, when detectable, were lower in the individuals with diabetes than in the CON group [median lower quartile (LQ)–upper quartile (UQ)] 5.0 (2.6–28.7) versus 650.9 (401.2–732.4) pmol/L respectively, p < 0.0001 and lower in childhood versus adult-onset diabetes [median (LQ–UQ) 4.2 (2.6–12.2) pmol/L vs. 8.0 (2.3–80.5) pmol/L, p = 0.02, respectively]. In the childhood-onset group more people with longer diabetes duration (> 20 years) had detectable C-peptide (60%) than in those with shorter diabetes duration (39%, p for trend < 0.05).
Nine miRs significantly correlated with detectable C-peptide levels in people with diabetes and 16 miRs correlated with C-peptide levels in CON. Our cross-sectional study results are supportive of (a) greater beta-cell function loss in younger onset Type 1 diabetes; (b) persistent insulin secretion in adult-onset diabetes and possibly regenerative secretion in childhood-onset long diabetes duration; and (c) relationships of C-peptide levels with circulating miRs. Confirmatory clinical studies and related basic science studies are merited.
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Affiliation(s)
- Andrzej S Januszewski
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia. .,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
| | - Yoon Hi Cho
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Mugdha V Joglekar
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Ryan J Farr
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Emma S Scott
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Wilson K M Wong
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Luke M Carroll
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Yik W Loh
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Paul Z Benitez-Aguirre
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Anthony C Keech
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - David N O'Neal
- Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Maria E Craig
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Anandwardhan A Hardikar
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.,School of Medicine, Western Sydney University, Sydney, NSW, Australia.,Department of Science and Environment, Roskilde University, Copenhagen, Denmark
| | - Kim C Donaghue
- Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW, Australia.,Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Alicia J Jenkins
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia. .,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia.
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Lam A, Dayan C, Herold KC. A little help from residual β cells has long-lasting clinical benefits. J Clin Invest 2021; 131:143683. [PMID: 33529163 PMCID: PMC7843219 DOI: 10.1172/jci143683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Following type 1 diabetes (T1D) diagnosis, declining C-peptide levels reflect deteriorating β cell function. However, the precise C-peptide levels that indicate protection from severe hypoglycemia remain unknown. In this issue of the JCI, Gubitosi-Klug et al. studied participants from the landmark and ongoing Diabetes Control and Complications Trial (DCCT) and the Epidemiology of Diabetes Interventions and Complications (EDIC) study that had long-standing (about 35 years) T1D. The authors correlated severe hypoglycemia and other disease outcomes with residual C-peptide levels. While C-peptide secretion failed to associate with hemoglobin A1c (HbA1c) or microvascular complications, C-peptide levels greater than 0.03 nmol/L were linked with fewer episodes of severe hypoglycemia. These findings suggest that efforts to preserve finite β cell function early in T1D can have meaningful, long-standing health benefits for patients.
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Affiliation(s)
- Anna Lam
- University of Alberta, Edmonton, Alberta, Canada
| | - Colin Dayan
- Cardiff University School of Medicine, Cardiff, United Kingdom
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Narsale A, Lam B, Moya R, Lu T, Mandelli A, Gotuzzo I, Pessina B, Giamporcaro G, Geoffrey R, Buchanan K, Harris M, Bergot AS, Thomas R, Hessner MJ, Battaglia M, Serti E, Davies JD. CD4+CD25+CD127hi cell frequency predicts disease progression in type 1 diabetes. JCI Insight 2021; 6:136114. [PMID: 33301420 PMCID: PMC7934872 DOI: 10.1172/jci.insight.136114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Accepted: 12/02/2020] [Indexed: 12/16/2022] Open
Abstract
Transient partial remission, a period of low insulin requirement experienced by most patients soon after diagnosis, has been associated with mechanisms of immune regulation. A better understanding of such natural mechanisms of immune regulation might identify new targets for immunotherapies that reverse type 1 diabetes (T1D). In this study, using Cox model multivariate analysis, we validated our previous findings that patients with the highest frequency of CD4+CD25+CD127hi (127-hi) cells at diagnosis experience the longest partial remission, and we showed that the 127-hi cell population is a mix of Th1- and Th2-type cells, with a significant bias toward antiinflammatory Th2-type cells. In addition, we extended these findings to show that patients with the highest frequency of 127-hi cells at diagnosis were significantly more likely to maintain β cell function. Moreover, in patients treated with alefacept in the T1DAL clinical trial, the probability of responding favorably to the antiinflammatory drug was significantly higher in those with a higher frequency of 127-hi cells at diagnosis than those with a lower 127-hi cell frequency. These data are consistent with the hypothesis that 127-hi cells maintain an antiinflammatory environment that is permissive for partial remission, β cell survival, and response to antiinflammatory immunotherapy.
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Affiliation(s)
- Aditi Narsale
- San Diego Biomedical Research Institute, San Diego, California, USA
| | - Breanna Lam
- San Diego Biomedical Research Institute, San Diego, California, USA
| | - Rosa Moya
- San Diego Biomedical Research Institute, San Diego, California, USA
| | - TingTing Lu
- Immune Tolerance Network, Bethesda, Maryland, USA
| | - Alessandra Mandelli
- San Raffaele Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Milan, Italy
| | - Irene Gotuzzo
- San Raffaele Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Milan, Italy
| | - Benedetta Pessina
- San Raffaele Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Milan, Italy
| | - Gianmaria Giamporcaro
- San Raffaele Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Milan, Italy
| | - Rhonda Geoffrey
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kerry Buchanan
- Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia.,Department of Pediatric Endocrinology, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Mark Harris
- Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia.,Department of Pediatric Endocrinology, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Anne-Sophie Bergot
- Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
| | - Ranjeny Thomas
- Diamantina Institute, University of Queensland, Woolloongabba, Queensland, Australia
| | - Martin J Hessner
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Manuela Battaglia
- San Raffaele Diabetes Research Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Raffaele Hospital, Milan, Italy
| | | | - Joanna D Davies
- San Diego Biomedical Research Institute, San Diego, California, USA
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25
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Bektaş G, Önal H, Adal E. The factors relevant to partial remission in children with type 1 diabetes mellitus after measles vaccination: A retrospective study. J Med Virol 2020; 92:2955-2960. [PMID: 32108356 DOI: 10.1002/jmv.25734] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 02/25/2020] [Indexed: 01/05/2023]
Abstract
We aimed to identify the determinants of partial remission in patients with type 1 diabetes mellitus (DM), and whether there is an influence of vaccination against measles on partial remission. This was a retrospective study consisting of consecutive patients diagnosed with type 1 DM followed-up from 1 September 2010, through 30 November 2011. The study included children vaccinated within 3 months after diagnosis, and children unvaccinated during the first 12 months of the disease. The daily insulin dose, hemoglobin A1c, and C-peptide levels, and whether children are in partial remission based on the insulin dose-adjusted HbA1c were recorded at diagnosis and 3, 6, 9, 12, 24, and 36 months. A total of 55 children with type 1 DM were analyzed. Thirty-one patients (56.4%) reached partial remission during the follow-up period, whereas 24 of them did not. Patients with diabetic ketoacidosis (DKA) at diagnosis were less likely to reach partial remission than patients without DKA (odds ratio [OR], 0.24; 95% confidence interval [CI], 0.062-0.946; P = .038). Patients vaccinated against measles were more likely to be in partial remission than patients unvaccinated (OR, 4.2; 95% CI, 1.35-13; P = .011). Partial remission was significantly associated with the C-peptide level and insulin dosage at diagnosis P = .002; P = .013, respectively). The lack of DKA, higher C-peptide level, and lower insulin dosage at diagnosis, and vaccination against measles after diagnosis may have an influence on partial clinical remission in patients with new-onset type 1 DM.
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Affiliation(s)
- Gonca Bektaş
- Department of Pediatrics, Bakırkoy Dr. Sadi Konuk Research and Training Hospital, Istanbul, Turkey
| | - Hasan Önal
- Department of Pediatric Metabolic Diseases, Kanuni Sultan Süleyman Training and Research Hospital, Istanbul, Turkey
| | - Erdal Adal
- Department of Pediatric Endocrinology and Metabolism, Istanbul Medipol University, Istanbul, Turkey
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26
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Nwosu BU, Villalobos-Ortiz TR, Jasmin GA, Parajuli S, Zitek-Morrison E, Barton BA. Mechanisms and early patterns of dyslipidemia in pediatric type 1 and type 2 diabetes. J Pediatr Endocrinol Metab 2020; 33:1399-1408. [PMID: 33027052 PMCID: PMC9064486 DOI: 10.1515/jpem-2020-0220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/17/2020] [Indexed: 12/23/2022]
Abstract
Objectives The is no consensus on the early patterns of lipid-based cardiovascular disease (CVD) risk in youth with either type 1 diabetes (T1D) or type 2 diabetes (T2D). The aim was todetermine the differences in CVD risk, using lipid profiles, in children and adolescents with either T1D or T2D at the time of their first lipid assessment, after stratifying the T1D cohort into remitters and non-remitters based on their honeymoon history. Methods A cross-sectional study of 249 subjects consisting of 73 controls, 53 T2D subjects, and 123 T1D subjects stratified into remitters (n=44), and non-remitters (n=79). Partial clinical remission (PCR) was defined as insulin-dose adjusted HbA1c of ≤9. Pubertal status was determined by Tanner staging. Results After adjusting for age, sex, BMI, race, and pubertal status, T2D patients had significantly higher LDL-C compared to the controls (p=0.022), the remitters (p=0.029), but not the non-remitters (103.1 ± 5.9 mg/dL vs. 91.4 ± 4.2 mg/dL, p=0.49). Similarly, T2D patients had significantly higher non-HDL-C compared to the controls (p=0.006), the remitters (p=0.0002), but not the non-remitters (137.6 ± 7.1 mg/dL vs. 111.71 ± 5.0 mg/dL, p=0.053). Total cholesterol was also significantly higher in T2D patients compared to the controls (p=0.0005), the remitters (p=0.006) but not the non-remitters (183.5 ± 6.6 mg/dL vs. 166.2 ± 4.8 mg/dL, p=0.27). Conclusions Lack of the honeymoon phase in children and adolescents with T1D confers early and significantly increased lipid-based cardiovascular risk to these patients that is similar to the elevated cardiovascular risk seen in T2D.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Department of Pediatrics, Division of Endocrinology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Tony R Villalobos-Ortiz
- Department of Pediatrics, Division of Endocrinology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Gabrielle A Jasmin
- Department of Pediatrics, Division of Endocrinology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sadichchha Parajuli
- Department of Pediatrics, Division of Endocrinology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Emily Zitek-Morrison
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Bruce A Barton
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Influence of Age on Partial Clinical Remission among Children with Newly Diagnosed Type 1 Diabetes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17134801. [PMID: 32635304 PMCID: PMC7369868 DOI: 10.3390/ijerph17134801] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 06/17/2020] [Accepted: 06/30/2020] [Indexed: 02/06/2023]
Abstract
Partial clinical remission (PCR) is a transitory period characterized by the residual endogenous insulin secretion following type 1 diabetes (T1D) diagnosis and introducing the insulin therapy. Scientific interest in PCR has been recently increasing, as this phase could be crucial to preserve functional beta cells after T1D onset, also taking advantage of new therapeutic opportunities. The aim of this study was to assess the frequency, duration and associated factors of PCR in children newly diagnosed with T1D. Our cohort study included 167 pediatric patients aged 13.8 ± 4.1 years. The association of clinical and laboratory factors with the occurrence and duration of PCR was evaluated via logistic regression and multivariable generalized linear model, respectively. PCR occurred in 63.5% of the examined patients. Patients who achieved the remission phase were significantly older, and they had lower daily insulin requirement compared with non-remitters. PCR was positively associated to body mass index (OR = 1.11; p = 0.032), pH value (OR 49.02; p = 0.003) and c-peptide levels (OR 12.8; p = 0.002). The average duration of PCR was 13.4 months, and older age at diagnosis was the only predictor factor. Two years after diagnosis remitter patients had lower HbA1c and daily insulin requirement.
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28
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Neuman V, Pruhova S, Kulich M, Kolouskova S, Vosahlo J, Romanova M, Petruzelkova L, Obermannova B, Funda DP, Cinek O, Sumnik Z. Gluten-free diet in children with recent-onset type 1 diabetes: A 12-month intervention trial. Diabetes Obes Metab 2020; 22:866-872. [PMID: 31984648 DOI: 10.1111/dom.13974] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/14/2020] [Accepted: 01/15/2020] [Indexed: 12/17/2022]
Abstract
AIM To test whether a gluten-free diet (GFD) is associated with the deceleration of the decline in beta-cell capacity in non-coeliac children with recently diagnosed type 1 diabetes. METHODS Forty-five children (aged 10.2 ± 3.3 years) were recruited into a self-selected intervention trial: 26 started with a GFD within a median of 38 days postonset, whereas 19 remained on a standard diet. The main outcomes were the decline in C-peptide area under the curve (AUC) in mixed-meal tolerance tests (MMTTs) at 6 and 12 months relative to 1 month after diabetes onset and the difference in insulin dose, insulin dose-adjusted A1c (IDAA1c) and HbA1c assessed every 3 months. The adherence to the GFD was verified by immunoreactive gluten in the stool and by food questionnaires at every visit. Quality of life (QoL) questionnaires were administered to the participants at the end of the intervention at 12 months. The data were analysed as per protocol (in 39 subjects who duly completed the whole follow-up: 20 in the GFD group, 19 in the control group) by linear and longitudinal regression models adjusted for sex, age and baseline variables. RESULTS At 12 months, the difference in C-peptide AUC between subjects in the GFD group and controls was 205 pmol/L (95% CI -223 to 633; P = 0.34) in a model adjusted for age, sex and body weight, and for baseline insulin dose, MMTT C-peptide AUC and HbA1c assessed at 1 month after diagnosis. In a longitudinal analysis of all three time points adjusted for age, sex and body weight, C-peptide declined more slowly in the GFD group than in controls, with the difference in trends being 409 pmol/L/year (P = 0.04). The GFD group had a marginally lower insulin dose (by 0.15 U/kg/day; P = 0.07), a lower IDAA1c (by 1.37; P = 0.01) and a lower mean HbA1c (by 0.7% [7.8 mmol/mol]; P = 0.02) than those of the controls at 12 months. There was no appreciable difference between the groups in daily carbohydrate intake (P = 0.49) or in the QoL reported by the patients (P = 0.70) and their parents/caregivers (P = 0.59). CONCLUSIONS A GFD maintained over the first year after type 1 diabetes diagnosis was associated with better HbA1c and a prolonged partial remission period. There was a hint of slower C-peptide decline but the association was not strong enough to make definite conclusions.
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Affiliation(s)
- Vit Neuman
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Stepanka Pruhova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Kulich
- Department of Probability and Mathematical Statistics, Faculty of Mathematics and Physics, Charles University, Prague, Czech Republic
| | - Stanislava Kolouskova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jan Vosahlo
- Department of Pediatrics, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Martina Romanova
- Department of Pediatrics, 3rd Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Lenka Petruzelkova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Barbora Obermannova
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - David P Funda
- Institute of Microbiology of the Czech Academy of Sciences, Prague, Czech Republic
| | - Ondrej Cinek
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
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Roshandel D, Chen Z, Canty AJ, Bull SB, Natarajan R, Paterson AD. DNA methylation age calculators reveal association with diabetic neuropathy in type 1 diabetes. Clin Epigenetics 2020; 12:52. [PMID: 32248841 PMCID: PMC7132894 DOI: 10.1186/s13148-020-00840-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/15/2020] [Indexed: 12/14/2022] Open
Abstract
Background Many CpGs become hyper or hypo-methylated with age. Multiple methods have been developed by Horvath et al. to estimate DNA methylation (DNAm) age including Pan-tissue, Skin & Blood, PhenoAge, and GrimAge. Pan-tissue and Skin & Blood try to estimate chronological age in the normal population whereas PhenoAge and GrimAge use surrogate markers associated with mortality to estimate biological age and its departure from chronological age. Here, we applied Horvath’s four methods to calculate and compare DNAm age in 499 subjects with type 1 diabetes (T1D) from the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) study using DNAm data measured by Illumina EPIC array in the whole blood. Association of the four DNAm ages with development of diabetic complications including cardiovascular diseases (CVD), nephropathy, retinopathy, and neuropathy, and their risk factors were investigated. Results Pan-tissue and GrimAge were higher whereas Skin & Blood and PhenoAge were lower than chronological age (p < 0.0001). DNAm age was not associated with the risk of CVD or retinopathy over 18–20 years after DNAm measurement. However, higher PhenoAge (β = 0.023, p = 0.007) and GrimAge (β = 0.029, p = 0.002) were associated with higher albumin excretion rate (AER), an indicator of diabetic renal disease, measured over time. GrimAge was also associated with development of both diabetic peripheral neuropathy (OR = 1.07, p = 9.24E−3) and cardiovascular autonomic neuropathy (OR = 1.06, p = 0.011). Both HbA1c (β = 0.38, p = 0.026) and T1D duration (β = 0.01, p = 0.043) were associated with higher PhenoAge. Employment (β = − 1.99, p = 0.045) and leisure time (β = − 0.81, p = 0.022) physical activity were associated with lower Pan-tissue and Skin & Blood, respectively. BMI (β = 0.09, p = 0.048) and current smoking (β = 7.13, p = 9.03E−50) were positively associated with Skin & Blood and GrimAge, respectively. Blood pressure, lipid levels, pulse rate, and alcohol consumption were not associated with DNAm age regardless of the method used. Conclusions Various methods of measuring DNAm age are sub-optimal in detecting people at higher risk of developing diabetic complications although some work better than the others.
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Affiliation(s)
- Delnaz Roshandel
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, ON, Canada
| | - Zhuo Chen
- Department of Diabetes Complications and Metabolism, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Angelo J Canty
- Department of Mathematics and Statistics, McMaster University, Hamilton, ON, Canada
| | - Shelley B Bull
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rama Natarajan
- Department of Diabetes Complications and Metabolism, Beckman Research Institute of City of Hope, Duarte, CA, USA
| | - Andrew D Paterson
- Genetics and Genome Biology Program, The Hospital for Sick Children, Toronto, ON, Canada. .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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Rickels MR, Evans-Molina C, Bahnson HT, Ylescupidez A, Nadeau KJ, Hao W, Clements MA, Sherr JL, Pratley RE, Hannon TS, Shah VN, Miller KM, Greenbaum CJ. High residual C-peptide likely contributes to glycemic control in type 1 diabetes. J Clin Invest 2020; 130:1850-1862. [PMID: 31895699 PMCID: PMC7108933 DOI: 10.1172/jci134057] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/26/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUNDResidual C-peptide is detected in many people for years following the diagnosis of type 1 diabetes; however, the physiologic significance of low levels of detectable C-peptide is not known.METHODSWe studied 63 adults with type 1 diabetes classified by peak mixed-meal tolerance test (MMTT) C-peptide as negative (<0.007 pmol/mL; n = 15), low (0.017-0.200; n = 16), intermediate (>0.200-0.400; n = 15), or high (>0.400; n = 17). We compared the groups' glycemia from continuous glucose monitoring (CGM), β cell secretory responses from a glucose-potentiated arginine (GPA) test, insulin sensitivity from a hyperinsulinemic-euglycemic (EU) clamp, and glucose counterregulatory responses from a subsequent hypoglycemic (HYPO) clamp.RESULTSLow and intermediate MMTT C-peptide groups did not exhibit β cell secretory responses to hyperglycemia, whereas the high C-peptide group showed increases in both C-peptide and proinsulin (P ≤ 0.01). All groups with detectable MMTT C-peptide demonstrated acute C-peptide and proinsulin responses to arginine that were positively correlated with peak MMTT C-peptide (P < 0.0001 for both analytes). During the EU-HYPO clamp, C-peptide levels were proportionately suppressed in the low, intermediate, and high C-peptide compared with the negative group (P ≤ 0.0001), whereas glucagon increased from EU to HYPO only in the high C-peptide group compared with negative (P = 0.01). CGM demonstrated lower mean glucose and more time in range for the high C-peptide group.CONCLUSIONThese results indicate that in adults with type 1 diabetes, β cell responsiveness to hyperglycemia and α cell responsiveness to hypoglycemia are observed only at high levels of residual C-peptide that likely contribute to glycemic control.FUNDINGFunding for this work was provided by the Leona M. and Harry B. Helmsley Charitable Trust, the National Center for Advancing Translational Sciences, and the National Institute of Diabetes and Digestive and Kidney Diseases.
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Affiliation(s)
- Michael R. Rickels
- Institute for Diabetes, Obesity and Metabolism, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Carmella Evans-Molina
- Center for Diabetes and Metabolic Disease, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Kristen J. Nadeau
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Wei Hao
- Benaroya Research Institute, Seattle, Washington, USA
| | | | | | - Richard E. Pratley
- AdventHealth Translational Research Institute for Metabolism and Diabetes, Orlando, Florida, USA
| | - Tamara S. Hannon
- Center for Diabetes and Metabolic Disease, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Viral N. Shah
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, Colorado, USA
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Primavera M, Giannini C, Chiarelli F. Prediction and Prevention of Type 1 Diabetes. Front Endocrinol (Lausanne) 2020; 11:248. [PMID: 32670194 PMCID: PMC7326081 DOI: 10.3389/fendo.2020.00248] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/03/2020] [Indexed: 12/19/2022] Open
Abstract
Type 1 Diabetes (T1D) is one of the most common chronic autoimmune diseases in children. The disease is characterized by the destruction of beta cells, leading to hyperglycemia, and to a lifelong insulin-dependent state. Although several studies in the last decades have added relevant insights, the complex pathogenesis of the disease is not yet completely understood. Recent studies have been focused on several factors, including family history and genetic predisposition (HLA and non-HLA genes) as well as environmental and metabolic biomarkers, with the aim of predicting the development and progression of T1D. Once a child becomes symptomatic, beta cell mass has already reached a critical threshold (usually a residual of 20-30% of normal amounts), thus representing only the very late phase of the disease. In particular, this final stage follows two preceding asymptomatic stages, which have been precisely identified. In view of the long natural history and complex pathogenesis of the disease, many strategies may be proposed for primary, secondary, and tertiary prevention. Strategies of primary prevention aim to prevent the onset of autoimmunity against beta cells in asymptomatic individuals at high risk for T1D. In addition, the availability of novel humoral and metabolic biomarkers that are able to characterize subjects at high risk of progression, have stimulated several studies on secondary and tertiary prevention, aimed to preserve residual beta cell destruction and/or to prolong the remission phase after the onset of T1D. This review focuses on the major current knowledge on prediction and prevention of T1D in children.
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Proportion of Basal to Total Insulin Dose Is Associated with Metabolic Control, Body Mass Index, and Treatment Modality in Children with Type 1 Diabetes-A Cross-Sectional Study with Data from the International SWEET Registry. J Pediatr 2019; 215:216-222.e1. [PMID: 31345576 DOI: 10.1016/j.jpeds.2019.06.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/09/2019] [Accepted: 06/04/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVES To investigate in a large population the proportion of daily basal insulin dose (BD) to daily total insulin dose (TD) (BD/TD) and its association with glycated hemoglobin A1c (HbA1c), body mass index (BMI)- SDS, and treatment modality in children with type 1 diabetes. STUDY DESIGN Cross-sectional study in subjects with type 1 diabetes, age ≤18 years, and ≥2 years of diabetes duration, registered in the international multicenter Better control in Pediatric and Adolescent diabeteS: Working to crEate CEnTers of Reference registry in March 2018. Variables included region, sex, age, diabetes duration, treatment modality (multiple daily injections [MDI] or continuous subcutaneous insulin infusion [CSII]), self-monitoring blood glucose, HbA1c, BD/TD, and BMI-SDS. BMI was converted to BMI-SDS using World Health Organization charts as reference. Hierarchic linear regression models were applied with adjustment for age, sex, and diabetes duration. RESULTS A total of 19 687 children with type 1 diabetes (49% female, 49% CSII users) with median age 14.8 (11.5; 17.2) years and diabetes duration 6.0 (3.9; 9.0) years were included. HbA1c was 63 (55; 74) mmol/mol (7.9 [7.2; 8.9]%), and BMI-SDS 0.55 (-0.13; 1.21). Unadjusted, a lower BD/TD was associated with lower HbA1c, male sex, younger age, shorter diabetes duration, lower BMI-SDS, higher numbers of self-monitoring blood glucose and CSII (all P < .01). After adjustment for confounders, lower BD/TD was associated with lower HbA1c (P < .01) and lower BMI-SDS (P < .01) in children on CSII, but not on MDI. CONCLUSIONS Lower BD/TD is positively associated with lower HbA1c and lower BMI-SDS in children with type 1 diabetes on CSII. It remains to be investigated in a prospective study whether reducing BD/TD insulin will improve metabolic control and normalize body weight in children with type 1 diabetes.
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Chiavaroli V, Derraik JGB, Jalaludin MY, Albert BB, Ramkumar S, Cutfield WS, Hofman PL, Jefferies CA. Partial remission in type 1 diabetes and associated factors: Analysis based on the insulin dose-adjusted hemoglobin A1c in children and adolescents from a regional diabetes center, Auckland, New Zealand. Pediatr Diabetes 2019; 20:892-900. [PMID: 31237756 DOI: 10.1111/pedi.12881] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/25/2019] [Accepted: 06/10/2019] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Partial remission (PREM) by the insulin dose-adjusted HbA1c (IDAA1c) method has not been evaluated for the combined associations of ethnicity and socioeconomic status in children and adolescents with type 1 diabetes (T1D). OBJECTIVE To investigate prevalence and predictors of PREM defined by IDAA1c. METHODS Six hundred fourteen of 678 children (aged <15 years) with new-onset T1D (2000-2013) from a regional pediatric diabetes service (Auckland, New Zealand). RESULTS Overall rate of PREM at 3 months was 42.4%, and lower in Māori/Pacific children (28.6%; P = .006) and those of other ethnicities (28.8%; P = .030) compared with New Zealand Europeans (50.4%). Comparing the most and least deprived socioeconomic quintiles, the odds of PREM were lower among the most deprived (adjusted odds ratio [aOR] 0.44; P = .019). Lower rates of PREM were seen in children aged 0 to 4.9 years (23.8%) and 10 to 14 years (40.9%) than in children aged 5 to 9.9 years (57.4%; P < .05). Further predictors of lower rates of PREM were ketoacidosis at diagnosis (aOR 0.54 with DKA; P = .002) and diabetes duration (aOR 0.84 per month; P < .0001). Patient's sex, body mass index standard deviation score, or autoantibodies were not associated with PREM. PREM at 3 months was associated with lower HbA1c over 18 months compared with children not in PREM (65.0 vs 71.3 mmol/mol; P < .0001), independent of ketoacidosis. CONCLUSIONS This study on a regional cohort of youth with T1D showed social and ethnic disparities in rates of PREM defined by IDAA1c. Further research into reducing ketoacidosis rates at diagnosis and addressing factors associated with lower rates of PREM in non-European children are important health priorities.
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Affiliation(s)
- Valentina Chiavaroli
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Neonatal Intensive Care Unit, Pescara Public Hospital, Pescara, Italy
| | - José G B Derraik
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start - National Science Challenge, University of Auckland, Auckland, New Zealand.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Muhammad Y Jalaludin
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Benjamin B Albert
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Selvarajan Ramkumar
- Department of Endocrinology, Apollo Hospitals, Chennai, India.,Department of Endocrinology, Madras Medical College, Chennai, India
| | - Wayne S Cutfield
- Liggins Institute, University of Auckland, Auckland, New Zealand.,A Better Start - National Science Challenge, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Paul L Hofman
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Craig A Jefferies
- Liggins Institute, University of Auckland, Auckland, New Zealand.,Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
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Dayan CM, Korah M, Tatovic D, Bundy BN, Herold KC. Changing the landscape for type 1 diabetes: the first step to prevention. Lancet 2019; 394:1286-1296. [PMID: 31533907 DOI: 10.1016/s0140-6736(19)32127-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/25/2019] [Accepted: 08/06/2019] [Indexed: 12/14/2022]
Abstract
Over several decades, studies have described the progression of autoimmune diabetes, from the first appearance of autoantibodies until, and after, the diagnosis of clinical disease with hyperglycaemia and insulin dependence. Despite the improved management of type 1 diabetes with exogenous insulin, most patients do not meet clinical glycaemic goals, and diabetes remains an important medical problem that affects children and adults. Clinical and preclinical studies have suggested strategies to prevent the diagnosis of type 1 diabetes in people at risk, but the outcomes of previous clinical trials have not met their primary endpoints of disease prevention or delay. The results from the TN-10 teplizumab prevention trial show that the diagnosis of type 1 diabetes can be delayed by treatment with a FcR non-binding monoclonal antibody to CD3 in people at high risk for disease. This Series paper discusses how this clinical achievement raises new questions about for whom, and when, immunological strategies might be developed to prevent type 1 diabetes, and how to achieve this goal.
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Affiliation(s)
- Colin M Dayan
- Diabetes Research Group, Cardiff University School of Medicine, Cardiff, UK
| | - Maria Korah
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT, USA
| | - Danijela Tatovic
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT, USA
| | - Brian N Bundy
- Health Informatics Institute, University of South Florida, Tampa, FL, USA
| | - Kevan C Herold
- Departments of Immunobiology and Internal Medicine, Yale University, New Haven, CT, USA.
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Miao H, Zhang J, Gu B, Gao A, Hong J, Zhang Y, Gu W. Prognosis for residual islet β-cell secretion function in young patients with newly diagnosed type 1 diabetes. J Diabetes 2019; 11:818-825. [PMID: 30848017 DOI: 10.1111/1753-0407.12912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 02/27/2019] [Accepted: 03/05/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND This study investigated possible predictors of residual islet β-cell function (RBF) in young patients with newly diagnosed type 1 diabetes (T1D). METHODS After analyzing RBF in 443 patients with T1D according to age at diagnosis and disease duration, 110 were followed-up over 18-60 months. A nomogram was developed by logistic regression to explore factors associated with long-term RBF. RESULTS Of the 443 T1D patients (mean [±SD] age 20.28 ± 5.50 years; mean [±SD] diabetes duration 28.5 ± 14.6 months), RBF was preserved in 64.3%. Independent predictors for poor RBF outcome among the 110 patients in the follow-up cohort were age at onset (odds ratio [OR] 0.82; 95% confidence interval [CI] 0.73-0.92; P < 0.001), high-risk human leukocyte antigen (HLA) status (OR 4.73; CI 1.28-17.52; P = 0.020), female sex (OR 3.39; CI 1.03-11.22; P = 0.045), and a history of diabetic ketoacidosis (DKA; OR 8.71; CI 2.31-32.83; P < 0.001). Baseline glutamic acid decarboxylase (GAD) antibody, family history of diabetes, body mass index, insulin dosage, and C-peptide and HbA1c levels were not associated with poor RBF outcome. Intensive glycemic control after T1D diagnosis may improve RBF within a mean (±SD) follow-up of 35.1 ± 13.8 months. The calibration plot for the probability of 2-, 3-, and 4-year RBF showed optimal agreement between nomogram-predicted and actual observed probabilities. CONCLUSIONS Younger age of onset, female sex, higher HLA risk status, and a history of DKA were the main factors predicting long-term poor preserved β-cell function. Glycemic control could improve RBF during the course of diabetes. The nomogram provides an individualized risk estimate of RBF in patients with newly diagnosed T1D within Chinese Han populations.
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Affiliation(s)
- Haitao Miao
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Juanjuan Zhang
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Bin Gu
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Aibo Gao
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Jie Hong
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Yifei Zhang
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
| | - Weiqiong Gu
- Department of Endocrinology and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao-Tong University, Shanghai, China
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Abstract
PURPOSE OF REVIEW To discuss the current understanding of "β cell identity" and factors underlying altered identity of pancreatic β cells in diabetes, especially in humans. RECENT FINDINGS Altered identity of β cells due to dedifferentiation and/or transdifferentiation has been proposed as a mechanism of loss of β cells in diabetes. In dedifferentiation, β cells do not undergo apoptosis; rather, they lose their identity and function. Dedifferentiation is well characterized by the decrease in expression of key β cell markers such as genes encoding major transcription factors, e.g., MafA, NeuroD1, Nkx6.1, and Foxo1, and an increase in atypical or "disallowed" genes for β cells such as lactate dehydrogenase, monocarboxylate transporter MCT1, or progenitor cell genes (Neurog3, Pax4, or Sox9). Moreover, altered identity of mature β cells in diabetes also involves transdifferentiation of β cells into other islet hormone producing cells. For example, overexpression of α cell specific transcription factor Arx or ablation of Pdx1 resulted in an increase of α cell numbers and a decrease in β cell numbers in rodents. The frequency of α-β double-positive cells was also prominent in human subjects with T2D. These altered identities of β cells likely serve as a compensatory response to enhance function/expand cell numbers and may also camouflage/protect cells from ongoing stress. However, it is equally likely that this may be a reflection of new cell formation as a frank regenerative response to ongoing tissue injury. Physiologically, all these responses are complementary. In diabetes, (1) endocrine identity recapitulates the less mature/less-differentiated fetal/neonatal cell type, possibly representing an adaptive mechanism; (2) residual β cells may be altered in their subtype proportions or other molecular features; (3) in humans, "altered identity" is a preferable term to dedifferentiation as their cellular fate (differentiated cells losing identity or progenitors becoming more differentiated) is unclear as yet.
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Affiliation(s)
- Abu Saleh Md Moin
- Diabetes Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110 Doha, Qatar
| | - Alexandra E. Butler
- Diabetes Research Center, Qatar Biomedical Research Institute, Hamad Bin Khalifa University, Qatar Foundation, PO Box 34110 Doha, Qatar
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Udoka Nwosu B. Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions. EUROPEAN MEDICAL JOURNAL 2019. [DOI: 10.33590/emj/10310168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving β cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA
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38
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Novac C, Radulian G, Orzan A, Balgradean M. Short Update on C-Peptide and its Clinical Value. MAEDICA 2019; 14:53-58. [PMID: 31123514 PMCID: PMC6511667 DOI: 10.26574/maedica.2019.14.1.53] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
C-Peptide (“connecting” peptide – molecular formula C112H179N35O46) is a peptide made of 31 aminoacids, making the bond between A and B chains of insulin from the pro-insulin molecule. Pro-insulin is the precursor of the insulin that is synthesized in the beta-pancreatic cells. After its discovery in 1967 by Steiner et al, together with the discovery of insulin biosynthesis, C-peptide seemed to bring new benefits, having similar effects as those of insulin. Unfortunately, the subsequent studies have classified C-peptide as a biologically inactive peptide. After the ‘90s, however, both studies on animals and those on human subjects with type 1 diabetes where C-peptide had been administered showed that it played important biological parts in improving kidney function and nerve conduction velocity, as well as in increasing blood flow in muscles, skin, kidneys, thus being seen as a possible treatment for chronic complications of type 1 diabetes. Although for a long time C-peptide has been considered to be an inert biological product, recent research has emphasized its active biological function. C-peptide bonds to the membrane of certain types of cells (neuronal, endothelial, renal tubular cells, fibroblasts) through a surface receptor coupled with a G protein, and it determines multiple effects at the cellular level: it improves the quality of red cells, generating a better oxygenation of tissues; it has a vasodilator effect for muscles, skin, kidneys; it generates blood flow increase in skeletal muscles and at the skin level; it decreases glomerular hyper-filtering; it reduces albumin urinary excretion; it improves the function and structure of nerves in patients with type 1 diabetes and C-peptide deficiency, but not in healthy subjects. Therefore, C-peptide could have a therapeutic potential in preventing some of the late complications of diabetes mellitus.
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Affiliation(s)
- Carmen Novac
- M. S. Curie" Children Emergency Hospital, Bucharest, Romania
| | - Gabriela Radulian
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Anca Orzan
- "M. S. Curie" Children Emergency Hospital, Bucharest, Romania
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39
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Nwosu BU. Partial Clinical Remission of Type 1 Diabetes Mellitus in Children: Clinical Applications and Challenges with its Definitions. EUROPEAN MEDICAL JOURNAL. DIABETES 2019; 4:89-98. [PMID: 31069088 PMCID: PMC6502244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The honeymoon phase, or partial clinical remission (PCR) phase, of Type 1 diabetes mellitus (T1DM) is a transitory period that is marked by endogenous insulin production by surviving 3 cells following a diabetes diagnosis and the introduction of insulin therapy. It is a critical window in the course of the disease that has short and long-term implications for the patient, such as a significant reduction in the risk of long-term complications of T1DM. To promote long-term cardiovascular health in children with newly diagnosed T1DM, three key steps are necessary: the generation of a predictive model for non-remission, the adoption of a user-friendly monitoring tool for remission and non-remission, and the establishment of the magnitude of the early-phase cardiovascular disease risk in these children in objective terms through changes in lipid profile. However, only about 50% of children diagnosed with T1DM experience the honeymoon phase. Accurate and prompt detection of the honeymoon phase has been hampered by the lack of an objective and easily applicable predictive model for its detection at the time of T1DM diagnosis, the complex formulas needed to confirm and monitor PCR, and the absence of a straightforward, user-friendly tool for monitoring PCR. This literature review discusses the most up-to-date information in this field by describing an objective predictive model for non-remission, an easy tool for monitoring remission or non-remission, and objective evidence for the cardiovascular protective effect of PCR in the early phase of the disease. The goal is to present non-remission as an independent clinical entity with significantly poorer long-term prognosis than partial remission.
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40
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Abstract
Type 1 diabetes is a chronic autoimmune disease characterised by insulin deficiency and resultant hyperglycaemia. Knowledge of type 1 diabetes has rapidly increased over the past 25 years, resulting in a broad understanding about many aspects of the disease, including its genetics, epidemiology, immune and β-cell phenotypes, and disease burden. Interventions to preserve β cells have been tested, and several methods to improve clinical disease management have been assessed. However, wide gaps still exist in our understanding of type 1 diabetes and our ability to standardise clinical care and decrease disease-associated complications and burden. This Seminar gives an overview of the current understanding of the disease and potential future directions for research and care.
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Affiliation(s)
- Linda A DiMeglio
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Carmella Evans-Molina
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Richard A Oram
- Institute of Biomedical and Clinical Science, University of Exeter Medical School, and The Academic Kidney Unit, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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41
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Nwosu BU, Zhang B, Ayyoub SS, Choi S, Villalobos-Ortiz TR, Alonso LC, Barton BA. Children with type 1 diabetes who experienced a honeymoon phase had significantly lower LDL cholesterol 5 years after diagnosis. PLoS One 2018; 13:e0196912. [PMID: 29768449 PMCID: PMC5955510 DOI: 10.1371/journal.pone.0196912] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Accepted: 04/23/2018] [Indexed: 01/12/2023] Open
Abstract
Importance Landmark studies showed that partial clinical remission in new-onset type 1 diabetes is associated with reduced prevalence of long-term complications, but early clinical indicators of this favorable outcome are poorly characterized. Aim To determine if there were any differences in lipid parameters, especially LDL-cholesterol, between remitters and non-remitters 4 to 5 years after the diagnosis of type 1 diabetes after controlling for hemoglobin A1c, body mass index, and pubertal status. Subjects and methods A longitudinal retrospective cohort study of 123 subjects of mean age 11.9 ± 2.9 years, [male 11.7 ± 2.9 years, (n = 55); female 12.0 ± 2.9 years, (n = 68), p = 0.60] with type 1 diabetes of 4–5 years duration. Anthropometric and biochemical data were collected at the 4th or 5th year after diagnosis in line with the American Diabetes Association recommendation to initiate screening for complications in children either at the beginning of puberty or 4–5 years after diagnosis. Puberty was defined by Tanner stages II-V. Partial clinical remission was defined by the gold-standard insulin-dose adjusted hemoglobin A1c (IDAA1c) of ≤9. Results There were 44 (35.8%) remitters (age 13.0 ± 2.5y; male 52.3%). Both the total cholesterol and LDL-cholesterol were significantly lower in remitters compared to non-remitters: LDL-C: 78.8 ± 28.7 mg/dL vs. 91.6 ± 26.5 mg/dL, p = 0.023; and total cholesterol: 151.5 ± 32.6 mg/dL vs. 167.0 ± 29.6 mg/dL, p = 0.015. Other lipid fractions were similar between the groups. There were no differences between the groups for glycemic control, body mass index z score, thyroid function, celiac disease occurrence, or vitamin D status. A greater number of remitters were in puberty compared to non-remitters (86.4% vs. 60.8%, p = 0.006). LDL-C concentration was similar in prepubertal remitters vs. non-remitters (p = 0.93), but was significantly lower in remitters in puberty compared to non-remitters in puberty (p = 0.018) after adjusting for age and duration of diabetes. Conclusions Children with type 1 diabetes who underwent a honeymoon phase had significantly lower LDL cholesterol 5 years after diagnosis. This early divergence in lipidemia may explain the dichotomy in the prevalence of long-term complication in type 1 diabetes between remitters and non-remitters. It also offers a pathway for targeted lipid monitoring in type 1 diabetes, by establishing non-remission as a non-modifiable risk factor for vascular complication in type 1 diabetes.
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Affiliation(s)
- Benjamin Udoka Nwosu
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
- * E-mail:
| | - Bo Zhang
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Sanaa S. Ayyoub
- Diabetes Division, Department of Internal Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Stephanie Choi
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Tony R. Villalobos-Ortiz
- Division of Endocrinology, Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Laura C. Alonso
- Diabetes Division, Department of Internal Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
| | - Bruce A. Barton
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, United States of America
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Roshandel D, Gubitosi-Klug R, Bull SB, Canty AJ, Pezzolesi MG, King GL, Keenan HA, Snell-Bergeon JK, Maahs DM, Klein R, Klein BEK, Orchard TJ, Costacou T, Weedon MN, Oram RA, Paterson AD. Meta-genome-wide association studies identify a locus on chromosome 1 and multiple variants in the MHC region for serum C-peptide in type 1 diabetes. Diabetologia 2018; 61:1098-1111. [PMID: 29404672 PMCID: PMC5876265 DOI: 10.1007/s00125-018-4555-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 12/15/2017] [Indexed: 01/01/2023]
Abstract
AIMS/HYPOTHESIS The aim of this study was to identify genetic variants associated with beta cell function in type 1 diabetes, as measured by serum C-peptide levels, through meta-genome-wide association studies (meta-GWAS). METHODS We performed a meta-GWAS to combine the results from five studies in type 1 diabetes with cross-sectionally measured stimulated, fasting or random C-peptide levels, including 3479 European participants. The p values across studies were combined, taking into account sample size and direction of effect. We also performed separate meta-GWAS for stimulated (n = 1303), fasting (n = 2019) and random (n = 1497) C-peptide levels. RESULTS In the meta-GWAS for stimulated/fasting/random C-peptide levels, a SNP on chromosome 1, rs559047 (Chr1:238753916, T>A, minor allele frequency [MAF] 0.24-0.26), was associated with C-peptide (p = 4.13 × 10-8), meeting the genome-wide significance threshold (p < 5 × 10-8). In the same meta-GWAS, a locus in the MHC region (rs9260151) was close to the genome-wide significance threshold (Chr6:29911030, C>T, MAF 0.07-0.10, p = 8.43 × 10-8). In the stimulated C-peptide meta-GWAS, rs61211515 (Chr6:30100975, T/-, MAF 0.17-0.19) in the MHC region was associated with stimulated C-peptide (β [SE] = - 0.39 [0.07], p = 9.72 × 10-8). rs61211515 was also associated with the rate of stimulated C-peptide decline over time in a subset of individuals (n = 258) with annual repeated measures for up to 6 years (p = 0.02). In the meta-GWAS of random C-peptide, another MHC region, SNP rs3135002 (Chr6:32668439, C>A, MAF 0.02-0.06), was associated with C-peptide (p = 3.49 × 10-8). Conditional analyses suggested that the three identified variants in the MHC region were independent of each other. rs9260151 and rs3135002 have been associated with type 1 diabetes, whereas rs559047 and rs61211515 have not been associated with a risk of developing type 1 diabetes. CONCLUSIONS/INTERPRETATION We identified a locus on chromosome 1 and multiple variants in the MHC region, at least some of which were distinct from type 1 diabetes risk loci, that were associated with C-peptide, suggesting partly non-overlapping mechanisms for the development and progression of type 1 diabetes. These associations need to be validated in independent populations. Further investigations could provide insights into mechanisms of beta cell loss and opportunities to preserve beta cell function.
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Affiliation(s)
- Delnaz Roshandel
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 1H3, Canada
| | | | - Shelley B Bull
- Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Angelo J Canty
- Department of Mathematics and Statistics, McMaster University, Hamilton, ON, Canada
| | - Marcus G Pezzolesi
- Division of Nephrology and Hypertension, Diabetes and Metabolism Center, University of Utah, Salt Lake City, UT, USA
| | - George L King
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Hillary A Keenan
- Research Division, Joslin Diabetes Center, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Janet K Snell-Bergeon
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - David M Maahs
- Barbara Davis Center for Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Paediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Ronald Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA
| | - Barbara E K Klein
- Department of Ophthalmology and Visual Sciences, University of Wisconsin, Madison, WI, USA
| | - Trevor J Orchard
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tina Costacou
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Weedon
- Institute for Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
| | | | - Richard A Oram
- Institute for Biomedical and Clinical Science, University of Exeter Medical School, Exeter, UK
- National Institute for Health Research, Exeter Clinical Research Facility, Exeter, UK
| | - Andrew D Paterson
- Genetics and Genome Biology Program, Peter Gilgan Centre for Research and Learning (PGCRL), The Hospital for Sick Children, 686 Bay Street, Toronto, ON, M5G 1H3, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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43
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Nielens N, Pollé O, Robert A, Lysy PA. Integration of Routine Parameters of Glycemic Variability in a Simple Screening Method for Partial Remission in Children with Type 1 Diabetes. J Diabetes Res 2018; 2018:5936360. [PMID: 29568778 PMCID: PMC5822787 DOI: 10.1155/2018/5936360] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Accepted: 12/06/2017] [Indexed: 12/11/2022] Open
Abstract
Although different criteria were used to define partial remission in type 1 diabetes, the IDAA1C formula has prevailed as it correlates with stimulated C-peptide levels. Our retrospective study evaluated clinical variables associated with the occurrence of IDAA1C-defined partial remission in a series of 239 pediatric patients. Diabetic ketoacidosis and age at diagnosis, but no other clinical feature, influenced the occurrence of remission. We then evaluated whether parameters of glycemic variability used in clinical routine may reliably define partial remission, as these would alleviate confounding factors related to insulin treatment. Using multiple linear regression, we observed that HbA1C levels and percentage of normoglycemia were efficient and sufficient to predict partial remission. These parameters were entered into a formula, called glycemic target-adjusted HbA1C (GTAA1C), that corresponded to HbA1C(%) - (3 × % of normoglycemic values(70-180 mg/dL)). With a threshold of 4.5, this alternative formula predicted partial remission with a sensitivity and a specificity of 72.3% and 92%, respectively, and yielded strong correlation with IDAA1C levels and BETA-2 score, which is a correlate of β-cell function after islet transplantation. We propose GTAA1C, based on routine and objective markers of glycemic variability, as a valid alternative for definition of partial remission in type 1 diabetes.
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Affiliation(s)
- Nina Nielens
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Olivier Pollé
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Annie Robert
- Pôle Epidémiologie et Biostatistique, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Av. Hippocrate 10, 1200 Brussels, Belgium
| | - Philippe A. Lysy
- Pediatric Endocrinology Unit, Cliniques Universitaires Saint Luc, Av. Hippocrate 10, 1200 Brussels, Belgium
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44
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Chisalita SI, Ludvigsson J. Insulin-Like Growth Factor-1 at Diagnosis and during Subsequent Years in Adolescents with Type 1 Diabetes. J Diabetes Res 2018; 2018:8623560. [PMID: 29744370 PMCID: PMC5883934 DOI: 10.1155/2018/8623560] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/10/2017] [Accepted: 12/18/2017] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Type 1 diabetes (T1D) in adolescents is associated with alterations in the insulin-like factor system probably caused both by a deranged metabolism and insulinopenia in the portal vein. OBJECTIVE To study how the circulating IGF-1 is affected at diagnosis and during subsequent years in adolescents with T1D. METHODS Ten girls and ten boys with type 1 diabetes (T1D), aged 13.0 ± 1.4 (mean ± SD) years at diagnosis, took part in the study. Blood samples were drawn at diagnosis and after 3, 9, 18, and 48 months. HbA1c, total IGF-1, and C-peptide were measured. RESULTS At diagnosis, the patients had high HbA1c, low IGF-1, and measurable C-peptide. After the start of insulin treatment, maximal improvement in glycemic control and IGF-1 occurred within 3 months and then both tended to deteriorate, that is, HbA1c to increase and IGF-1 to decrease. C-peptide decreased with time, and after 4 years, half of the patients were C-peptide negative. At diagnosis, C-peptide correlated positively to IGF-1 (r = 0.50; p < 0.03). C-peptide correlated negatively with insulin dose (U/kg) after 18 and 48 months from diagnosis (r = -0.48; p < 0.03 and r = -0.72; p < 0.001, resp.). CONCLUSIONS In conclusion, our results show that in newly diagnosed adolescents with type 1 diabetes and deranged metabolism, the IGF-1 level is low and rapidly improves with insulin treatment but later tends to decrease concomitantly with declining endogenous insulin secretion.
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Affiliation(s)
- Simona I. Chisalita
- Department of Endocrinology and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - J. Ludvigsson
- Division of Pediatrics, Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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45
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Graveling AJ, Frier BM. The risks of nocturnal hypoglycaemia in insulin-treated diabetes. Diabetes Res Clin Pract 2017; 133:30-39. [PMID: 28888993 DOI: 10.1016/j.diabres.2017.08.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 12/29/2022]
Abstract
Over half of all episodes of severe hypoglycaemia (requiring external help) occur during sleep, but nocturnal hypoglycaemia is often asymptomatic and unrecognised. The precise incidence of nocturnal hypoglycaemia is difficult to determine with no agreed definition, but continuous glucose monitoring has shown that it occurs frequently in people taking insulin. Attenuation of the counter-regulatory responses to hypoglycaemia during sleep may explain why some episodes are undetected and more prolonged, and modifies cardiovascular responses. The morbidity and mortality associated with nocturnal hypoglycaemia is probably much greater than realised, causing seizures, coma and cardiovascular events and affecting quality of life, mood and work performance the following day. It may induce impaired awareness of hypoglycaemia. Cardiac arrhythmias that occur during nocturnal hypoglycaemia include bradycardia and ectopics that may provoke dangerous arrhythmias. Treatment strategies are discussed that may help to minimise the frequency of nocturnal hypoglycaemia.
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Affiliation(s)
- Alex J Graveling
- JJR Macleod Centre for Diabetes & Endocrinology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZP, UK.
| | - Brian M Frier
- The Queen's Medical Research Institute, The University of Edinburgh, Edinburgh EH16 4TJ, UK.
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46
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Hwang JW, Kim MS, Lee DY. Factors Associated with C-peptide Levels after Diagnosis in Children with Type 1 Diabetes Mellitus. Chonnam Med J 2017; 53:216-222. [PMID: 29026710 PMCID: PMC5636761 DOI: 10.4068/cmj.2017.53.3.216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 12/11/2022] Open
Abstract
C-peptide is the best indicator of endogenous insulin secretion in patients with diabetes. This study investigated the relationship between C-peptide levels and clinical/laboratory parameters of children with type 1 diabetes mellitus (T1DM), as measured at 6-month intervals after diagnosis. We retrospectively reviewed the data of 34 children with newly diagnosed T1DM. The study subjects were subdivided into a rapid progression group with C-peptide levels <0.6 ng/mL at 36 months (n=27; Group A) and a slow progression group with C-peptide levels >0.6 ng/mL at 36 months (n=7; Group B). Patients in Group A had a younger mean age at diagnosis (A: 9±4.3 years vs. B: 13.6±3.6 years; p=0.013) and lower body mass index (BMI) (A: 15.5±2.5 kg/m2 vs. B: 18.7±3.3 kg/m2; p=0.035). There were fewer asymptomatic patients with glucosuria in Group A, with these patients showing more severe symptoms, such as diabetic ketoacidosis (p=0.035), than those in Group B. Group A also had lower initial C-peptide levels (A: 0.5±0.46 ng/mL vs. B: 1.87±1.08 ng/mL; p=0.001). There were no significant intergroup differences in sex, family history, baseline hemoglobin A1c (HbA1c), potential of hydrogen (pH), autoantibodies or serum insulin. Simple correlation analyses showed that C-peptide levels were correlated with age and BMI, but not with pH, insulin, or HbA1c. Younger patients, who had a lower BMI, significant symptoms with complications, and/or a low initial C-peptide level, tended to show a rapid rate of decrease in C-peptide levels. Early intensive insulin therapy to preserve beta-cell function should be considered in these groups.
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Affiliation(s)
- Jung Won Hwang
- Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea
| | - Min Sun Kim
- Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
| | - Dae-Yeol Lee
- Department of Pediatrics, Chonbuk National University Medical School, Jeonju, Korea.,Research Institute of Clinical Medicine of Chonbuk National University-Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Korea
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47
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Lundberg RL, Marino KR, Jasrotia A, Maranda LS, Barton BA, Alonso LC, Nwosu BU. Partial clinical remission in type 1 diabetes: a comparison of the accuracy of total daily dose of insulin of <0.3 units/kg/day to the gold standard insulin-dose adjusted hemoglobin A1c of ≤9 for the detection of partial clinical remission. J Pediatr Endocrinol Metab 2017; 30:823-830. [PMID: 28753540 DOI: 10.1515/jpem-2017-0019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Accepted: 06/12/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND It is unclear whether the gold standard test for the detection of partial clinical remission (PCR) in new-onset type 1 diabetes (T1D), the insulin-dose adjusted Hemoglobin A1c (IDAA1c) of ≤9, is superior to a new tool, total daily dose of insulin (TDD) of <0.3 units/kg/day. The aim of the study was to test the superiority of IDAA1c over TDD of <0.3 units/kg/day for the detection of PCR. METHODS A retrospective analysis of 204 subjects of ages 2-14 years, mean age 7.9±3.2 years, (male 7.8±3.4 years, [n=98]; female 7.9±3.0 years, [n=106], p=0.816) with new-onset T1D. Anthropometric and biochemical data were collected for the first 36 months of disease. PCR was defined by both IDAA1c≤9 and TDD<0.3 units/kg/day. RESULTS There were 86 (42.2%) (age 9.1±3.0 years; male 57%) remitters by IDAA1c≤9 criterion, and 82 (40.2%) remitters (age 7.3±2.8 years) by TDD of <0.3 units/kg/day criterion (p=0.655). The duration of PCR was 10.0±6.1 months using TDD<0.3 units/kg/day, and 9.2±5.5 months using IDAA1c (p=0.379). Subjects in PCR as denoted by TDD<0.3 units/kg/day had 1.44 times increased probability of entering PCR than those denoted by IDAA1c of ≤9, after adjusting for BMI, bicarbonate, and HbA1c:(OR=1.44, 95% CI [1.03-2.00], p=0.033). Peak prevalence for PCR was at 6-12 months by either definition; more subjects were in PCR at 6 months by IDAA1c ≤9: 62/86 (72.1%) than by TDD<0.3 units/kg/day: 43/82 (52.4%), (p=0.011). CONCLUSIONS There were no significant differences in the number of remitters, duration of PCR, or the time of peak remission defined by IDAA1c of ≤9 or TDD of <0.3 units/kg/day.
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Alhadj Ali M, Liu YF, Arif S, Tatovic D, Shariff H, Gibson VB, Yusuf N, Baptista R, Eichmann M, Petrov N, Heck S, Yang JHM, Tree TIM, Pujol-Autonell I, Yeo L, Baumard LR, Stenson R, Howell A, Clark A, Boult Z, Powrie J, Adams L, Wong FS, Luzio S, Dunseath G, Green K, O’Keefe A, Bayly G, Thorogood N, Andrews R, Leech N, Joseph F, Nair S, Seal S, Cheung H, Beam C, Hills R, Peakman M, Dayan CM. Metabolic and immune effects of immunotherapy with proinsulin peptide in human new-onset type 1 diabetes. Sci Transl Med 2017; 9:9/402/eaaf7779. [DOI: 10.1126/scitranslmed.aaf7779] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 04/13/2017] [Accepted: 07/11/2017] [Indexed: 12/18/2022]
Abstract
Immunotherapy using short immunogenic peptides of disease-related autoantigens restores immune tolerance in preclinical disease models. We studied safety and mechanistic effects of injecting human leukocyte antigen–DR4(DRB1*0401)–restricted immunodominant proinsulin peptide intradermally every 2 or 4 weeks for 6 months in newly diagnosed type 1 diabetes patients. Treatment was well tolerated with no systemic or local hypersensitivity. Placebo subjects showed a significant decline in stimulated C-peptide (measuring insulin reserve) at 3, 6, 9, and 12 months versus baseline, whereas no significant change was seen in the 4-weekly peptide group at these time points or the 2-weekly group at 3, 6, and 9 months. The placebo group’s daily insulin use increased by 50% over 12 months but remained unchanged in the intervention groups. C-peptide retention in treated subjects was associated with proinsulin-stimulated interleukin-10 production, increased FoxP3 expression by regulatory T cells, low baseline levels of activated β cell–specific CD8 T cells, and favorable β cell stress markers (proinsulin/C-peptide ratio). Thus, proinsulin peptide immunotherapy is safe, does not accelerate decline in β cell function, and is associated with antigen-specific and nonspecific immune modulation.
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49
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A predictive model for lack of partial clinical remission in new-onset pediatric type 1 diabetes. PLoS One 2017; 12:e0176860. [PMID: 28459844 PMCID: PMC5411061 DOI: 10.1371/journal.pone.0176860] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 04/18/2017] [Indexed: 01/12/2023] Open
Abstract
IMPORTANCE >50% of patients with new-onset type 1 diabetes (T1D) do not enter partial clinical remission (PCR); early identification of these patients may improve initial glycemic control and reduce long-term complications. AIM To determine whether routinely obtainable clinical parameters predict non-remission in children and adolescents with new-onset T1D. SUBJECTS AND METHODS Data on remission were collected for the first 36 months of disease in 204 subjects of ages 2-14 years with new-onset type 1 diabetes. There were 86 remitters (age 9.1±3.0y; male 57%), and 118 non-remitters (age 7.0±3.1y; male 40.7%). PCR was defined as insulin-dose adjusted hemoglobin A1c of ≤9. RESULTS Non-remission occurred in 57.8% of subjects. Univariable analysis showed that the risk for non-remission was increased 9-fold in patients with 4 diabetes-associated auto-antibodies (OR = 9.90, p = 0.010); 5-fold in patients <5 years old (odds ratio = 5.38, p = 0.032), 3-fold in those with bicarbonate of <15 mg/dL at diagnosis (OR = 3.71, p = 0.008). Combined estimates of risk potential for HC03 and the number of autoantibodies by multivariable analysis, adjusted for BMI standard deviation score, showed HC03 <15 mg/dL with a clinically significant 10-fold risk (OR = 10.1, p = 0.074); and the number of autoantibodies with a 2-fold risk for non-remission (OR = 1.9, p = 0.105). Male sex and older age were associated with decreased risk for non-remission. A receiver-operating characteristic curve model depicting sensitivity by 1-specificity for non-remission as predicted by bicarbonate <15 mg/dL, age <5y, female sex, and >3 diabetes-associated autoantibodies had an area under the curve of 0.73. CONCLUSIONS More than 50% of children and adolescents with new-onset T1D do not undergo partial clinical remission and are thus at an increased risk for long-term complications of diabetes mellitus. A predictive model comprising of bicarbonate <15 mg/dL, age <5y, female sex, and >3 diabetes-associated autoantibodies has 73% power for correctly predicting non-remission in children and adolescents with new-onset T1D. Early identification of these non-remitters may guide the institution of targeted therapy to limit dysglycemia and reduce the prevalence of long-term deleterious complications.
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50
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Birkebaek NH, Drivvoll AK, Aakeson K, Bjarnason R, Johansen A, Samuelsson U, Skrivarhaug T, Thorsson AV, Svensson J. Incidence of severe hypoglycemia in children with type 1 diabetes in the Nordic countries in the period 2008-2012: association with hemoglobin A 1c and treatment modality. BMJ Open Diabetes Res Care 2017; 5:e000377. [PMID: 28761652 PMCID: PMC5530237 DOI: 10.1136/bmjdrc-2016-000377] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 04/11/2017] [Accepted: 04/17/2017] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Treatment of type 1 diabetes has been intensified aiming at normalizing blood glucose, which may increase the risk of severe hypoglycemia (SH). We aimed to compare the incidence of SH events in the four Nordic countries Denmark, Iceland, Norway and Sweden, and to assess the influence of hemoglobin A1c (HbA1c) and treatment modalities on the frequency of SH; particularly, to explore if a HbA1c target ≤6.7% (50 mmol/mol) is feasible. RESEARCH DESIGN AND METHODS Data on children below 15 years with a diabetes duration more than 1 year, registered in the national childhood diabetes databases in the four Nordic countries from 2008 to 2012, were compiled. Data completeness was more than 95%. RESULTS Totally 8806 (48% females) patients with 29 715 person years were included, mean age and diabetes duration were 11 years and 5.1 years, respectively. The overall rate of SH was 6.0 per 100 patient-years, and did not change during the study period. The Swedish population constantly had the lowest SH incidence while it decreased significantly in the Danish population. HbA1c decreased significantly over time (p<0.01), while the number of pump users increased (p<0.01). Stratifying for HbA1c levels showed the lowest risk of SH in patients with HbA1c ≤6.7% (≤50 mmol/mol), but in the statistical models adjusting for possible confounders the difference between the HbA1c groups disappeared. Pump users had the lowest SH risk, also after adjusting for possible confounders. CONCLUSIONS Risk of SH differs between the Nordic countries with the lowest risk in Sweden. Pump therapy was associated with decreased risk of SH. The low HbA1c group had the same or a lower risk of SH compared with the highest HbA1c groups. A target HbA1c ≤6.7% (≤50 mmol/mol) seems achievable without increasing the risk of SH.
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Affiliation(s)
- NH Birkebaek
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - AK Drivvoll
- Norwegian Childhood Diabetes Registry, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - K Aakeson
- Department of Pediatrics, County Hospital Ryhov, Jönköping, Sweden
| | - R Bjarnason
- Medical Center, Landspitali University Hospital, Reykjavik, Iceland
- Department of Pediatrics, University of Iceland, Reykjavik, Iceland
| | - A Johansen
- Department of Growth and Reproduction, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - U Samuelsson
- Department of Pediatrics, Linköping University Hospital, Linköping, Sweden
| | - T Skrivarhaug
- Norwegian Childhood Diabetes Registry, Division of Pediatric and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - AV Thorsson
- Medical Center, Landspitali University Hospital, Reykjavik, Iceland
- Department of Pediatrics, University of Iceland, Reykjavik, Iceland
| | - J Svensson
- Copenhagen Diabetes Research Center (CPH-DIRECT), Department of Children and Adolescents, Copenhagen University Hospital, Herlev, Denmark
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