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Kikani N, Balasubramanyam A. Remission in Ketosis-Prone Diabetes. Endocrinol Metab Clin North Am 2023; 52:165-174. [PMID: 36754492 DOI: 10.1016/j.ecl.2022.06.005] [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] [Indexed: 11/06/2022]
Abstract
Heterogeneous forms of Ketosis-prone diabetes (KPD) are characterized by patients who present with diabetic ketoacidosis (DKA) but lack the typical features and biomarkers of autoimmune T1D. The A-β+ subgroup of KPD provides unique insight into the concept of "remission" since these patients have substantial preservation of beta-cell function permitting the discontinuation of insulin therapy, despite initial presentation with DKA. Measurements of C-peptide levels are essential to predict remission and guide potential insulin withdrawal. Further studies into predictors of remission and relapse can help us guide patients with A-β+ KPD toward remission and develop targeted treatments for this form of atypical diabetes.
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Affiliation(s)
- Nupur Kikani
- Department of Endocrine Neoplasia and Hormonal Disorders, University of Texas MD Anderson Cancer Center, Unit 1461, 1515 Holcombe Boulevard, Houston, TX 77030, USA
| | - Ashok Balasubramanyam
- Division of Diabetes, Endocrinology, and Metabolism, Baylor College of Medicine, BCM 179A, One Baylor Plaza, Houston, TX 77030, USA.
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2
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Rojano-Toimil A, Rivera-Esteban J, Manzano-Nuñez R, Bañares J, Martinez Selva D, Gabriel-Medina P, Ferrer R, Pericàs JM, Ciudin A. When Sugar Reaches the Liver: Phenotypes of Patients with Diabetes and NAFLD. J Clin Med 2022; 11:jcm11123286. [PMID: 35743358 PMCID: PMC9225139 DOI: 10.3390/jcm11123286] [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] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 01/27/2023] Open
Abstract
Type 2 diabetes mellitus (T2DM) and non-alcoholic fatty liver disease (NAFLD) have been traditionally linked to one another. Recent studies suggest that NAFLD may be increasingly common in other types of diabetes such as type 1 diabetes (T1DM) and less frequently ketone-prone and Maturity-onset Diabetes of the Young (MODY) diabetes. In this review, we address the relationship between hyperglycemia and insulin resistance and the onset and progression of NAFLD. In addition, despite the high rate of patients with T2DM and other diabetes phenotypes that can alter liver metabolism and consequently develop steatosis, fibrosis, and cirrhosis, NALFD screening is not still implemented in the daily care routine. Incorporating a clinical algorithm created around a simple, non-invasive, cost-effective model would identify high-risk patients. The principle behind managing these patients is to improve insulin resistance and hyperglycemia states with lifestyle changes, weight loss, and new drug therapies.
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Affiliation(s)
- Alba Rojano-Toimil
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
| | - Jesús Rivera-Esteban
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Ramiro Manzano-Nuñez
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - Juan Bañares
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
| | - David Martinez Selva
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
| | - Pablo Gabriel-Medina
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
- Biochemistry and Molecular Biology Department, Universitat Autònoma de Barcelona (UAB), Bellaterra, 08193 Barcelona, Spain
| | - Roser Ferrer
- Biochemistry Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain; (P.G.-M.); (R.F.)
| | - Juan M Pericàs
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Liver Unit, Vall d’Hebron University Hospital, 08035 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Liver and Digestive Diseases (CIBERehd), 28801 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
| | - Andreea Ciudin
- Endocrinology Department, Vall d’Hebron University Hospital, 08035 Barcelona, Spain;
- Vall d’Hebron Institut de Recerca (VHIR), 08035 Barcelona, Spain; (J.R.-E.); (R.M.-N.); (J.B.); (D.M.S.)
- Medicine Department Bellaterra, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain
- Spanish Network of Biomedical Research Centers, Diabetes and Metabolic Associated Disorders (CIBERdem), 28029 Madrid, Spain
- Correspondence: (J.M.P.); (A.C.)
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Patil SP. Atypical Diabetes and Management Considerations. Prim Care 2022; 49:225-237. [DOI: 10.1016/j.pop.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Adler A, Bennett P, Colagiuri Chair S, Gregg E, Narayan KMV, Inês Schmidt M, Sobngwi E, Tajima N, Tandon N, Unwin N, Wild S, Yudkin J, Levitt N, Mohan V, Montgomery S, Nyirenda MJ, Tuomilehto J, Den Boon S, Hocking S. REPRINT OF: CLASSIFICATION OF DIABETES MELLITUS. Diabetes Res Clin Pract 2021:108972. [PMID: 34343595 DOI: 10.1016/j.diabres.2021.108972] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Executive Summary This document updates the 1999 World Health Organization (WHO) classification of diabetes. It prioritizes clinical care and guides health professionals in choosing appropriate treatments at the time of diabetes diagnosis, and provides practical guidance to clinicians in assigning a type of diabetes to individuals at the time of diagnosis. It is a compromise between clinical and aetiological classification because there remain gaps in knowledge of the aetiology and pathophysiology of diabetes. While acknowledging the progress that is being made towards a more precise categorization of diabetes subtypes, the aim of this document is to recommend a classification that is feasible to implement in different settings throughout the world. The revised classification is presented in Table 1. Unlike the previous classification, this classification does not recognize subtypes of type 1 diabetes and type 2 diabetes and includes new types of diabetes ("hybrid types of diabetes" and "unclassified diabetes").
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Affiliation(s)
| | - Peter Bennett
- Phoenix Epidemiology & Clinical Research Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Phoenix, USA
| | | | - Edward Gregg
- Centers for Disease Control and Prevention, Atlanta, USA
| | | | | | - Eugene Sobngwi
- Faculté de Medecine et des Sciences Biomedicales et Centre de Biotechnologie, Université de Yaounde 1, Cameroon
| | - Naoko Tajima
- Jikei University School of Medicine, Tokyo, Japan
| | - Nikhil Tandon
- All India Institute of Medical Sciences, New Delhi, India
| | - Nigel Unwin
- Chronic Disease Research Centre, The University of the West Indies, Bridgetown, Barbados, and MRC Epidemiology Unit, University of Cambridge, UK
| | | | | | - Naomi Levitt
- Diabetic Medicine and Endocrinology, Department of Medicine at Groote Schuur Hospital and University of Cape Town, South Africa
| | | | | | - Moffat J Nyirenda
- Medical Research Council/Uganda Virus Research Institute/London School of Hygiene and Tropical Medicine, Uganda Research Unit, Entebbe, Uganda
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Waddankeri SS, Swaraj Waddankeri M, Gurushantappa Mangshetty B. Clinical and Biochemical Characteristics and Treatment Outcomes of Ketosis-Prone Diabetes: The Remission Prone Diabetes. Int J Endocrinol Metab 2021; 19:e106799. [PMID: 34149844 PMCID: PMC8198612 DOI: 10.5812/ijem.106799] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 11/22/2020] [Accepted: 02/01/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is one of the severe acute complications of diabetes. It has long been considered a key clinical characteristic of type 1 diabetes mellitus (T1DM) with severe and irreversible deficient insulin levels. Ketosis-prone diabetes (KPD) has pathophysiology close to T2DM but shows signs and symptoms associated with T1DM. In general, patients with ketosis-prone diabetes display elevated glucose and ketone levels; also, a higher hemoglobin A1C than conventional T2DM. OBJECTIVES The current research aimed to elucidate the clinical presentation and outline a management plan for KPD in the Indian population. METHODS The present case series is a descriptive, prospective, and observational case series on six unprovoked cases of KPD. They were managed using the standard protocol of DKA management. RESULTS The recruited cases followed a set pattern of very high insulin requirement at diagnosis. On follow-up, the insulin requirement progressively declined, and all of the cases were able to stop insulin therapy after a mean period of four weeks. None of the cases presented any organ damage at diagnosis. There was no recurrence of DKA during the two-year follow-up. All of the cases had normal liver and renal functions. Autoantibodies were negative in all of the cases. CONCLUSIONS Ketosis-prone diabetes is the most under-recognized and under-diagnosed among all types of diabetes. Its recognition is of utmost importance as the approach of its treatment varies widely from that of the conventional type of diabetes. Proper follow-up, especially in unprovoked cases of DKA with obese phenotype, could help elucidate this rare entity of KPD where insulin can be stopped and maintain normoglycemia for a substantial period without insulin.
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Affiliation(s)
- Swaraj Shrikant Waddankeri
- Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India
- Corresponding Author: Department of Medicine, Division of Diabetes and Endocrinology, M R Medical College, Kalaburgi, India.
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Vellanki P, Stefanovski D, Anzola II, Smiley DD, Peng L, Umpierrez GE. Long-term changes in carbohydrate tolerance, insulin secretion and action in African-American patients with obesity and history of hyperglycemic crises. BMJ Open Diabetes Res Care 2020; 8:8/1/e001062. [PMID: 32475838 PMCID: PMC7265016 DOI: 10.1136/bmjdrc-2019-001062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 03/31/2020] [Accepted: 05/01/2020] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Many African-Americans (AA) with obesity with newly diagnosed diabetes presenting with diabetic ketoacidosis (DKA) or severe hyperglycemia (SH) discontinue insulin therapy and achieve near-normoglycemia remission (hemoglobin A1c (HbA1c) <7%, fasting blood glucose (FBG) <130 mg/dL) and able to be managed on oral antidiabetic agents (OAD) during follow-up. Using combined data from two randomized controlled trials, we assessed long-term carbohydrate tolerance and changes in insulin sensitivity and insulin secretion. RESEARCH DESIGN AND METHODS Seventy-five participants with DKA (n=33) and SH (n=42) underwent 2-hour 75 g oral glucose tolerance test (OGTT) after insulin discontinuation and every 6 months until hyperglycemia relapse (FBG ≥130 mg/dL, HbA1c >7% or two random BG ≥180 mg/dL) while treated with OAD (metformin, sitagliptin or pioglitazone) or placebo. Glucose tolerance status was defined as per the American Diabetes Association. Sensitivity index (Si) was calculated by oral minimal model, insulin secretion as the incremental area under the curve of insulin (IncreAUCi) and disposition index (DI) as Si×IncreAUCi. RESULTS During remission, OGTT showed normal glucose tolerance (NGT) (n=9 (12%)), prediabetes (n=34 (45%)) and diabetes (n=32 (43%)). DI and Si were higher in patients with NGT versus prediabetes versus diabetes (p<0.001), while IncreAUCi was not significantly different among NGT, prediabetes and diabetes (p=0.14). Achieving NGT status did not prolong near-normoglycemia remission. OAD treatment significantly prolonged hyperglycemia relapse-free survival (log-rank p=0.0012) compared with placebo and was associated with lower hyperglycemia relapse (HR: 0.45, 95% CI: (0.21 to 0.96), p=0.04). CONCLUSIONS In AA patients with obesity with history of DKA and SH, near-normoglycemia remission is associated with improved insulin secretion and action with half of patients achieving NGT or prediabetes, and only half having diabetes on OGTT. NGT and prediabetes on OGTT were not associated with prolonged hyperglycemia relapse-free survival. TRIAL REGISTRATION NUMBER NCT01099618, NCT00426413.
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Affiliation(s)
- Priyathama Vellanki
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Darko Stefanovski
- Department of Clinical Studies-New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Philadelphia, Pennsylvania, USA
| | - Isabel I Anzola
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dawn D Smiley
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Limin Peng
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Guillermo E Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism and Lipids, Emory University School of Medicine, Atlanta, Georgia, USA
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Zhu B, Lin Z, Chen X, Gusdon AM, Shen W, Chen J, Zheng L, Sun H, Li Y, Zhu C, Li J, Qu S. Circulating osteocalcin: A potential predictor of ketosis in type 2 diabetes. Diabetes Metab Res Rev 2020; 36:e3265. [PMID: 31850672 DOI: 10.1002/dmrr.3265] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 07/05/2019] [Accepted: 12/11/2019] [Indexed: 12/28/2022]
Abstract
AIMS Osteocalcin contributes to the regulation of endocrine system. However, the association between osteocalcin and ketosis has not been evaluated. We thus aimed to explore the relationship between total osteocalcin and risk of ketosis in type 2 diabetes (T2DM). MATERIALS AND METHODS We identified 6157 diabetes patients from Shanghai Tenth People's Hospital between 1 January 2011 and 1 March 2017. Six hundred eight subjects were enrolled in the retrospective cross-sectional study: 304 T2DM patients with ketosis whose age, gender, and body mass index were matched with 304 T2DM patients without ketosis. A further retrospective nested case-control study was conducted in 252 T2DM patients without ketosis for a mean duration of 21.58 ± 12.43 months to investigate the occurrence of ketosis. RESULTS Osteocalcin levels were negatively correlated with blood ketones (adjusted r = -0.263) and urine ketones (adjusted r = -0.183). The inverse dose-dependent relationship of osteocalcin and risk of ketosis was present across osteocalcin level quintiles (top quintile as the reference, adjusted odds ratio [95% CI] = 2.56 [0.80-8.17], 3.71 [0.90-15.29], 10.77 [2.63-44.15], 23.81 [4.32-131.17] per osteocalcin quintile, respectively). Ketosis occurred in 17 of the 252 T2DM patients during follow-up. The Cox regression analysis indicated that osteocalcin was an independent protective factor against development of ketosis (adjusted hazard ratio [95% CI]: 0.668 [0.460-0.971]). CONCLUSIONS Total osteocalcin can be used as a predictor of ketosis in T2DM.
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Affiliation(s)
- Bing Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Ziwei Lin
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Xianying Chen
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
| | - Aaron M Gusdon
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Wenjun Shen
- Division of Endocrinology,Gerontology and Metabolism, Stanford University, Stanford, CA, USA
- Veterans Affairs Palo AltoHealth Care System, Palo Alto, CA, USA
| | - Jia Chen
- Department of Endocrinology, Beijing Jishuitan Hospital, 4th Medical College of Peking University, Beijing, China
| | - Liang Zheng
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Hang Sun
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Yan Li
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Cuiling Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
| | - Jue Li
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
- National Metabolic Management Center, Shanghai, China
- Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
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Wang X, Wang F, Wu H, Chen X, Xie R, Chen T, Sun H, Zhang D, Chen L. Detection and analysis of glucose metabolism-related genes in childhood diabetes using targeted next-generation sequencing: In pediatric population-a hospital-based study. Exp Ther Med 2020; 19:3398-3404. [PMID: 32266039 DOI: 10.3892/etm.2020.8579] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 02/04/2020] [Indexed: 02/07/2023] Open
Abstract
The aim of the present study was to explore the genetic causes of antibody-negative diabetes and investigate its characteristics. A total of 64 patients with new-onset diabetes (>6 m, <16 y) were identified and their initial clinical characteristics were analyzed. Of which, 32 cases with autoantibody-negative diabetes (male, 16 cases; female, 16 cases) were screened for auto-antibodies, including islet cell antibody, glutamic acid decarboxylase antibody and islet antigen-2, which were negative, and fasting C-peptide was ≥0.3 ng/ml. Peripheral blood DNA was extracted from the subjects and their parents for high-throughput sequencing of glucose metabolism-related genes. The group with the pathogenic variation was used as the experimental group. The control group comprised 32 cases of type 1 diabetes (T1D). Their baseline clinical characteristics were determined and statistically analyzed. Out of the 32 antibody-negative diabetes cases, 21 had possible related mutations. There were 2 HNF1B missense mutations, 1 GCK missense mutation and 1 de novo KCNJ11 missense mutation. GCGR c.118G>A p.G40S was present in patients with type 2 DM (T2DM); the locus is associated with T2DM susceptibility in China. An LIPC frameshift mutation was identified, which had not been previously reported; the gene was found to markedly affect protein function and be associated with glucose and lipid metabolism. It was concluded that children with antibody-negative T1D have monogenic diabetes. The present findings shed light on the etiology and mechanism of antibody-negative diabetes, which will enable the comprehensive analysis of antibody-negative diabetes genotypes and phenotypes and further help improved precision treatment.
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Affiliation(s)
- Xiaoyan Wang
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Fengyun Wang
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Haiying Wu
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Xiuli Chen
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Rongrong Xie
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Ting Chen
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Hui Sun
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Dandan Zhang
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
| | - Linqi Chen
- Department of Endocrinology, Genetics and Metabolism, Children's Hospital of Soochow University, Suzhou, Jiangsu 215003, P.R. China
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Shidler KL, Letourneau LR, Novak LM. Uncommon Presentations of Diabetes: Zebras in the Herd. Clin Diabetes 2020; 38:78-92. [PMID: 31975755 PMCID: PMC6969666 DOI: 10.2337/cd19-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The majority of patients with diabetes are diagnosed as having either type 1 or type 2 diabetes. However, when encountered in clinical practice, some patients may not match the classic diagnostic criteria or expected clinical presentation for either type of the disease. Latent autoimmune, ketosis-prone, and monogenic diabetes are nonclassical forms of diabetes that are often misdiagnosed as either type 1 or type 2 diabetes. Recognizing the distinguishing clinical characteristics and understanding the diagnostic criteria for each will lead to appropriate treatment, facilitate personalized medicine, and improve patient outcomes.
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Affiliation(s)
- Karen L. Shidler
- North Central Indiana Area Health Education Center, Rochester, IN
| | | | - Lucia M. Novak
- Riverside Diabetes Center, Riverside Medical Associates, Riverdale, MD
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Lontchi-Yimagou E, Boudou P, Nguewa JL, Noubiap JJ, Kamwa V, Djahmeni EN, Atogho-Tiedeu B, Azabji-Kenfack M, Etoa M, Lemdjo G, Dehayem MY, Mbanya JC, Gautier JF, Sobngwi E. Acute phase ketosis-prone atypical diabetes is associated with a pro-inflammatory profile: a case-control study in a sub-Saharan African population. J Diabetes Metab Disord 2018; 17:37-43. [PMID: 30288384 PMCID: PMC6154517 DOI: 10.1007/s40200-018-0336-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 01/01/2018] [Indexed: 12/01/2022]
Affiliation(s)
- Eric Lontchi-Yimagou
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon
| | - Philippe Boudou
- 2Unit of Hormonal Biology, Department of Biochemistry, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 1 avenue Claude Vellefaux, 75010 Paris, France
| | - Jean Louis Nguewa
- 3Inserm UMRS 1138, Cordeliers Research Centre, University Paris-6, 75006 Paris, France
| | - Jean Jacques Noubiap
- 4Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Vicky Kamwa
- University hospital of Birmingham, Birmingham, UK
| | | | - Babara Atogho-Tiedeu
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon
| | - Marcel Azabji-Kenfack
- 7Department of Physiological Sciences and Biochemistry, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Martine Etoa
- National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Gaelle Lemdjo
- National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon
| | | | - Jean Claude Mbanya
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon.,National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon.,8Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
| | - Jean-Francois Gautier
- 2Unit of Hormonal Biology, Department of Biochemistry, Saint-Louis University Hospital, Assistance Publique-Hôpitaux de Paris (APHP), 1 avenue Claude Vellefaux, 75010 Paris, France.,3Inserm UMRS 1138, Cordeliers Research Centre, University Paris-6, 75006 Paris, France
| | - Eugène Sobngwi
- 1Laboratory for Molecular Medicine and Metabolism, Biotechnology Center, University of Yaoundé 1, PO Box 87, Yaoundé, Cameroon.,National Obesity Centre, Yaoundé Central Hospital, Yaoundé, Cameroon.,8Department of Internal Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé 1, Yaoundé, Cameroon
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Hui Fang CE, Rafey MF, Cunningham A, Dinneen SF, Finucane FM. Risperidone-induced type 2 diabetes presenting with diabetic ketoacidosis. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180031. [PMID: 29770221 PMCID: PMC5948194 DOI: 10.1530/edm-18-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 11/28/2022] Open
Abstract
A 28-year-old male presented with 2 days of vomiting and abdominal pain, preceded by 2 weeks of thirst, polyuria and polydipsia. He had recently started risperidone for obsessive-compulsive disorder. He reported a high dietary sugar intake and had a strong family history of type 2 diabetes mellitus (T2DM). On admission, he was tachycardic, tachypnoeic and drowsy with a Glasgow Coma Scale (GCS) of 10/15. We noted axillary acanthosis nigricans and obesity (BMI 33.2 kg/m2). Dipstick urinalysis showed ketonuria and glycosuria. Blood results were consistent with diabetic ketoacidosis (DKA), with hyperosmolar state. We initiated our DKA protocol, with intravenous insulin, fluids and potassium, and we discontinued risperidone. His obesity, family history of T2DM, acanthosis nigricans and hyperosmolar state prompted consideration of T2DM presenting with ‘ketosis-prone diabetes’ (KPD) rather than T1DM. Antibody markers of beta-cell autoimmunity were subsequently negative. Four weeks later, he had modified his diet and lost weight, and his metabolic parameters had normalised. We reduced his total daily insulin dose from 35 to 18 units and introduced metformin. We stopped insulin completely by week 7. At 6 months, his glucometer readings and glycated haemoglobin (HbA1c) level had normalised.
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Affiliation(s)
- Clarissa Ern Hui Fang
- Bariatric Medicine Service, Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
| | - Mohammed Faraz Rafey
- Bariatric Medicine Service, Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland.,HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - Aine Cunningham
- Bariatric Medicine Service, Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland
| | - Sean F Dinneen
- Bariatric Medicine Service, Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland.,HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - Francis M Finucane
- Bariatric Medicine Service, Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Galway, Ireland.,HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
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12
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Gupta RD, Ramachandran R, Gangadhara P, Anoop S, Singh SH, Satyaraddi A, Sathyakumar S, Asha HS, Thomas N. Clinical characteristics, beta-cell dysfunction and treatment outcomes in patients with A-β+ Ketosis-Prone Diabetes (KPD): The first identified cohort amongst Asian Indians. J Diabetes Complications 2017; 31:1401-1407. [PMID: 28668376 DOI: 10.1016/j.jdiacomp.2017.06.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/01/2017] [Accepted: 06/16/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Ketosis-prone diabetes (KPD), an atypical form of diabetes, has emerged as a heterogeneous syndrome in multiple ethnic groups. The objectives of this study were to look into the clinical characteristics of adult Asian Indian patients with recently diagnosed, antibody negative diabetes presenting with unprovoked ketoacidosis (A-β+ KPD) and to determine the natural course of recovery of beta-cell functions on serial follow-up over one year. RESEARCH DESIGN AND METHODS Newly diagnosed adult diabetes patients (n=11) with suspected KPD (A-β+) were prospectively studied over a period of 1-year with serial evaluations of clinical, biochemical and beta-cell secretion characteristics. These were compared with a control group (n=23) of KPD (A+β-) (classical Type 1A diabetes) with similar presentation. Beta-cell secretion was assessed by fasting and stimulated C-peptide values after a standard mixed meal challenge. Glycaemic control and treatment outcomes were also documented. RESULTS In comparison to the A+β- KPD controls, the A-β+ KPD patients had a significantly older age, higher BMI, stronger family history of type 2 diabetes, more severe ketoacidosis and higher fasting and stimulated C-peptide level at presentation. On serial follow-up, the patients with KPD achieved complete recovery of their beta-cell function with remission from insulin-dependence within 3-4months without further recurrences of DKA. CONCLUSIONS This is the first reported series of A-β+ KPD from India. The phenotype of Indian A-β+ KPD patients differs from their Western counterparts in that they are relatively younger and leaner, though the male preponderance and natural history of recovery of beta-cell dysfunction bears similarity.
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Affiliation(s)
- Riddhi Das Gupta
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
| | - Roshna Ramachandran
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Praveen Gangadhara
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Shajith Anoop
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Surjitkumar H Singh
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
| | - Anil Satyaraddi
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Samantha Sathyakumar
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - H S Asha
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India
| | - Nihal Thomas
- Department of Endocrinology, Diabetes and Metabolism, Christian Medical College (CMC), Vellore, India.
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Vellanki P, Umpierrez GE. DIABETIC KETOACIDOSIS: A COMMON DEBUT OF DIABETES AMONG AFRICAN AMERICANS WITH TYPE 2 DIABETES. Endocr Pract 2017; 23:971-978. [PMID: 28534682 DOI: 10.4158/ep161679.ra] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE More than half of African Americans (AA) with a new diagnosis of diabetic ketoacidosis have clinical and metabolic features of type 2 diabetes during follow-up. This particular presentation of diabetes has been termed as ketosis-prone type 2 diabetes (KPDM) or atypical diabetes. METHODS We review the epidemiology, diagnosis, pathophysiology, and acute and long-term management of AA with KPDM and compare these similarities to patients with type 2 diabetes. RESULTS In contrast to the long-term insulin requirement of auto-immune type 1 diabetes, patients with KPDM are able to discontinue insulin after a few months of therapy and maintain acceptable glycemic control for many years on either diet or oral agents. Patients with KPDM have significant impairment of both insulin secretion and insulin action at presentation; however, at the time of near-normoglycemia remission, insulin secretion and action improve to levels similar to hyperglycemic patients with ketosis-resistant type 2 diabetes. In the long term, however, patients with KPDM have a decline in β-cell function similar to patients with type 2 diabetes. Recent studies indicate that treatment with metformin and dipeptidyl peptidase-4 inhibitors can prolong the period of near-normoglycemia remission for several years compared to placebo therapy. CONCLUSION KPDM is a unique but common presentation of newly diagnosed African Americans with type 2 diabetes. ABBREVIATIONS A(+/-) = auto-antibody positive/negative AA = African Americans DKA = diabetic ketoacidosis FFA = free fatty acids G6PD = glucose-6-phosphate dehydrogenase GAD-65 = 65-kDA glutamic acid decarboxylase HBA1c = glycated hemoglobin A1c HHV8 = human herpes virus 8 HLA = human leukocyte antigen KPDM = ketosis-prone type 2 diabetes.
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Small C, Egan AM, Elhadi EM, O’Reilly MW, Cunningham A, Finucane FM. Diabetic ketoacidosis: a challenging diabetes phenotype. Endocrinol Diabetes Metab Case Rep 2017; 2017:16-0109. [PMID: 28458888 PMCID: PMC5404460 DOI: 10.1530/edm-16-0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 01/31/2017] [Indexed: 11/11/2022] Open
Abstract
SUMMARY We describe three patients presenting with diabetic ketoacidosis secondary to ketosis prone type 2, rather than type 1 diabetes. All patients were treated according to a standard DKA protocol, but were subsequently able to come off insulin therapy while maintaining good glycaemic control. Ketosis-prone type 2 diabetes (KPD) presenting with DKA has not been described previously in Irish patients. The absence of islet autoimmunity and evidence of endogenous beta cell function after resolution of DKA are well-established markers of KPD, but are not readily available in the acute setting. Although not emphasised in any current guidelines, we have found that a strong family history of type 2 diabetes and the presence of cutaneous markers of insulin resistance are strongly suggestive of KPD. These could be emphasised in future clinical practice guidelines. LEARNING POINTS Even in white patients, DKA is not synonymous with type 1 diabetes and autoimmune beta cell failure. KPD needs to be considered in all patients presenting with DKA, even though it will not influence their initial treatment.Aside from markers of endogenous beta cell function and islet autoimmunity, which in any case are unlikely to be immediately available to clinicians, consideration of family history of type 2 diabetes and cutaneous markers of insulin resistance might help to identify those with KPD and are more readily apparent in the acute setting, though not emphasised in guidelines.Consideration of KPD should never alter the management of the acute severe metabolic derangement of DKA, and phasing out of insulin therapy requires frequent attendance and meticulous and cautious surveillance by a team of experienced diabetes care providers.
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Affiliation(s)
- Cliona Small
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
| | - Aoife M Egan
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
| | - El Muntasir Elhadi
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
| | - Michael W O’Reilly
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
| | - Aine Cunningham
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
| | - Francis M Finucane
- HRB Clinical Research Facility, Galway University Hospitals, National University of Ireland, GalwayIreland
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15
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Zhu B, Bu L, Zhang M, Gusdon AM, Zheng L, Rampersad S, Li J, Qu S. HbA 1c as a Screening tool for Ketosis in Patients with Type 2 Diabetes Mellitus. Sci Rep 2016; 6:39687. [PMID: 28009017 PMCID: PMC5180185 DOI: 10.1038/srep39687] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 11/25/2016] [Indexed: 12/21/2022] Open
Abstract
Ketosis in patients with type 2 diabetes mellitus (T2DM) is overlooked due to atypical symptoms. The objective of this study is to evaluate the value of hemoglobin A1c (HbA1c) as a screening tool for ketosis in T2DM patients. This retrospective study consisted of 253 T2DM patients with ketosis at Shanghai 10th People’s Hospital during a period from January 1, 2011 to June 30, 2015. A control group consisted of 221 T2DM patients without ketosis randomly selected from inpatients during the same period. Receiver operating characteristic curve (ROC) analysis was used to examine the sensitivity and specificity of HbA1c as an indicator for ketosis. Higher HbA1c levels were correlated with ketosis. In patients with newly diagnosed T2DM, the area under the curve (AUC) was 0.832, with 95% confidence interval (CI) 0.754–0.911. The optimal threshold was 10.1% (87 mmol/mol). In patients with previously diagnosed T2DM, the AUC was 0.811 (95% CI: 0.767–0.856), with an optimal threshold of 8.6% (70 mmol/mol). HbA1c is a potential screening tool for ketosis in patients with T2DM. Ketosis is much more likely with HbA1c values at ≥10.1% in patients with newly diagnosed T2DM and HbA1c values at ≥8.6% in patients with previously diagnosed T2DM.
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Affiliation(s)
- Bing Zhu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Le Bu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Manna Zhang
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Aaron M Gusdon
- Department of Neurology and Neuroscience, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, United States of America
| | - Liang Zheng
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Sharvan Rampersad
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Jue Li
- Heart, Lung and Blood Vessel Center, Tongji University, Shanghai, China
| | - Shen Qu
- Department of Endocrinology and Metabolism, Shanghai Tenth People's Hospital, School of Medicine, Tongji University, Shanghai, China.,Department of Endocrinology, School of Medicine, Nanjing Medical University, Nanjing, China
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Nyenwe EA, Kitabchi AE. The evolution of diabetic ketoacidosis: An update of its etiology, pathogenesis and management. Metabolism 2016; 65:507-21. [PMID: 26975543 DOI: 10.1016/j.metabol.2015.12.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/10/2015] [Accepted: 12/16/2015] [Indexed: 12/11/2022]
Abstract
The prognosis of diabetic ketoacidosis has undergone incredibly remarkable evolution since the discovery of insulin nearly a century ago. The incidence and economic burden of diabetic ketoacidosis have continued to rise but its mortality has decreased to less than 1% in good centers. Improved outcome is attributable to a better understanding of the pathophysiology of the disease and widespread application of treatment guidelines. In this review, we present the changes that have occurred over the years, highlighting the evidence behind the recommendations that have improved outcome. We begin with a discussion of the precipitants and pathogenesis of DKA as a prelude to understanding the rationale for the recommendations. A brief review of ketosis-prone type 2 diabetes, an update relating to the diagnosis of DKA and a future perspective are also provided.
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Affiliation(s)
- Ebenezer A Nyenwe
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163.
| | - Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, University of Tennessee Health Science Center, 920 Madison Ave., Suite 300A, Memphis, TN 38163
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Zhang M, Li Y, Cui W, Yang P, Li H, Sheng C, Cheng X, Qu S. THE CLINICAL AND METABOLIC CHARACTERISTICS OF YOUNG-ONSET KETOSIS-PRONE TYPE 2 DIABETES IN CHINA. Endocr Pract 2015; 21:1364-71. [PMID: 26372299 DOI: 10.4158/ep15778.or] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate the prevalence and clinical characteristics of ketosis-prone type 2 diabetes (KPD) in Chinese patients with young-onset diabetes. METHODS A total of 238 young diabetic patients were recruited from our inpatient department from January 1, 2012, to December 28, 2014. KPD was defined as diabetes without precipitating illness and with the presence of ketosis or diabetic ketoacidosis in the absence of autoantibodies at the time of diagnosis. We reviewed the clinical characteristics and disease progression of this group of patients. RESULTS Eighteen patients fulfilled the criteria for KPD, and the prevalence of patients with KPD was 7.6%. The mean (SD) age of the KPD group at the time of diagnosis of diabetes was 27.6 (4.85) years, and these patients were predominantly male (male to female ratio, 8:1) and had a high proportion of obesity and new-onset diabetes and a strong family history of diabetes. β-Cell function in the KPD group was intermediate between type 1 and type 2 diabetes. Patients with KPD had the highest levels of glycated hemoglobin, triglycerides, total cholesterol, and free fatty acids and the lowest levels of high-density lipoprotein. After 3 to 12 months of follow-up, 17 of 18 patients with KPD (94.4%) were able to discontinue insulin therapy, and 11 patients (61.1%) were managed with diet or exercise alone. CONCLUSION KPD patients accounted for 7.6% of the diabetic patients requiring admission to a large urban hospital in China, with an age of onset of diabetes of ≤35 years. These patients are more likely to be male, have abnormal lipid metabolism, and have more reversible β-cell dysfunction.
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18
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Hyperglycaemia per se does not affect erythrocyte glucose-6-phosphate dehydrogenase activity in ketosis-prone diabetes. DIABETES & METABOLISM 2015; 41:326-330. [PMID: 26337344 DOI: 10.1016/j.diabet.2014.07.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 07/06/2014] [Accepted: 07/15/2014] [Indexed: 11/23/2022]
Abstract
AIM Previously, we described patients with ketosis-prone type 2 diabetes (KPD) and glucose-6-phosphate dehydrogenase (G6PD) deficiency, but no mutation of the G6PD gene. Our present study used two complementary approaches to test whether hyperglycaemia might inhibit G6PD activity: (1) effect of acute hyperglycaemia induced by glucose ramping; and (2) effect of chronic hyperglycaemia using correlation between G6PD activity and HbA1c levels. METHODS In the first substudy, 16 KPD patients were compared with 11 healthy, non-diabetic control subjects of the same geographical background. Erythrocyte G6PD activity and plasma glucose were assessed at baseline and every 40 min during intravenous glucose ramping that allowed maintaining hyperglycaemia for more than 3h. In the second substudy, erythrocyte G6PD activity and HbA1c levels were evaluated in 108 consecutive African patients with either type 2 diabetes or KPD, and a potential correlation sought between the two variables. RESULTS The maximum plasma glucose level after 200 min of glucose perfusion was 20.9±3.7 mmol/L for patients and 10.7±2.3mmol/L for controls. There was no difference between baseline and repeated G6PD activity levels during acute hyperglycaemia in either KPD patients (P=0.94) or controls (P=0.57), nor was there any significant correlation between residual erythrocyte G6PD activity and HbA1c levels (r=-0.085, P=0.38). CONCLUSION Neither acute nor chronic hyperglycaemia affects erythrocyte G6PD activity. Thus, hyperglycaemia alone does not explain cases of G6PD deficiency in the absence of gene mutation as described earlier.
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Gaba R, Gambhire D, Uy N, Gonzalez EV, Iyer D, Hampe CS, Ram N, Balasubramanyam A. Factors associated with early relapse to insulin dependence in unprovoked A-β+ ketosis-prone diabetes. J Diabetes Complications 2015; 29:918-22. [PMID: 26071380 PMCID: PMC4540630 DOI: 10.1016/j.jdiacomp.2015.04.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Revised: 04/13/2015] [Accepted: 04/20/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Unprovoked "A-β+" Ketosis-Prone Diabetes (KPD), a unique diabetic syndrome of adult-onset, obesity and proneness to ketoacidosis, is associated with rapid recovery of β cell function and insulin-independence. Whereas most patients experience prolonged remission, a subset relapses early to insulin dependence. We sought to define factors associated with early relapse. METHODS We utilized a prospective, longitudinal database to analyze 50 unprovoked A-β+ KPD patients with >2 measurements of β cell function and glycemia following baseline assessment. RESULTS 19 patients (38%) relapsed to insulin dependence <1 year after the index DKA episode, while 31 (62%) remained insulin-independent for >1 year (median 4.2 years). Younger age at baseline (OR=0.947, P=0.033), and lower HOMA2-%β (OR=0.982, P=0.001), lower HOMA2-IR (OR=0.582, P=0.046) and higher HbA1c at 1 year (OR=1.71, P=0.002) were associated with early relapse. A multivariate model with these variables and the interaction of HOMA2-%β and HbA1c at 1 year provided a good fit (P<0.05). CONCLUSIONS Relapse to insulin dependence in unprovoked A-β+ KPD patients is associated with younger age and, after 1 year, lack of robust increase in β cell functional reserve, and suboptimal glycemic control. Measurements of these parameters 1 year after the index DKA episode can be used to assess the need for insulin therapy.
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Affiliation(s)
- Ruchi Gaba
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | | | - Natalie Uy
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | - Erica V Gonzalez
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Dinakar Iyer
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX
| | | | - Nalini Ram
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Ashok Balasubramanyam
- Translational Metabolism Unit, Diabetes Research Center, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX.
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Affiliation(s)
- Sabina B. Safder
- Internal Medicine Department, University of Kansas School of Medicine, Wichita, KA
| | - Rami Mortada
- Department of Endocrinology, University of Kansas School of Medicine, Wichita, KA
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21
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Seth P, Kaur H, Kaur M. Clinical Profile of Diabetic Ketoacidosis: A Prospective Study in a Tertiary Care Hospital. J Clin Diagn Res 2015; 9:OC01-4. [PMID: 26266145 DOI: 10.7860/jcdr/2015/8586.5995] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Accepted: 04/09/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Diabetic ketoacidosis, a well-known and major acute metabolic complication classically occurs in young patients with type 1 diabetes. However, it may occur in patients with type 2 Diabetes Mellitus too. OBJECTIVE Aim of this study was to look into the clinical profile, precipitating factors and clinical outcome in the patients presenting with Diabetic ketoacidosis in the Emergency of a Tertiary care hospital. DESIGN The study was a prospective study conducted over a period of two years in Kasturba Medical College, Manipal Karnataka, India. MATERIALS AND METHODS Clinical profile of 60 diabetic patients admitted in the Emergency with the diagnosis of Diabetic ketoacidosis were analysed. RESULTS Out of 60 patients, 12 were of Type 1 and 48 were Type 2 Diabetes Mellitus. Mean duration of diabetes was 8.65 years. Only 14 (23.3%) patients were taking regular treatment for Diabetes Mellitus whereas 32 (53.33%) patients were on irregular treatment and eight (13.33%) were not on any treatment at all. Among 12 Type 1 Diabetic patients, six patients were freshly diagnosed to be diabetic when they presented with Diabetic ketoacidosis complication. Nausea and vomiting (63.33%) were the most common symptoms of these patients. Infections (73.33%) were the most common precipitating factor for Diabetic ketoacidosis. Mean fluid requirement on first day of therapy was 3.51 liters. Mortality of 10% was seen. CONCLUSION Diabetic ketoacidosis is a fatal acute metabolic complication of Diabetes Mellitus with heterogeneous clinical presentation. Early diagnosis and treatment can avoid morbidity & mortality.
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Affiliation(s)
- Pankaj Seth
- Assistant Professor, Department of Emergency Medicine, Dayanand Medical College and Hospital , Ludhiana, India
| | - Harpreet Kaur
- Assistant Professor, Department of Emergency Medicine, Dayanand Medical College and Hospital , Ludhiana, India
| | - Maneet Kaur
- Assistant Professor, Department of Emergency Medicine, Dayanand Medical College and Hospital , Ludhiana, India
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Gaillard TR, Osei K. Racial Disparities in the Pathogenesis of Type 2 Diabetes and its Subtypes in the African Diaspora: A New Paradigm. J Racial Ethn Health Disparities 2015; 3:117-28. [PMID: 26896111 DOI: 10.1007/s40615-015-0121-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 04/22/2015] [Accepted: 04/24/2015] [Indexed: 01/23/2023]
Abstract
The global epidemic of diabetes has extended to the developing countries including Sub-Sahara Africa. In this context, blacks with type 2 diabetes in the African Diaspora continue to manifest 1.5-2 times higher prevalent rates than in their white counterparts. Previous studies have demonstrated that blacks with and without type 2 diabetes have alterations in hepatic and peripheral insulin sensitivity, beta-cell function, and hepatic insulin clearance as well as hepatic glucose dysregulation when compared to whites. In addition, non-diabetic blacks in the African Diaspora manifest multiple metabolic mediators that predict type 2 diabetes and its subtypes. These pathogenic modifiers include differences in subclinical inflammation, oxidative stress burden, and adipocytokines in blacks in the African Diaspora prior to clinical diagnosis. Consequently, blacks in the African Diaspora manifest subtypes of type 2 diabetes, including ketosis-prone diabetes and J type diabetes. Given the diversity of type 2 diabetes in blacks in the African Diaspora, we hypothesize that blacks manifest multiple early pathogenic defects prior to the diagnosis of type 2 diabetes and its subtypes. These metabolic alterations have strong genetic component, which appears to play pivotal and primary role in the pathogenesis of type 2 diabetes and its subtypes in blacks in the African Diaspora. However, environmental factors must also be considered as major contributors to the higher prevalence of type 2 diabetes and its subtypes in blacks in the African Diaspora. These multiple alterations should be targets for early prevention of type 2 diabetes in blacks in the African Diaspora.
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Affiliation(s)
- Trudy R Gaillard
- Division of Endocrinology Diabetes and Metabolism, The Ohio State University Wexner Medical Center, 561 McCampbell Hall, South, 1581 Dodd Drive, Columbus, OH, 43210, USA.
| | - Kwame Osei
- The Ohio State University Wexner Medical Center, 561 McCampbell Hall, 5th Floor South, 1581 Dodd Hall, Columbus, OH, 43210, USA.
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23
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Gupta P, Liu Y, Lapointe M, Yotsapon T, Sarat S, Cianflone K. Changes in circulating adiponectin, leptin, glucose and C-peptide in patients with ketosis-prone diabetes. Diabet Med 2015; 32:692-700. [PMID: 25407468 DOI: 10.1111/dme.12638] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 01/01/2023]
Abstract
AIMS To evaluate circulating adipokines in people with ketosis-prone diabetes, a heterogeneous disorder characterized by unprovoked ketoacidosis in people with previously unrecognized diabetes. METHODS Patients presenting with ketoacidosis with no previous diabetes diagnosis were compared with patients with previously established Type 1 diabetes. Baseline assessments of autoimmune status (A+/A-), and β-cell function (B+/B-), as well as leptin and adiponectin levels during a standardized mixed-meal tolerance test of 120 min, were performed. In all, 20 patients with heterogeneous ketosis-prone diabetes and 12 patients with Type 1 diabetes were evaluated at baseline, 12 and 24 months. RESULTS At baseline, during a mixed-meal tolerance test, glucose and adiponectin concentrations were lower in patients with ketosis-prone diabetes than in those with Type 1 diabetes (P = 0.0023 and P < 0.0001, respectively), whereas C-peptide concentrations were higher, with no significant difference in leptin concentrations. Within 12 months, 11 patients with ketosis-prone diabetes (all A-/B+) were discontinued from insulin treatment (ketosis-prone diabetes - insulin group), while nine patients (four A-B-, four A+B- and one A-B+) were maintained on insulin (ketosis-prone diabetes + insulin group). Fasting C-peptide levels increased significantly over 24 months in the ketosis-prone diabetes - insulin group (P = 0.01), while HbA1c levels decreased (P < 0.0001). Overall, the ketosis-prone diabetes - insulin group had a higher BMI (P = 0.018), yet a lower fasting glucose concentration (P = 0.003) compared with the ketosis-prone diabetes + insulin group. Over 24 months, the mixed-meal tolerance test area-under-the-curve of C-peptide increased in the ketosis-prone diabetes - insulin group, with no change in ketosis-prone diabetes + insulin (P < 0.0001). At 24 months, in spite of the higher BMI in the ketosis-prone diabetes - insulin group, mixed-meal tolerance test glucose and leptin concentrations were significantly lower (P < 0.0001 and P = 0.017, respectively), while adiponectin levels were higher (P = 0.023) compared with the ketosis-prone diabetes + insulin group. CONCLUSIONS In spite of the higher BMI in the ketosis-prone diabetes - insulin group, lower leptin and higher adiponectin levels may contribute to improved β-cell function and insulin sensitivity, as evidenced by lower glucose and higher C-peptide levels. This allows insulin therapy to be withdrawn.
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Affiliation(s)
- P Gupta
- Centre de Recherche de l'Institut Universitaire de Cardiologie & Pneumologie de Québec, Université Laval, Québec, Canada
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Radhakutty A, Shen J, Hooper AJ, Miller SA, Burnett JR, Mah PM, Burt MG, Doogue MP. Quantification and genotyping of lipoprotein lipase in patients with diabetic lipaemia. Diabet Med 2014; 31:1702-7. [PMID: 25131724 DOI: 10.1111/dme.12565] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 05/24/2014] [Accepted: 06/11/2014] [Indexed: 01/24/2023]
Abstract
AIMS To determine if diabetic lipaemia is caused by loss of function mutations in the lipoprotein lipase gene, LPL. METHODS We conducted a case-control study over 2 years in two tertiary care hospitals in South Australia. Six patients with a history of diabetic lipaemia and 12 control subjects, with previous diabetic ketoacidosis and peak triglyceride concentrations < 2.4 mmol/l were included. Participants were well at the time of study investigations. RESULTS Only one patient with lipaemia had a loss of function mutation in LPL and no functional mutations in APOC2 or GPIHBP1 were identified. The mean lipoprotein lipase concentration was lower in patients with diabetic lipaemia than in control subjects (306 vs. 484 μg/l, P = 0.04). The mean fasting C-peptide concentration was higher in patients with diabetic lipaemia than in control subjects (771 vs. 50 pmol/l; P = 0.001). CONCLUSIONS Lipoprotein lipase deficiency in patients with a history of diabetic lipaemia was predominantly quantitative, rather than secondary to mutations in LPL, APOC2 or GPIHBP1. The majority of patients with severe hypertriglyceridaemia in diabetic ketoacidosis may have ketosis-prone Type 2, rather than Type 1, diabetes.
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Affiliation(s)
- A Radhakutty
- Southern Adelaide Diabetes and Endocrine Services, Adelaide, Australia
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Liu Y, Gupta P, Lapointe M, Yotsapon T, Sarat S, Cianflone K. Acylation stimulating protein, complement C3 and lipid metabolism in ketosis-prone diabetic subjects. PLoS One 2014; 9:e109237. [PMID: 25275325 PMCID: PMC4183552 DOI: 10.1371/journal.pone.0109237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 09/03/2014] [Indexed: 01/29/2023] Open
Abstract
Background Ketosis-prone diabetes (KPDM) is new-onset diabetic ketoacidosis without precipitating factors in non-type 1 diabetic patients; after management, some are withdrawn from exogenous insulin, although determining factors remain unclear. Methods Twenty KPDM patients and twelve type 1 diabetic patients (T1DM), evaluated at baseline, 12 and 24 months with/without insulin maintenance underwent a standardized mixed-meal tolerance test (MMTT) for 2 h. Results At baseline, triglyceride and C3 were higher during MMTT in KPDM vs. T1DM (p<0.0001) with no differences in non-esterified fatty acids (NEFA) while Acylation Stimulating Protein (ASP) tended to be higher. Within 12 months, 11 KPDM were withdrawn from insulin treatment (KPDM-ins), while 9 were maintained (KPDM+ins). NEFA was lower in KPDM-ins vs. KPDM+ins at baseline (p = 0.0006), 12 months (p<0.0001) and 24 months (p<0.0001) during MMTT. NEFA in KPDM-ins decreased over 30–120 minutes (p<0.05), but not in KPDM+ins. Overall, C3 was higher in KPDM-ins vs KPDM+ins at 12 months (p = 0.0081) and 24 months (p = 0.0019), while ASP was lower at baseline (p = 0.0024) and 12 months (p = 0.0281), with a decrease in ASP/C3 ratio. Conclusions Notwithstanding greater adiposity in KPDM-ins, greater NEFA decreases and lower ASP levels during MMTT suggest better insulin and ASP sensitivity in these patients.
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Affiliation(s)
- Yan Liu
- Centre de Recherche de l’Institut Universitaire de Cardiologie & Pneumologie de Québec, Université Laval, Québec, Canada
- Department of Pediatrics, Tongji Hospital, HuaZhong University of Science and Technology, Wuhan, Hubei, P. R. China
| | - Priyanka Gupta
- Centre de Recherche de l’Institut Universitaire de Cardiologie & Pneumologie de Québec, Université Laval, Québec, Canada
| | - Marc Lapointe
- Centre de Recherche de l’Institut Universitaire de Cardiologie & Pneumologie de Québec, Université Laval, Québec, Canada
| | - Thewjitcharoen Yotsapon
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sunthornyothin Sarat
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Katherine Cianflone
- Centre de Recherche de l’Institut Universitaire de Cardiologie & Pneumologie de Québec, Université Laval, Québec, Canada
- * E-mail:
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O Ekpebegh C, Longo-Mbenza B, Blanco-Blanco E. Glycosylated haemoglobin is markedly elevated in new and known diabetes patients with hyperglycaemic ketoacidosis. Afr Health Sci 2014; 14:526-32. [PMID: 25352868 DOI: 10.4314/ahs.v14i3.5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Glycosylated haemoglobin (HbA1c) and random blood glucose are markers of chronic and acute hyperglycaemia respectively. OBJECTIVE We compared HbA1c levels in ketoacidosis (DKA) occurring in known and newly diagnosed diabetes. METHODS Retrospective review of medical records for 83 DKA admissions in 2008 and 2009 with results for HbA1c at presentation. RESULTS There were 52 and 31 DKA admissions in known and newly diagnosed diabetes patients respectively. Fifty of the 83 DKA admissions were in females. The mean age (per admissions) and HbA1c of all admissions are 43.4 ± 20.3 years (n=83) and 12.7 ± 3.4 % (n=83) respectively. Mean HbA1c in known Type 1, known Type 2 and newly diagnosed diabetes patients were similarly very high: 12.4 ± 3.3 %, 12.5 ± 3.3 %, 13.1 ± 3.7 %; P = 0.6828. The HbA1c levels in newly diagnosed diabetes patients less than 30 years (likely Type 1 diabetes) and ≥ 30 years (likely Type 2 diabetes) were similar. There was a tendency to significantly positive correlation between blood glucose and HbA1c in new diabetes patients. CONCLUSIONS In our setting, DKA is associated with markedly elevated HbA1c levels in known type 1, known type 2 and new onset diabetes.
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Affiliation(s)
- Chukwuma O Ekpebegh
- Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, Private Mail Bag X1, Mthatha, Postal code 5117, Mthatha, Eastern Cape Province, South Africa
| | - Benjamin Longo-Mbenza
- Department of Internal Medicine, Faculty of Health Sciences, Walter Sisulu University, Mthatha, Private Mail Bag X1, Mthatha, Postal code 5117, Mthatha, Eastern Cape Province, South Africa
| | - Ernesto Blanco-Blanco
- Department of Chemical Pathology, Faculty of Health Sciences, Walter Sisulu University, Mthatha, Private Mail Bag X1, Mthatha, Postal code 5117, Mthatha, Eastern Cape Province, South Africa
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Li MF, Ren Y, Zhao CC, Zhang R, Li LX, Liu F, Lu JX, Tu YF, Zhao WJ, Bao YQ, Jia WP. Prevalence and clinical characteristics of lower limb atherosclerotic lesions in newly diagnosed patients with ketosis-onset diabetes: a cross-sectional study. Diabetol Metab Syndr 2014; 6:71. [PMID: 24926320 PMCID: PMC4054910 DOI: 10.1186/1758-5996-6-71] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 05/26/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The clinical features of atherosclerotic lesions in ketosis-onset diabetes are largely absent. We aimed to compare the characteristics of lower limb atherosclerotic lesions among type 1, ketosis-onset and non-ketotic type 2 diabetes. METHODS A cross-sectional study was performed in newly diagnosed Chinese patients with diabetes, including 53 type 1 diabetics with positive islet-associated autoantibodies, 208 ketosis-onset diabetics without islet-associated autoantibodies, and 215 non-ketotic type 2 diabetics. Sixty-two subjects without diabetes were used as control. Femoral intima-media thickness (FIMT), lower limb atherosclerotic plaque and stenosis were evaluated and compared among the four groups based on ultrasonography. The risk factors associated with lower limb atherosclerotic plaque were evaluated via binary logistic regression in patients with diabetes. RESULTS After adjusting for age and sex, the prevalence of lower limb plaque in the patients with ketosis-onset diabetes (47.6%) was significantly higher than in the control subjects (25.8%, p = 0.013), and showed a higher trend compared with the patients with type 1 diabetes (39.6%, p = 0.072), but no difference was observed in comparison to the patients with non-ketotic type 2 diabetes (62.3%, p = 0.859). The mean FIMT in the ketosis-onset diabetics (0.73 ± 0.17 mm) was markedly greater than that in the control subjects (0.69 ± 0.13 mm, p = 0.045) after controlling for age and sex, but no significant differences were found between the ketosis-onset diabetics and the type 1 diabetics (0.71 ± 0.16 mm, p = 0.373), and the non-ketotic type 2 diabetics (0.80 ± 0.22 mm, p = 0.280), respectively. Age and FIMT were independent risk factors for the presence of lower limb plaque in both the ketosis-onset and non-ketotic type 2 diabetic patients, while sex and age in the type 1 diabetic patients. CONCLUSIONS The prevalence and risk of lower limb atherosclerotic plaque in the ketosis-onset diabetes were remarkably higher than in the control subjects without diabetes. The features and risk factors of lower limb atherosclerotic lesions in the ketosis-onset diabetes resembled those in the non-ketotic type 2 diabetes, but different from those in the type 1 diabetes. Our findings provide further evidences to support the classification of ketosis-onset diabetes as a subtype of type 2 diabetes rather than idiopathic type 1 diabetes.
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Affiliation(s)
- Mei-Fang Li
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Ying Ren
- Department of VIP, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Cui-Chun Zhao
- Department of VIP, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, 600 Yishan Road, Shanghai 200233, China
| | - Rong Zhang
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Lian-Xi Li
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Fang Liu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Jun-Xi Lu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Yin-Fang Tu
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Wei-Jing Zhao
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Yu-Qian Bao
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
| | - Wei-Ping Jia
- Department of Endocrinology and Metabolism, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital; Shanghai Diabetes Institute; Shanghai Clinical Center for Diabetes; Shanghai key Laboratory of Diabetes Mellitus, 600 Yishan Road, Shanghai 200233, China
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Xie XJ, Hu Y, Cheng C, Feng TT, He K, Mao XM. Should diabetic ketosis without acidosis be included in ketosis-prone type 2 diabetes mellitus? Diabetes Metab Res Rev 2014; 30:54-9. [PMID: 24038858 DOI: 10.1002/dmrr.2448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Revised: 07/31/2013] [Accepted: 08/19/2013] [Indexed: 11/07/2022]
Abstract
BACKGROUND The incidence of ketosis-prone type 2 diabetes is very low except for people of sub-Saharan African origin and African Americans. However, there also are some type 2 diabetes patients with diabetic ketosis without acidosis (DKWA). We question whether DKWA should be included as a subtype of ketosis-prone type 2 diabetes mellitus and compared the clinical characteristics of DKWA and diabetic ketoacidosis (DKA) patients. METHODS The study population consisted of 594 consecutive unrelated Chinese inpatients with newly diagnosed type 2 diabetes. Demographic and clinical characteristics (age, gender, family history of diabetes, body mass index, blood pressure and plasma lipid parameters) were recorded. The patients were divided into ketosis-resistant diabetes (KRD), DKWA and DKA groups on the basis of urinary ketones, blood pH and bicarbonate levels. The blood glucose and c-peptide levels of the patients were also evaluated. RESULTS The prevalence of KRD, DKWA and DKA were 78.33%, 19.72% and 1.95%, respectively, in the study population. The clinical characteristics of patients with DKWA group patients were similar to those with DKA, except that DKA patients had higher blood glucose and deteriorated β cell function. CONCLUSIONS Diabetic ketosis without acidosis and DKA patients share similar clinical characteristics; DKWA should be considered ketosis-prone type 2 diabetes. Therefore, the prevalence of ketosis-prone type 2 diabetes might be underestimated.
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Affiliation(s)
- Xiao-Jing Xie
- Department of Endocrinology, Nanjing First Hospital Affiliated to Nanjing Medical University, 68 ChangLe St., Nanjing, China
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Comparison of Diabetic Ketoacidosis in Patients With Type-1 and Type-2 Diabetes Mellitus. Am J Med Sci 2013; 345:326-330. [DOI: 10.1097/maj.0b013e31827424ab] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Vaibhav A, Mathai M, Gorman S. Atypical diabetes in children: ketosis-prone type 2 diabetes. BMJ Case Rep 2013; 2013:bcr-2012-007704. [PMID: 23302548 DOI: 10.1136/bcr-2012-007704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Ketosis-prone type 2 diabetes mellitus also known as atypical or flatbush diabetes is being increasingly recognised worldwide. These patients are typically obese, middle-aged men with a strong family history of type 2 diabetes. The aetiology and pathophysiological mechanism is still unclear but some initial research suggests that patients with ketosis-prone type 2 diabetes have a unique predisposition to glucose desensitisation. These patients have negative autoantibodies typically associated with type 1 diabetes but have shown to have human leucocyte antigen (HLA) positivity. At initial presentation, there is an impairment of both insulin secretion and action. β Cell function and insulin sensitivity can be markedly improved by initiating aggressive diabetes management to allow for discontinuation of insulin therapy within a few months of treatment. These patients can be maintained on oral hypoglycaemic agents and insulin therapy can be safely discontinued after few months depending on their β cell function.
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Affiliation(s)
- Atul Vaibhav
- Department of Paediatrics, Bradford Royal Infirmary, Bradford, West Yorkshire, UK.
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Low JC, Felner EI, Muir AB, Brown M, Dorcelet M, Peng L, Umpierrez GE. Do obese children with diabetic ketoacidosis have type 1 or type 2 diabetes? Prim Care Diabetes 2012; 6:61-65. [PMID: 22230097 PMCID: PMC3746511 DOI: 10.1016/j.pcd.2011.11.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2011] [Revised: 11/20/2011] [Accepted: 11/22/2011] [Indexed: 01/14/2023]
Abstract
OBJECTIVE Many obese children with unprovoked diabetic ketoacidosis (DKA) display clinical features of type 2 diabetes during follow up. We describe the clinical presentation, autoimmune markers and the long-term course of obese and lean children with DKA. RESEARCH DESIGN AND METHODS We reviewed the medical records on the initial acute hospitalization and outpatient follow-up care of 21 newly diagnosed obese and 20 lean children with unprovoked DKA at Emory University affiliated children's hospitals between 1/2003 and 12/2006. RESULTS Obese children with DKA were older and predominantly male, had acanthosis nigricans, and had lower prevalence of autoantibodies to islet cells and glutamic acid decarboxylase than lean children. Half of the obese, but none of the lean children with DKA achieve near-normoglycemia remission and discontinued insulin therapy during follow-up. Time to achieve remission was 2.2±2.3 months. There were no differences on clinical presentation between obese children who achieved near-normoglycemia remission versus those who did not. The addition of metformin to insulin therapy shortly after resolution of DKA resulted in lower hemoglobin A1c (HbA1c) levels, higher rates of near-normoglycemia remission, and lower frequency of DKA recurrence. Near-normoglycemia remission, however, was of short duration and the majority of obese patients required reinstitution of insulin treatment within 15 months of follow-up. CONCLUSION In contrast to lean children with DKA, many obese children with unprovoked DKA display clinical and immunologic features of type 2 diabetes during follow-up. The addition of metformin to insulin therapy shortly after resolution of DKA improves glycemic control, facilitates achieving near-normoglycemia remission and prevents DKA recurrence in obese children with DKA.
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Affiliation(s)
- Joey C. Low
- Department of Pediatrics, Division of Endocrinology, Atlanta, GA, United States
| | - Eric I. Felner
- Department of Pediatrics, Division of Endocrinology, Atlanta, GA, United States
| | - Andrew B. Muir
- Department of Pediatrics, Division of Endocrinology, Atlanta, GA, United States
| | - Milton Brown
- Department of Pediatrics, Division of Endocrinology, Atlanta, GA, United States
| | - Margalie Dorcelet
- Department of Pediatrics, Division of Endocrinology, Atlanta, GA, United States
| | - Limin Peng
- Rollins School of Public Health, Atlanta, GA, United States
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Smiley D, Chandra P, Umpierrez GE. Update on diagnosis, pathogenesis and management of ketosis-prone Type 2 diabetes mellitus. ACTA ACUST UNITED AC 2011; 1:589-600. [PMID: 22611441 DOI: 10.2217/dmt.11.57] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Diabetic ketoacidosis (DKA) has been considered a key clinical feature of Type 1 diabetes mellitus; however, increasing evidence indicates that DKA is also a common feature of Type 2 diabetes (T2DM). Many cases of DKA develop under stressful conditions such as trauma or infection but an increasing number of cases without precipitating cause have been reported in children and adults with T2DM. Such patients present with severe hyperglycemia and ketosis as in Type 1 diabetes mellitus but can discontinue insulin after a few months and maintain acceptable glycemic control on diet or oral agents. This subtype of diabetes has been referred to as ketosis-prone T2DM. In this article, we reviewed the literature on ketosis-prone T2DM and summarized the epidemiology, putative pathophysiology and approaches to management.
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Affiliation(s)
- Dawn Smiley
- Emory University School of Medicine, Division of Endocrinology & Metabolism, Atlanta, GA 30303, USA
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Modern concepts of preoperative preparation of patients with thyroid gland disease. ACTA CHIRURGICA IUGOSLAVICA 2011; 58:103-8. [PMID: 21879658 DOI: 10.2298/aci1102103s] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Preoperative evaluation of patients with thyroid land disease, in any kind of surgery, should include the possibility of difficult intubation caused by thyromegaly, the hormonal status (its disbalance), as well as the screening, and therapy of consequences of thyroid imbalance on specific organ systems, especially cardiovascular. It is necessary to select the adequate anesthetics and other pharmacological agents, according to current hormonal status. It is also necessary to select the adequate medications and other therapeutic measures for prevention and treatment of possible complications in perioperative period, some of which are life-threatening (thyroid storm and mixedema coma).
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HLA class II alleles susceptibility markers of type 1 diabetes fail to specify phenotypes of ketosis-prone diabetes in adult Tunisian patients. EXPERIMENTAL DIABETES RESEARCH 2011; 2011:964160. [PMID: 21461382 PMCID: PMC3063415 DOI: 10.1155/2011/964160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2010] [Revised: 12/28/2010] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
Abstract
We aimed to characterize the different subgroups of ketosis-prone diabetes (KPD) in a sample of Tunisian patients using the Aβ scheme based on the presence or absence of β-cell autoantibodies (A+ or A-) and β-cell functional reserve (β+ or β-) and we investigated whether HLA class II alleles could contribute to distinct KPD phenotypes. We enrolled 43 adult patients with a first episode of ketosis. For all patients we evaluated clinical parameters, β-cell autoimmunity, β-cell function and HLA class II alleles. Frequency distribution of the 4 subgroups was 23.3% A+β-, 23.3% A-β-, 11.6% A+β+ and 41.9% A-β+. Patients from the group A+β- were significantly younger than those from the group A-β- (P = .002). HLA susceptibility markers were significantly more frequent in patients with autoantibodies (P = .003). These patients also had resistance alleles but they were more frequent in A+β+ than A+β- patients (P = .04). Insulin requirement was not associated to the presence or the absence of HLA susceptibility markers. HLA class II alleles associated with susceptibility to autoimmune diabetes have not allowed us to further define Tunisian KPD groups. However, high prevalence of HLA resistance alleles in our patients may reflect a particular genetic background of Tunisian KPD population.
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Nalini R, Ozer K, Maldonado M, Patel SG, Hampe CS, Guthikonda A, Villanueva J, Smith EO, Gaur LK, Balasubramanyam A. Presence or absence of a known diabetic ketoacidosis precipitant defines distinct syndromes of "A-β+" ketosis-prone diabetes based on long-term β-cell function, human leukocyte antigen class II alleles, and sex predilection. Metabolism 2010; 59:1448-55. [PMID: 20170930 PMCID: PMC2888957 DOI: 10.1016/j.metabol.2010.01.009] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2009] [Revised: 01/01/2010] [Accepted: 01/14/2010] [Indexed: 11/20/2022]
Abstract
Ketosis-prone diabetes (KPD) is heterogeneous. Longitudinal follow-up revealed that patients with "A-β+" KPD (absent autoantibodies and preserved β-cell function) segregated into 2 subgroups with distinct evolution of β-cell function and glycemic control. Generalized linear analysis demonstrated that the variable that most significantly differentiated them was presence of a clinically evident precipitating event for the index diabetic ketoacidosis (DKA). Hence, we performed a comprehensive analysis of A-β+ KPD patients presenting with "provoked" compared with "unprovoked" DKA. Clinical, biochemical, and β-cell functional characteristics were compared between provoked and unprovoked A-β+ KPD patients followed prospectively for 1 to 8 years. Human leukocyte antigen class II allele frequencies were compared between these 2 groups and population controls. Unprovoked A-β+ KPD patients (n = 83) had greater body mass index, male preponderance, higher frequency of women with oligo-/anovulation, more frequent African American ethnicity, and less frequent family history of diabetes than provoked A-β+ KPD patients (n = 64). The provoked group had higher frequencies of the human leukocyte antigen class II type 1 diabetes mellitus susceptibility alleles DQB1*0302 (than the unprovoked group or population controls) and DRB1*04 (than the unprovoked group), whereas the unprovoked group had a higher frequency of the protective allele DQB1*0602. β-Cell secretory reserve and glycemic control improved progressively in the unprovoked group but declined in the provoked group. The differences persisted in comparisons restricted to patients with new-onset diabetes. "Unprovoked" A-β+ KPD is a distinct syndrome characterized by reversible β-cell dysfunction with male predominance and increased frequency of DQB1*0602, whereas "provoked" A-β+ KPD is characterized by progressive loss of β-cell reserve and increased frequency of DQB1*0302 and DRB1*04. Unprovoked DKA predicts long-term β-cell functional reserve, insulin independence, and glycemic control in KPD.
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Affiliation(s)
- Ramaswami Nalini
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Kerem Ozer
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Mario Maldonado
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Novartis, Inc., Basel, Switzerland
| | - Sanjeet G. Patel
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
| | | | - Anu Guthikonda
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - Jesus Villanueva
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Endocrine Service, Ben Taub General Hospital, Houston, TX
| | - E. O'Brian Smith
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Lakshmi K. Gaur
- Puget Sound Blood Center, University of Washington, Seattle, WA
| | - Ashok Balasubramanyam
- Translational Metabolism Unit, Baylor College of Medicine, Houston, TX
- Endocrine Service, Ben Taub General Hospital, Houston, TX
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Gosmanov AR, Smiley D, Robalino G, Siqueira JM, Peng L, Kitabchi AE, Umpierrez GE. Effects of intravenous glucose load on insulin secretion in patients with ketosis-prone diabetes during near-normoglycemia remission. Diabetes Care 2010; 33:854-60. [PMID: 20067967 PMCID: PMC2845041 DOI: 10.2337/dc09-1687] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Most patients with ketosis-prone type 2 diabetes (KPD) discontinue insulin therapy and remain in near-normoglycemic remission. The aim of this study was to determine the effect of glucotoxicity on beta-cell function during remission in obese patients with KPD. RESEARCH DESIGN AND METHODS Age- and BMI-matched obese African Americans with a history of KPD (n = 8), severe hyperglycemia but without ketosis (ketosis-resistant type 2 diabetes, n = 7), and obese control subjects (n = 13) underwent intravenous infusion of 10% dextrose at a rate of 200 mg per m(2)/min for 20 h. beta-Cell function was assessed by changes in insulin and C-peptide concentrations during dextrose infusion and by changes in acute insulin response (AIR) and first-phase insulin release (FPIR) to arginine stimulation before and after dextrose infusion. RESULTS The mean +/- SD time to discontinue insulin therapy was 7.1 +/- 1.7 weeks in KPD and 9.6 +/- 2.3 weeks in ketosis-resistant type 2 diabetes (NS). During a 20-h dextrose infusion, changes in insulin, C-peptide, and the C-peptide-to-glucose ratio were similar among diabetic and control groups. During dextrose infusion, subjects with ketosis-resistant type 2 diabetes had greater areas under the curve for blood glucose than subjects with KPD and control subjects (P < 0.05). The AIR and FPIR to arginine stimulation as well as glucose potentiation to arginine assessed before and after dextrose infusion were not different among the study groups. CONCLUSIONS Near-normoglycemia remission in obese African American patients with KPD and ketosis-resistant type 2 diabetes is associated with a remarkable recovery in basal and stimulated insulin secretion. At near-normoglycemia remission, patients with KPD displayed a pattern of insulin secretion similar to that of patients with ketosis-resistant type 2 diabetes and obese nondiabetic subjects.
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Umpierrez GE, Smiley D, Robalino G, Peng L, Gosmanov AR, Kitabchi AE. Lack of lipotoxicity effect on {beta}-cell dysfunction in ketosis-prone type 2 diabetes. Diabetes Care 2010; 33:626-31. [PMID: 20028938 PMCID: PMC2827521 DOI: 10.2337/dc09-1369] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Over half of newly diagnosed obese African Americans with diabetic ketoacidosis (DKA) discontinue insulin therapy and go through a period of near-normoglycemia remission. This subtype of diabetes is known as ketosis-prone type 2 diabetes (KPDM). RESEARCH DESIGN AND METHODS To investigate the role of lipotoxicity on beta-cell function, eight obese African Americans with KPDM, eight obese subjects with type 2 diabetes with severe hyperglycemia without ketosis (ketosis-resistant type 2 diabetes), and nine nondiabetic obese control subjects underwent intravenous infusion of 20% intralipid at 40 ml/h for 48 h. beta-Cell function was assessed by changes in insulin and C-peptide concentration during infusions and by changes in acute insulin response to arginine stimulation (AIR(arg)) before and after lipid infusion. RESULTS The mean time to discontinue insulin therapy was 11.0 +/- 8.0 weeks in KPDM and 9.6 +/- 2.2 weeks in ketosis-resistant type 2 diabetes (P = NS). At remission, KPDM and ketosis-resistant type 2 diabetes had similar glucose (94 +/- 14 vs. 109 +/- 20 mg/dl), A1C (5.7 +/- 0.4 vs. 6.3 +/- 1.1%), and baseline AIR(arg) response (34.8 +/- 30 vs. 64 +/- 69 microU/ml). P = NS despite a fourfold increase in free fatty acid (FFA) levels (0.4 +/- 0.3 to 1.8 +/- 1.1 mmol/l, P < 0.01) during the 48-h intralipid infusion; the response to AIR(arg) stimulation, as well as changes in insulin and C-peptide levels, were similar among obese patients with KPDM, patients with ketosis-resistant type 2 diabetes, and nondiabetic control subjects. CONCLUSIONS Near-normoglycemia remission in obese African American patients with KPDM and ketosis-resistant type 2 diabetes is associated with a remarkable recovery in basal and stimulated insulin secretion. A high FFA level by intralipid infusion for 48 h was not associated with beta-cell decompensation (lipotoxicity) in KPDM patients.
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA.
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Kim MK, Lee SH, Kim JH, Lee JI, Kim JH, Jang EH, Yoon KH, Lee KW, Song KH. Clinical characteristics of Korean patients with new-onset diabetes presenting with diabetic ketoacidosis. Diabetes Res Clin Pract 2009; 85:e8-11. [PMID: 19477546 DOI: 10.1016/j.diabres.2009.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 03/18/2009] [Accepted: 04/22/2009] [Indexed: 11/24/2022]
Abstract
We studied 65 adult patients without a history of diabetes who were diagnosed with diabetic ketoacidosis. Ketosis-prone type 2 diabetes was common (42%) among this group of Korean patients with new-onset diabetes presenting with diabetic ketoacidosis. These patients were younger, showed a greater defect in insulin secretion.
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Affiliation(s)
- Mee Kyoung Kim
- Department of Internal Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Choukem SP, Boudou P, Sobngwi E, Villette JM, Ibrahim F, Moulin P, Hadjadj S, Eberle D, Foufelle F, Vexiau P, Gautier JF. The polymorphism Arg585Gln in the gene of the sterol regulatory element binding protein-1 (SREBP-1) is not a determinant of ketosis prone type 2 diabetes (KPD) in Africans. DIABETES & METABOLISM 2009; 35:20-4. [DOI: 10.1016/j.diabet.2008.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 06/04/2008] [Accepted: 06/13/2008] [Indexed: 10/21/2022]
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Leslie RDG, Kolb H, Schloot NC, Buzzetti R, Mauricio D, De Leiva A, Yderstraede K, Sarti C, Thivolet C, Hadden D, Hunter S, Schernthaner G, Scherbaum W, Williams R, Pozzilli P. Diabetes classification: grey zones, sound and smoke: Action LADA 1. Diabetes Metab Res Rev 2008; 24:511-9. [PMID: 18615859 DOI: 10.1002/dmrr.877] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diseases gain identity from clinical phenotype as well as genetic and environmental aetiology. The definition of type 1 diabetes is clinically exclusive, comprising patients who are considered insulin dependent at diagnosis, whilst the definition of type 2 diabetes is inclusive, only excluding those who are initially insulin dependent. Ketosis-prone diabetes (KPD) and latent autoimmune diabetes in adults (LADA) are each exclusive forms of diabetes which are, at least initially, clinically distinct from type 2 diabetes and type 1 diabetes, and each have a different natural history from these major types of diabetes.KPD can be diagnosed unequivocally as diabetes presenting with the categorical clinical feature, ketoacidosis. In contrast, LADA can be diagnosed by the co-occurrence of three traits, not one of which is categorical or exclusive to the condition: adult-onset non-insulin-requiring diabetes, an islet autoantibody such as glutamic acid decarboxylase autoantibodies (GADA) or cytoplasmic islet cell autoantibodies (ICA), and no need for insulin treatment for several months post-diagnosis. But while some would split diabetes into distinct subtypes, there is a strong case that these subtypes form a continuum of varying severity of immune and metabolic dysfunction modified by genetic and non-genetic factors. This article discusses the nature of disease classification in general, and KPD and LADA in particular, emphasizing the potential value and pitfalls in classifying diabetes and suggesting a need for more research in this area.
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Affiliation(s)
- R D G Leslie
- Institute of Cell and Molecular Science, University of London, London, UK.
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Nalini R, Gaur LK, Maldonado M, Hampe CS, Rodriguez L, Garza G, Lernmark A, Balasubramanyam A. HLA class II alleles specify phenotypes of ketosis-prone diabetes. Diabetes Care 2008; 31:1195-200. [PMID: 18316396 PMCID: PMC10027360 DOI: 10.2337/dc07-1971] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Ketosis-prone diabetes (KPD) comprises four subgroups based on the presence or absence of beta-cell autoantibodies (A+ or A-) and beta-cell functional reserve (beta+ or beta-). Genetic factors could contribute to their distinctive phenotypes. Our aim was to specify the role of HLA class II alleles associated with susceptibility or resistance to autoimmune type 1 diabetes in determining KPD phenotypes. RESEARCH DESIGN AND METHODS A total of 185 adults presenting with diabetic ketoacidosis were followed longitudinally for a mean of 5.5 years, with measurements of autoantibodies, beta-cell functional reserve, insulin sensitivity, and insulin requirement. Frequencies of susceptibility and resistance alleles at HLA DQA1, DQB1, and DRB1 loci were correlated with clinical and phenotypic features of KPD subgroups and compared with those of ethnic-specific population control subjects. RESULTS Susceptibility alleles were more frequent (P < 0.0001) in the two A+ than the two A- KPD subgroups; in the latter, the frequency was no greater than in population control subjects (except for DQB1*0302). Susceptibility alleles differentiated the two clinically similar beta- subgroups (more frequent in A+beta- than A-beta- KPD; P < 0.01). Resistance alleles were more frequent in the two beta+ than the two beta- KPD subgroups (P < 0.01). The frequencies of certain susceptibility (e.g., DQB1*02) and resistance (DQB1*0602) alleles were higher in African-American A-beta+ KPD patients than in African-American control subjects. DQB1*0302 was more frequent in all KPD subgroups compared with control subjects. CONCLUSIONS HLA class II alleles associated with susceptibility or resistance to autoimmune type 1 diabetes help specify the four subgroups of KPD. Inheritance of these alleles may influence long-term beta-cell functional reserve.
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Affiliation(s)
- Ramaswami Nalini
- Translational Metabolism Unit, Division of Endocrinology, Diabetes, and Metabolism, Baylor College of Medicine, Houston, Texas 77030, USA
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Kitabchi AE, Umpierrez GE, Fisher JN, Murphy MB, Stentz FB. Thirty years of personal experience in hyperglycemic crises: diabetic ketoacidosis and hyperglycemic hyperosmolar state. J Clin Endocrinol Metab 2008; 93:1541-52. [PMID: 18270259 PMCID: PMC2386681 DOI: 10.1210/jc.2007-2577] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
CONTEXT Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) cause major morbidity and significant mortality in patients with diabetes mellitus. For more than 30 yr, our group, in a series of prospective, randomized clinical studies, has investigated the pathogenesis and evolving strategies of the treatment of hyperglycemic crises. This paper summarizes the results of these prospective studies on the management and pathophysiology of DKA. SETTING Our earliest studies evaluated the comparative efficacy of low-dose vs. pharmacological amounts of insulin and the use of low-dose therapy by various routes in adults and later in children. Subsequent studies evaluated phosphate and bicarbonate therapy, lipid metabolism, ketosis-prone type 2 patients, and use of rapid-acting insulin analogs as well as leptin status, cardiac risk factors, proinflammatory cytokines, and the mechanism of activation of T lymphocytes in hyperglycemic crises. MAIN OUTCOME The information garnered from these studies resulted in the creation of the 2001 American Diabetes Association (ADA) technical review on DKA and HHS as well as the ADA Position and Consensus Paper on the therapy for hyperglycemic crises. CONCLUSIONS Areas of future research include prospective randomized studies to do the following: 1) establish the efficacy of bicarbonate therapy in DKA for a pH less than 6.9; 2) establish the need for a bolus insulin dose in the initial therapy of DKA; 3) determine the pathophysiological mechanisms for the absence of ketosis in HHS; 4) investigate the reasons for elevated proinflammatory cytokines and cardiovascular risk factors; and 5) evaluate the efficacy and cost benefit of using sc regular insulin vs. more expensive insulin analogs on the general ward for the treatment of DKA.
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Affiliation(s)
- Abbas E Kitabchi
- Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, 920 Madison Avenue #909, Memphis, TN 38163, USA.
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Abstract
Ketosis-prone diabetes (KPD) is a widespread, emerging, heterogeneous syndrome characterized by patients who present with diabetic ketoacidosis or unprovoked ketosis but do not necessarily have the typical phenotype of autoimmune type 1 diabetes. Multiple, severe forms of beta-cell dysfunction appear to underlie the pathophysiology of KPD. Until recently, the syndrome has lacked an accurate, clinically relevant and etiologically useful classification scheme. We have utilized a large, longitudinally followed, heterogeneous, multiethnic cohort of KPD patients to identify four clinically and pathophysiologically distinct subgroups that are separable by the presence or absence of beta-cell autoimmunity and the presence or absence of beta-cell functional reserve. The resulting "Abeta" classification system of KPD has proven to be highly accurate and predictive of such clinically important outcomes as glycemic control and insulin dependence, as well as an aid to biochemical and molecular investigations into novel causes of beta-cell dysfunction. In this review, we describe the current state of knowledge in regard to the natural history, pathophysiology, and treatment of the subgroups of KPD, with an emphasis on recent advances in understanding their immunological and genetic bases.
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Affiliation(s)
- Ashok Balasubramanyam
- Translational Metabolism Unit, Division of Diabetes, Endocrinology and Metabolism, Baylor College of Medicine, Room 700B, One Baylor Plaza, and Endocrine Service, Ben Taub General Hospital, Houston, Texas 77030, USA.
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Umpierrez GE, Smiley D, Gosmanov A, Thomason D. Ketosis-prone type 2 diabetes: effect of hyperglycemia on beta-cell function and skeletal muscle insulin signaling. Endocr Pract 2007; 13:283-90. [PMID: 17599861 DOI: 10.4158/ep.13.3.283] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the underlying mechanism for the severe and transient beta-cell dysfunction and impaired insulin action in obese African American patients with ketosis-prone diabetes. METHODS The effect of sustained hyperglycemia (glucotoxicity) and increased free fatty acids (lipotoxicity) on beta-cell function was assessed by changes in insulin secretion during a 20-hour glucose (200 mg/m2 per minute) and a 48-hour Intralipid (40 mL/h) infusion, respectively. Insulin-activated signaling pathways and pattern of Akt-1 and Akt-2 expression and insulin-stimulated phosphorylation were analyzed in skeletal muscle biopsy specimens. Studies were performed in an obese African American woman within 48 hours after resolution of diabetic ketoacidosis and 1 week after discontinuation of insulin treatment. RESULTS Dextrose infusion rapidly increased C-peptide levels from a baseline of 3.2 ng/mL to a mean of 7.1 +/- 0.5 ng/mL during the first 8 hours of infusion; thereafter, C-peptide levels progressively declined. Lipid infusion was not associated with any deleterious effect on insulin and C-peptide secretion. Initial in vitro stimulation of muscle tissue with insulin resulted in a substantial and selectively decreased Akt-2 expression and insulin-stimulated phosphorylation on the serine residue. Improved metabolic control resulted in 70% greater Akt expression at near-normoglycemic remission in comparison with the period of hyperglycemia. CONCLUSION Hyperglycemia, but not increased free fatty acid levels, led to progressive beta-cell dysfunction and impaired insulin secretion. Hyperglycemia was also associated with diminished skeletal muscle Akt expression and phosphorylation in an African American woman with ketosis-prone diabetes, and this defect improved notably with aggressive insulin therapy. These results indicate the importance of glucose toxicity in the pathogenesis of ketosis-prone diabetes in obese African American patients.
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Banerji MA, Dham S. A comparison of classification schemes for ketosis-prone diabetes. ACTA ACUST UNITED AC 2007; 3:506-7. [PMID: 17489086 DOI: 10.1038/ncpendmet0516] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2007] [Accepted: 03/21/2007] [Indexed: 11/08/2022]
Affiliation(s)
- Mary Ann Banerji
- Division of Endocrinology, State University of New York, Downstate Medical Center, Brooklyn, NY 11203, USA.
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Abstract
Endocrine emergencies constitute only a small percentage of the emergency workload of general doctors, comprising about 1.5% of all hospital admission in England in 2004-5. Most of these are diabetes related with the remaining conditions totalling a few hundred cases at most. Hence any individual doctor might not have sufficient exposure to be confident in their management. This review discusses the management of diabetic ketoacidosis, hyperosmolar hyperglycaemic state, hypoglycaemia, hypercalcaemia, thyroid storm, myxoedema coma, acute adrenal insufficiency, phaeochromocytoma hypertensive crisis and pituitary apoplexy in the adult population.
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Affiliation(s)
- T Kearney
- Hope Hospital, Stott Lane, Salford M6 8HD, UK.
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Hampe CS, Nalini R, Maldonado MR, Hall TR, Garza G, Iyer D, Balasubramanyam A. Association of amino-terminal-specific antiglutamate decarboxylase (GAD65) autoantibodies with beta-cell functional reserve and a milder clinical phenotype in patients with GAD65 antibodies and ketosis-prone diabetes mellitus. J Clin Endocrinol Metab 2007; 92:462-7. [PMID: 17090641 DOI: 10.1210/jc.2006-1719] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT We previously characterized patients presenting with diabetic ketoacidosis prospectively into four subgroups of ketosis-prone diabetes mellitus (KPDM), based on the presence or absence of beta-cell autoimmunity (A+ or A-) and beta-cell functional reserve (B+ or B-). The A+B- KPDM subgroup comprises patients with classic, autoimmune type 1 diabetes, whereas the A+B+ KPDM subgroup has only partial beta-cell loss and a distinct clinical phenotype. OBJECTIVE We hypothesized that epitope specificity of autoantibodies directed against the 65-kDa isoform of glutamate decarboxylase (GAD65) reflects differences in beta-cell destruction. DESIGN Sera of sequential GAD65Ab-positive KPDM patients admitted for diabetic ketoacidosis (n = 36) were analyzed for their epitope recognition using five GAD65-specific recombinant Fab and their ability to inhibit GAD65 enzymatic activity. All patients were followed longitudinally to assess beta-cell functional reserve and insulin dependence. RESULTS Binding to an amino-terminal epitope defined by monoclonal antibody DPD correlated positively with fasting serum C-peptide levels at baseline (P = 0.0008) and after 1 yr (P = 0.007). Binding to the DPD-defined epitope also correlated positively with area under the curve for C-peptide after glucagon stimulation (P = 0.007) and with homeostasis model assessment percent B at 1 yr (P = 0.03). Binding to the DPD-defined epitope was significantly stronger in A+B+ than in A+B- patients (P = 0.001). Sera of 16 patients (44%) significantly inhibited GAD65 enzymatic activity, but this did not correlate with beta-cell function. CONCLUSION DPD-defined epitope specificity is correlated directly with preserved beta-cell functional reserve in GAD65Ab-positive patients and is associated with the milder clinical phenotype of A+B+ KPDM.
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Affiliation(s)
- Christiane S Hampe
- Robert H. Williams Laboratory, Department of Medicine, University of Washington, Seattle, Washington 98195, USA.
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Rodacki M, Zajdenverg L, Lima GAB, Cavalcante Nunes R, Milech A, de Oliveira JEP. Relato de caso: diabetes Flatbush - da cetoacidose ao tratamento não-farmacológico. ACTA ACUST UNITED AC 2007; 51:131-5. [PMID: 17435867 DOI: 10.1590/s0004-27302007000100021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2006] [Accepted: 06/30/2006] [Indexed: 11/21/2022]
Abstract
Um subgrupo de pacientes, em sua maioria negros ou hispânicos e obesos, tem a cetoacidose diabética (CAD) como forma de apresentação de diabetes mellitus (DM), mas, devido à sua evolução clínica, posteriormente é classificado como DM tipo 2. Estes indivíduos têm pesquisa de auto-anticorpos anti-GAD, anti-IA2 e anti-insulina negativa, mas freqüentemente em associação com HLA classe II de risco para DM tipo 1 (DRB1*03 e/ou DRB1*04). Este subtipo peculiar de DM é denominado diabetes flatbush. Neste artigo, relatamos o caso de uma paciente de origem caucasiana com tais características, na qual foi possível retirada da insulinoterapia. Os possíveis fatores associados a esta evolução favorável serão discutidos.
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Affiliation(s)
- Melanie Rodacki
- Serviço de Nutrologia, Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, RJ.
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Nyenwe E, Loganathan R, Blum S, Ezuteh D, Erani D, Palace M, Ogugua C. Admissions for diabetic ketoacidosis in ethnic minority groups in a city hospital. Metabolism 2007; 56:172-8. [PMID: 17224329 DOI: 10.1016/j.metabol.2006.09.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2006] [Accepted: 09/18/2006] [Indexed: 12/29/2022]
Abstract
Hospitalization for diabetic ketoacidosis (DKA) is increasing, perhaps due to the rising incidence of DKA in patients with type 2 diabetes mellitus (T2DM). Ethnic minority groups are at increased risk for T2DM. This study aimed at elucidating the characteristics of patients with ketosis-prone diabetes in a predominantly ethnic minority population. We performed a retrospective analysis of adults admitted with DKA at the Bronx Lebanon Hospital Center, Bronx, NY over 3 years. The patients were divided into cohorts based on type of diabetes and ethnicity. The cohorts were described and compared using statistical methods. We recorded 219 cases of DKA in 168 patients, 97% of whom were African American or Hispanic. Fifty-three (32%) patients had T2DM. New-onset diabetes, which was more common in T2DM (P < .0001), and African Americans (P = .008), occurred in 42 patients (25%). Readmission with DKA was more common in the Hispanic patients with type 1 diabetes mellitus (T1DM) (P = .0001). Type 2 diabetes mellitus was more prevalent in the African Americans (P = .04). Patients with T1DM had more severe acidosis than patients with T2DM (lower pH and bicarbonate and larger anion gap; P = .03, .02, and .005, respectively). Creatinine level was higher in patients with T2DM (P = .04) who were also less likely to have identifiable precipitating causes (P = .02). Hemoglobin A(1c) level was higher in patients with new-onset diabetes (P < .05), but did not differ between those with T1DM and T2DM. Mortality, which was 2%, occurred only in the African Americans with T2DM. We conclude that DKA is an important mode of initial presentation of T2DM, with new-onset T2DM accounting for about 60% of all new cases of DKA. African American patients with T2DM, in comparison with the Hispanic patients, are more susceptible to developing DKA. Diabetic ketoacidosis could occur in T2DM without any identifiable precipitant. The rising incidence of DKA may be attributable to its increasing occurrence in T2DM; therefore, measures aimed at primary prevention of T2DM are worthwhile.
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Affiliation(s)
- Ebenezer Nyenwe
- Department of Medicine, Bronx Lebanon Hospital Center, Albert Einstein College of Medicine, Bronx, NY 10457, USA.
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