A specific gut microbiota signature is associated with an enhanced GLP-1 and GLP-2 secretion and improved metabolic control in patients with type 2 diabetes after metabolic Roux-en-Y gastric bypass

Objective

To determine changes in incretins, systemic inflammation, intestinal permeability and microbiome modifications 12 months after metabolic RYGB (mRYGB) in patients with type 2 diabetes (T2D) and their relationship with metabolic improvement.

Materials and methods

Prospective single-center non-randomized controlled study, including patients with class II-III obesity and T2D undergoing mRYGB. At baseline and one year after surgery we performed body composition measurements, biochemical analysis, a meal tolerance test (MTT) and lipid test (LT) with determination of the area under the curve (AUC) for insulin, C-peptide, GLP-1, GLP-2, and fasting determinations of succinate, zonulin, IL-6 and study of gut microbiota.

Results

Thirteen patients aged 52.6 ± 6.5 years, BMI 39.3 ± 1.4 kg/m2, HbA1c 7.62 ± 1.5% were evaluated. After mRYGB, zonulin decreased and an increase in AUC after MTT was observed for GLP-1 (pre 9371 ± 5973 vs post 15788 ± 8021 pM, P<0.05), GLP-2 (pre 732 ± 182 vs post 1190 ± 447 ng/ml, P<0.001) and C- peptide, as well as after LT. Species belonging to Streptococaceae, Akkermansiacea, Rickenellaceae, Sutterellaceae, Enterobacteriaceae, Oscillospiraceae, Veillonellaceae, Enterobacterales_uc, and Fusobacteriaceae families increased after intervention and correlated positively with AUC of GLP-1 and GLP-2, and negatively with glucose, HbA1c, triglycerides and adiposity markers. Clostridium perfringens and Roseburia sp. 40_7 behaved similarly. In contrast, some species belonging to Lachnospiraceae, Erysipelotricaceae, and Rumnicocaceae families decreased and showed opposite correlations. Higher initial C-peptide was the only predictor for T2D remission, which was achieved in 69% of patients.

Conclusions

Patients with obesity and T2D submitted to mRYGB show an enhanced incretin response, a reduced gut permeability and a metabolic improvement, associated with a specific microbiota signature.

Xanthogranuloma of the sellar region: a systematic review

Knowledge of xanthogranuloma (XG) of the sellar region comes from short series or single cases. We performed a systematic review, using the PubMed, Web of Science, Embase, Scopus, eLibrary, and BIOSIS Preview databases, of all cases reported from 2000 to the present. We also describe one unreported patient treated in our institution. A search of the literature revealed that of 71 patients 50.7% were male and that mean age at diagnosis was 34.7 ± 19.2 years old. Median time from clinical onset until diagnosis was 7 (3-21) months. Hypopituitarism (70.4%), visual disorders (64.7%), headache (53.5%), and polyuria-polydipsia (28.2%) were the most common symptoms. On MRI, median tumor size was 20 (16-29) mm, while 71.8% were sellar/suprasellar and less frequently exclusively suprasellar (15.5%) or sellar (12.7%). On T1-weighted imaging, XG was hyperintense in 76.3% of patients, while it showed variable appearance on T2-weighted imaging. The tumor showed cystic features in 50.7%, gadolinium enhancement in 45.1%, and calcification in 22.5% of patients. All patients underwent surgery (77.4% transphenoidal approach and 18.3% craniotomy), with hypopituitarism (56.4%), diabetes insipidus (34.5%), and visual defects (7.3%) being the most common complications. Total/subtotal resection was achieved in 93.5%, while the tumor was partially removed in 6.6%. Median follow-up was 24 (6-55) months and no tumor recurrence or remnant growth was reported in 97.5% of cases. In conclusion, XG affects the younger population, manifested by hormonal deficit and mass effect symptoms. Surgery is safe and offers excellent outcomes, though hypopituitarism is frequent post-surgery. Tumor recurrence or remnant growth is rare and radiological surveillance is a good option for patients with remnant lesions.

Review of SGLT2i for the Treatment of Renal Complications: Experience in Patients with and Without T2D

The management of type 2 diabetes (T2D) involves decreasing plasma glucose levels and reducing cardiovascular and microvascular complications. Diabetic kidney disease (DKD), defined as presence of albuminuria, impaired glomerular filtration, or both, is an insidious microvascular complication of diabetes that generates a substantial personal and clinical burden. The progressive reduction in renal function and increased albuminuria results in an increase of cardiovascular events. Thus, patients with DKD require exhaustive control of the associated cardiovascular risk factors. People with diabetes and renal impairment have fewer options of antidiabetic drugs because of contraindications, adverse effects, or altered pharmacokinetics. Sodium-glucose cotransporter type 2 inhibitors (SGLT2i) reduce blood glucose concentrations by blocking the uptake of sodium and glucose in the proximal tubule and promoting glycosuria, and these agents now have an important role in the management of T2D. The results of several cardiovascular outcomes trials suggested that SGLT2i are associated with improvements in renal endpoints in addition to their reduction in cardiovascular events and mortality, which represents a major advance in the care of this population. The dedicated kidney outcomes trials have confirmed the renoprotective action of SGLT2i across different glomerular filtration and albuminuria values, even in patients with non-diabetic chronic kidney disease. Notably, this improvement in kidney function may indirectly benefit cardiac function through multifaceted interorgan cross talk, which can break the cardiorenal vicious circle linked to T2D. In this article, we briefly review the different mechanisms of action that may explain the renal beneficial effects of SGLT2i and disclose the results of the key renal outcome trials and the subsequent update of related clinical guidelines.

Information and consensus document for the detection and management of chronic kidney disease

Chronic kidney disease (CKD) is a major public health problem worldwide that affects more than 10% of the Spanish population. CKD is associated with high comorbidity rates, poor prognosis and major consumption of health system resources. Since the publication of the last consensus document on CKD seven years ago, little evidence has emerged and few clinical trials on new diagnostic and treatment strategies in CKD have been conducted, apart from new trials in diabetic kidney disease. Therefore, CKD international guidelines have not been recently updated. The rigidity and conservative attitude of the guidelines should not prevent the publication of updates in knowledge about certain matters that may be key in detecting CKD and managing patients with this disease. This document, also prepared by 10 scientific associations, provides an update on concepts, clarifications, diagnostic criteria, remission strategies and new treatment options. The evidence and the main studies published on these aspects of CKD have been reviewed. This should be considered more as an information document on CKD. It includes an update on CKD detection, risk factors and screening; a definition of renal progression; an update of remission criteria with new suggestions in the older population; CKD monitoring and prevention strategies; management of associated comorbidities, particularly in diabetes mellitus; roles of the Primary Care physician in CKD management; and what not to do in Nephrology. The aim of the document is to serve as an aid in the multidisciplinary management of the patient with CKD based on current recommendations and knowledge.

Long-Term Effects in Bone Mineral Density after Different Bariatric Procedures in Patients with Type 2 Diabetes: Outcomes of a Randomized Clinical Trial

There is scant evidence of the long-term effects of bariatric surgery on bone mineral density (BMD). We compared BMD changes in patients with severe obesity and type 2 diabetes (T2D) 5 years after randomization to metabolic gastric bypass (mRYGB), sleeve gastrectomy (SG) and greater curvature plication (GCP). We studied the influence of first year gastrointestinal hormone changes on final bone outcomes. Forty-five patients, averaging 49.4 (7.8) years old and body mass index (BMI) 39.4 (1.9) kg/m², were included. BMD at lumbar spine (LS) was lower after mRYGB compared to SG and GCP: 0.89 [0.82;0.94] vs. 1.04 [0.91;1.16] vs. 0.99 [0.89;1.12], p = 0.020. A higher percentage of LS osteopenia was present after mRYGB 78.6% vs. 33.3% vs. 50.0%, respectively. BMD reduction was greater in T2D remitters vs. non-remitters. Weight at fifth year predicted BMD changes at the femoral neck (FN) (adjusted R²: 0.3218; p = 0.002), and type of surgery (mRYGB) and menopause predicted BMD changes at LS (adjusted R²: 0.2507; p < 0.015). In conclusion, mRYGB produces higher deleterious effects on bone at LS compared to SG and GCP in the long-term. Women in menopause undergoing mRYGB are at highest risk of bone deterioration. Gastrointestinal hormone changes after surgery do not play a major role in BMD outcomes.

Analysis of the characteristics of patients with diabetes mellitus who attend a tertiary hospital emergency department for a hypoglycemic event

INTRODUCTION AND OBJECTIVE

Hypoglycemia associated to insulin or other glucose-lowering agents is one of the most common causes of visits to the emergency department for adverse drug reactions. The study objective was to analyze the characteristics of patients with diabetes mellitus (DM) who attend a tertiary hospital emergency department for a hypoglycemic event.

PATIENTS AND METHODS

A 3-year retrospective analysis was conducted of patients with DM who attended the emergency department of Hospital Universitari de Bellvitge for a hypoglycemic event. An analysis was made of epidemiological and diabetes-related characteristics, prevalence of chronic diabetic complications and other comorbidities, the glucose-lowering treatment and the result of the hypoglycemic episode.

RESULTS

Of the 149 hypoglycemic events analyzed, 81.9% occurred in patients with type 2 DM. Mean age of patients with type 2 DM was 75.4 years. DM duration was longer than 10 years in 69.4% of patients. The prevalence rates of chronic kidney disease and cognitive decline were 38.5% and 19.7% respectively in patients with type 2 DM. Insulin with or without other concomitant glucose-lowering agents was associated to 78.7% of episodes in type 2 DM patients. The remaining 21.3% were associated to oral hypoglycemic agents, mainly glibenclamide. After the event, 13.4% of patients required hospital admission, and in 36.8% of these hypoglycemia was associated to use of glibenclamide.

CONCLUSIONS

A majority of hypoglycemic events occurred in elderly patients with type 2 DM, with a high prevalence of associated comorbidities and treated with insulin and sulfonylureas, particularly glibenclamide.

Impact and characteristics of the non-Caucasian population in hospital admissions for diabetes onset during 2003-2010

AIMS

To assess the prevalence of non-Caucasian patients in hospital admissions for onset of symptomatic diabetes mellitus during the 2003-2010 period, and to analyze the characteristics differentiating them from the Caucasian population at diagnosis and 2 years later.

MATERIAL AND METHODS

A retrospective, observational study.

INCLUSION CRITERIA

Patients aged 18-40 years admitted for de novo symptomatic diabetes from January 2003 to October 2010. Prevalence of patients of non-Caucasian origin was analyzed, and clinical, biochemical, immunological, and beta-cell function of both populations were compared at diagnosis and 2 years later.

RESULTS

Nineteen percent of patients admitted to hospital for de novo symptomatic diabetes were non-Caucasian, with a progressive increase in recent years. Non-Caucasian patients had milder decompensation (3.0% had ketoacidosis, as compared to 15.2% in the Caucasian group, P<.05), lower presence of autoimmunity (27.2 vs. 73.1%, P<.01) and higher stimulated C-peptide levels (0.70±0.56 vs. 0.42±0.39 nmol/l, P<.05), mainly because of the subgroup with negative autoimmunity (0.82 vs. 0.25). Two years after diagnosis, less non-Caucasian patients were on intensified treatment (39.1 vs. 93.8%).

CONCLUSIONS

Non-Caucasian patients had a lower prevalence of autoimmunity, better beta-cell function at diagnosis, particularly due to the subgroup with negative autoimmunity, and less need for intensive treatment 2 years after diagnosis, features which are more characteristic of type 2 diabetes mellitus.

Comparison of human insulin and insulin analogues on hypoglycaemia and metabolic variability in type 1 diabetes using standardized measurements (HYPO score and Lability Index)

To evaluate whether treatment with insulin analogues is associated with a lower risk of hypoglycaemia (HYPO score) and less glycaemic variability (Lability Index) than treatment with human insulin in patients with type 1 diabetes. In a 6-month prospective, open-labelled trial, we randomized 47 patients treated with human insulin to receive treatment with human insulin (n = 21) or insulin analogues (n = 26). HYPO score, Lability Index (LI), and hypoglycaemic episode characteristics were assessed at baseline and at the end of follow-up. A 72-h, continuous glucose monitoring was performed at the end in a subgroup of patients. Groups were compared with nonparametric tests. Significance was defined as P < 0.05. HYPO score (71.5 [36.0-162] vs. 260 [52.0-676], P < 0.05), nocturnal hypoglycaemia (0.4 vs. 1.4 events/patient/4-week, P < 0.05), and <2.5 mmol/l hypoglycaemic events were lower in insulin analogue group after 6 months. There was a trend towards a lower LI in insulin analogue group (74.3 [51.3-133] vs. 123 [76.4-171] mmol/l(2)/h week(-1), P = 0.064). HbA1c and insulin dose were comparable between groups. In type 1 diabetes, insulin analogues were associated with a lower hypoglycaemic risk and a trend towards reduced glycaemic variability compared with human insulin. These effects occurred despite comparable metabolic control.

Renoprotective effect of diltiazem in hypertensive type 2 diabetic patients with persistent microalbuminuria despite ACE inhibitor treatment

The aim of the study was to evaluate the effects of the non-dihydropyridine calcium antagonist (NDCA) diltiazem on the development of urinary albumin excretion (UAE) in type 2 hypertensive diabetic patients with persistent microalbuminuria despite ACE inhibitor treatment. Thirty-six type 2 diabetic hypertensive patients with microalbuminuria persisting after at least 1 year of treatment with ACE inhibitors were randomized to receive captopril (n=22) or combined therapy with captopril and 120 mg diltiazem (n=14) for 2 years. Captopril dose was individualized according to blood pressure. Changes in UAE, blood pressure, and metabolic control were monitored to analyze the influence of the addition of diltiazem on progression of diabetic nephropathy. In patients treated with captopril and diltiazem, absolute UAE did not change during the study (baseline: 101 mg/24 h, range 39-298; 2 years after randomization: 74 mg/24 h, range 12-665). In contrast, UAE increased in patients treated with captopril monotherapy (baseline: 118 mg/24 h, range 32-282; 2 years after randomization: 164 mg/24 h, range 15-1161, p<0.05). In addition, fewer patients in the captopril/diltiazem group progressed to macroalbuminuria (eight patients in captopril group and one in captopril/diltiazem group, p<0.05). The beneficial effects of the addition of diltiazem were independent of blood pressure and metabolic control. We suggest that the combination of ACE inhibitors and NDCA should be considered in type 2 microalbuminuric patients at high risk for progression to established diabetic nephropathy.

[Early diabetic nephropathy and cardiovascular disease in a Mediterranean population: risk factors and treatment intensity]

The objective of this cross-sectional study was to evaluate the impact of early diabetic nephropathy on the presence of cardiovascular disease (CVD) in a Mediterranean population, as well as the prevalence in these patients of traditional cardiovascular risk factors and its treatment intensity in accordance with international recommendations. In 123 patients with type 2 diabetes and incipient nephropathy the presence of CVD, smoking, hypertension, dyslipemia, and their treatment was recorded. CVD prevalence was 34%. Age, nephropathy stage (micro/macroalbuminuria), and smoking were associated with the presence of CVD. Hypertension, dyslipemia, and smoking were present in 83%, 81%, and 59%, respectively. Coexistence of several risk factors was frequent and was associated with a higher incidence of CVD. 79% hypertensive patients and 43% dyslipemic patients received pharmacological treatment but only 17% and 9%, respectively, reached a good control of their disease. Patients with known CVD showed also a deficient control. Accordingly, early diabetic nephropathy induces a multiplier effect on the cardiovascular risk of a Mediterranean population. Higher prevalence and association with cardiovascular risk factors, with smoking in a predominant role, are associated with this higher risk. Despite this, the intensity of treatment and control of these risk factors is deficient, which means that a better and more intensive treatment should reduce the morbidity and mortality in these patients.