04_leslie
DESCRIPTION
•Autoantibodies •Genes Transmitter •Signal A IR ( U 100 300 400 500 200 / m L ) Insulin Sensitivity A IR ( U 100 300 400 500 200 / m L ) Membrane Hyperpolarised ATP does not lead to K ATP channel closure No calcium influx No insulin secretion V59 Selectivity Filter I296 ATP Membrane Slide Helix Haider, Sansom and Ashcroft Outside Inside 75% Transcription factors 11% MODY x 4% HNF4 61% HNF1TRANSCRIPT
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• Genes
• Autoantibodies
• HbA1c
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• Signal
Transmitter
• Receiver
Transducer
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100
200
300
400
500
00 1 2 3 4 5
Insulin Sensitivity
AIR
(U
/mL)
Changes in Insulin Secretion and Sensitivity
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100
200
300
400
500
00 1 2 3 4 5
Insulin Sensitivity
AIR
(U
/mL)
Changes in Insulin Secretion and Sensitivity
Insulin Treatment
Metabolic Syndrome
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Mutated KATP channel fails to close in
response to increased ATP which decreases
insulin secretion
ATP
ATP does not lead to
KATP channel closure
Membrane
Hyperpolarised
No insulin secretion
No calcium influx
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Slide
Helix
OutsideSelectivity
Filter
Site of Kir6.2 mutations associates
with phenotypeATP-binding site: isolated PNDM Gating/pore: neurological features
V59
R50R201Y330
Inside
Membrane
I296
Haider, Sansom and Ashcroft
ATP
Q52
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MODY
11%
MODY x
75%
Transcription factors22%
Glucokinase
2%
HNF1
61%
HNF14%
HNF4
<1%
IPF1
The Genetic Causes of MODY
Ellard, Frayling et al Diabetes 2001
<1%
NeuroD1
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-7
-6
-5
-4
-3
-2
-1
0
1
p<0.0001
Gliclazide Metformin
Change
in fasting
plasma
glucose
with
treatment
(mmol/l)
HNF1
MODYType 2HNF1
MODYType 2
Gliclazide
Metformin
HNF1 patients respond better to
Gliclazide than Type 2 patients
Pearson et al Lancet 2003
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0
50
100
Cumulative prevalence of diabetes
0 20 40 60 80
100
50
0
Type 1 Type 2
% %
Age at onset (years)
LADA
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Latent Adult onset Autoimmune
Diabetes (LADA)
• Age at diagnosis 30 - 70 years.
• Diabetes-Associated Autoantibody positive.
• Treatment without insulin for 6 months.
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Autoimmune Diabetes Spectrum
T1D in children
T1D in adults
LADA
InsulinImmunity BMIAge Genes
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ction
ADA
Adult-onset diabetes (age 30 – 70 years) (n=6,136)
GADA positive 538 (8.8%) :
T1DM (n=109) (20.2%)
LADA (n=277) (51.5%)
Unclassified (n=152) (29.3%)
GADA negative 5, 598 (91.2%)
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Usual Clinical PhenotypeType 1 Diabetes
• Adult-onset
• Non-insulin requiring.
Type 2 Diabetes
• Adult-onset
• Non-insulin requiring.
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UKPDS: Need for insulin treatment
100
80
60
40
20
0
0 1 2 3 4 5 6
Years from diagnosis
Ab-ve
GAD +ve
GAD +ve
ICA +ve
Turner et al 1997
%
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Microvascular
complications
Myocardial infarction
HbA1c
37%
14%
Lowering HbA1c reduces the risk of
complications (UKPDS)
Deaths related to
diabetes21%
1%
Stratton IM, et al. BMJ 2000; 321:405–412.
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Re
lative
Ris
k
Retinopathy
Nephropathy
Neuropathy
Microalbuminuria
HbA1c (%)
15
13
11
9
7
5
3
16 7 8 9 10 11 12
Skyler. Endocrinol Metab Clin 1996;25:243–254
DCCT: HbA1c and risk of microvascular
complications
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HbA1c in DCCT
ACCOUNTS FOR ONLY:
• 11%
OF THE MICROVASCULAR RISK
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Mean Plasma Glucose vs. HbA1c
Rohlfing CL et al Diabetes Care. 2002 ;25:275-8
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Between instrument imprecision
Mean 7.89%, SD 0.27%, n=327UKNEQAS Dec 2007
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Standardisation
of HbA1c
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National Glycohemoglobin Standardization Program
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DCCT vs. IFCC HbA1c
DCCT HbA1c
(%)
6
7
8
9
10
IFCC HbA1c
(mmol/mol)
42
53
64
74
85
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Mean Plasma Glucose vs. HbA1c
Rohlfing CL et al Diabetes Care. 2002 ;25:275-8
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The appeal of eAG
• Patients with diabetes can converse with
clinicians in a common ‘currency’
• Especially if they self-monitor their BG
• Clinicians are also already familiar with the
concept of eGFR and estimated LDL
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Acceptability of Data
HbA1c (%)
0
2
4
6
8
10
12
14
16
18
3 4 5 6 7 8 9 10 11 12 13
calcAG = 1.58x -2.52
R2=0.84
n=427
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Acceptability of Data
HbA1c (%)
0
2
4
6
8
10
12
14
16
18
3 4 5 6 7 8 9 10 11 12 13
90% of
values
fall in this
range
calcAG = 1.58x -2.52
R2=0.84
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Biological variation in HbA1c
• Not all individuals with the same mean glucose levels have the same HbA1c.
• Race and age associated with higher HbA1c.
• Variation in red blood cell half life (0.9% HbA1c).
• Heritability of HbA1c (62 – 74%).
• Hexokinase associated with HbA1c in genome study.
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Hyperglycemia
O2-
PKC
O2-
NAD(P)H
oxidase
Peroxynitrite
NF-kB
iNOS eNOS
NO
DNA damage
Endothelial disfunction
Polyol Pathway
AGE Formation
Hexosamine Flux
Diabetic
Complications
Mitochondria
Glycated protein
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Worldwide standardisation?
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Conclusion
• ‘Worldwide Standardisation’ is forcing us to
choose the way we report HbA1c.
• Different countries seem likely to make different
choices.
• HbA1c and eAG are not interchangeable.
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• Genes
• Autoantibodies
• HbA1c