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Query: UMLS:C0011854 (type 1 diabetes)
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A subtype of idiopathic type 1 diabetes with a rapid onset and no diabetes-related antibodies has been recently advocated as non-autoimmune fulminant type 1 diabetes. However, it is not definite yet that this subtype is always caused by non-autoimmune mechanism. A 48-year-old man was admitted to our hospital because of high plasma glucose and renal insufficiency. Laboratory findings were as follows: plasma glucose 1052 mg/dL, urinary ketone bodies (+/-), arterial blood pH 7.44, bicarbonate 23.8 mmol/L, base excess 0.3 mmol/L, plasma osmolality 342 mOsm/L, serum creatinine 2.1 mg/dL, blood urea nitrogen 69.7 mg/dL, and serum creatine kinase 1024 IU/L, giving a diagnosis of acute renal failure secondary to rhabdomyolysis associated with diabetes. Urinary C-peptide reactivity was 4.7 microg/day. The level of HbAlc was 7.0%, not so high as compared to that of plasma glucose, indicating an aggravation of diabetes within the recent short period. Antibodies to islet cell antigen, IA-2 and insulin were negative, while those to glutamic acid decarboxylase (GAD) were positive at 13.1 U/mL, which were negative half a year and two years and a half later. Serum amylase level was within normal range at admission, increased to 380 IU/L and normalized in 4 to 5 weeks as serum creatinine lowered. These data are compatible to the diagnosis of fulminant type 1 diabetes. However, the present case is different from others in positive antibodies to GAD at admission that turned to be negative subsequently. Considering our results and others together, further investigations are necessary to clarify whether all cases of fulminant type 1 diabetes are non-autoimmune or some of them are caused by autoimmune mechanism.
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PMID:A case of fulminant type 1 diabetes with transiently positive anti-GAD antibodies. 1280 44

Early retinal vessel caliber changes may predict risk of diabetic nephropathy. We examined the association of retinal vessel diameters and the incidence of gross proteinuria and renal insufficiency in a population-based cohort of people with type 1 diabetes (n = 557). Baseline retinal photographs were digitized, and diameters of individual retinal vessels were measured and summarized. Incident cases of gross proteinuria and renal insufficiency were identified over a 16-year period. Larger retinal venular diameter was associated with higher cumulative incidence of gross proteinuria (18.6, 25.4, 37.7, and 50.4%, comparing increasing venular diameter quartiles) and renal insufficiency (10.7, 15.5, 23.2, and 32.8%). After adjusting for age, sex, duration of diabetes, HbA(1c) levels, baseline retinopathy levels, and other factors, larger retinal venular diameter was associated with an increased risk of gross proteinuria (RR 1.53, 95% CI 1.19-1.97, comparing 4th vs. 1st to 3rd quartiles of venular diameter) and renal insufficiency (1.51, 1.05-2.17). Retinal arteriolar diameter was not associated with either gross proteinuria or renal insufficiency. We conclude that in individuals with type 1 diabetes, larger retinal venular diameter is independently associated with the long-term incidence of gross proteinuria and renal insufficiency and may provide additional predictive information regarding risk of nephropathy.
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PMID:Retinal vessel diameters and the incidence of gross proteinuria and renal insufficiency in people with type 1 diabetes. 1469 13

Patients with diabetes mellitus are at increased risk for repeat interventions and mortality after coronary angioplasty and stenting. The efficacy of sirolimus-eluting stents (SESs) to improve the outcomes of these patients is a focus of interest. In the first 1,407 patients treated with SESs at our institution, 492 were diabetic (insulin dependent diabetes mellitus [IDDM], n = 160 and non-insulin-dependent DM [NIDDM], n = 332). The in-hospital and 1- and 6-month clinical outcomes were compared with those of 915 patients without DM (non-DM). The baseline characteristics were similar, except for more women, obesity, previous myocardial infarction, coronary artery bypass grafting, and renal insufficiency in the DM group (p <0.001). Compared with non-DM patients, DM patients had higher in-hospital (p <0.05) and 1-month mortality (p = 0.02). IDDM patients had more in-hospital renal failure (p = 0.04) and Q-wave myocardial infarctions (1.6% vs 0%, p = 0.04) compared with NIDDM patients, and higher mortality (3.1% vs 0.8%, p = 0.04) and subacute stent thromboses (2.3% vs 0.5%, p = 0.07) than non-DM patients at 30 days. At 6 months, DM patients had a higher incidence of Q-wave myocardial infarction, target lesion revascularization-major adverse cardiac events, and composite of death and Q-wave myocardial infarction than non-DM patients (6.0% vs 2.7%, p = 0.01). Late outcomes between the IDDM and NIDDM groups were similar. Multivariate analysis showed diabetes and acute renal failure as independent predictors of target lesion revascularization-major adverse cardiac events. In conclusion, our data showed that, despite a reduction in repeat revascularization, coronary intervention with SESs in diabetic patients is limited by higher mortality at 1 month and a higher incidence of Q-wave myocardial infarction and target lesion revascularization-major adverse cardiac events at 6 months compared with non-DM patients. Careful surveillance is required in IDDM patients undergoing SES implantation.
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PMID:Impact of treatment of coronary artery disease with sirolimus-eluting stents on outcomes of diabetic and nondiabetic patients. 1621 45

Although organ transplantation has matured into a proven therapy for end-stage organ failure, the many notable developments of the past 5 years speak to the multitude of remaining challenges. Two new procedures, islet transplantation and adult-to-adult living donor liver transplantation, have emerged to enlarge our therapeutic armamentarium for Type 1 diabetes mellitus and end-stage liver disease, respectively. In cardiac transplantation, the acceptance of ventricular assist devices as destination therapy is a notable event in light of critical shortage of deceased donor organs. Both liver and lung allocation policies have made a dramatic paradigm shift away from waiting time toward the survival benefit of transplantation. Finally, primary threats to post-transplant longevity have gained an increasing share of the spotlight. Recognition of the impact of renal insufficiency for all nonrenal transplant recipients, of recurrent hepatitis C virus for liver recipients, and of accelerated vasculopathy for cardiac have identified novel end points for clinical trials.
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PMID:Developments in clinical islet, liver thoracic, kidney and pancreas transplantation in the last 5 years. 1677 14

Haemolytic-uraemic syndrome (HUS) is a rare cause of insulin-dependent diabetes mellitus during the acute stage. We previously reported the case of a 3-year-old girl having presented with typical HUS with diarrhea, microangiopathic anaemia, thrombocytopenia and acute renal failure (17 days of anuria). Transient hyperglycaemia (highest level: 513 mg/dl) was observed, requiring continuous intravenous insulin infusion for 9 days. Subcutaneous insulin injections were stopped after 24 days. Oral glucose tolerance test performed 4 months after normalization of blood glucose was normal. HLA DQ genotype (DQA1-DQB1.AZH/DQA3-DQB3.1) was not at risk for type 1 diabetes and there were no auto-antibodies (ICA and IAA). The 3-years follow-up was marked by persistent arterial hypertension, proteinuria and slight renal insufficiency despite angiotensin-converting enzyme inhibitor treatment. Ten years after HUS occurred (the patient had been lost to follow-up for 7 years), she came back with complaints of headache but neither polyurodipsia nor weight loss. She was found to have arterial hypertension. Chronic renal impairment had moderately progressed with decreased glomerular filtration rate (63 ml/min/1.73 m2) and proteinuria (2 g/24 hours). Fasting blood glucose was 189 mg/dl and reached 315 mg/dl during an oral glucose tolerance test. HbA1c level was 8.2% (N<6.2%) and diabetes mellitus was diagnosed without any signs of autoimmunity (IAA, ICA, GADA and IA2B were negative). Good glycaemic control was obtained with 0.5 U/kg/day of insulin. In conclusion, transient beta-cell dysfunction complicating HUS acute stage may evolve to overt non-autoimmune diabetes mellitus (microangiopathic process?), even after a long free interval. This case emphasizes the need for a long-term follow-up of patients with HUS.
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PMID:Insulin-dependent diabetes mellitus as long term complication of haemolytic-uraemic syndrome. 1679 6

Simultaneous pancreas and kidney transplantation (spktx) is currently the most effective method of treatment of type 1 diabetes complicated by renal insufficiency. The first successful spktx in Poland was performed in the Department of General, Vascular and Transplant Surgery of the Warsaw Medical University on the 4th of February 1988. Since then 70 spktx were performed in our Department. We present a 44-year-old patient who after 16 years of good function of both transplanted organs presented with elevated creatinine levels (>4 mg/dl) as a result of chronic rejection of the kidney allograft. On the 22nd of January 2005 the patient underwent secondary kidney transplantation. The immunosuppresive protocol consisted of MMF, CsA and steroids. Humanized anti-lL-2 monoclonal antibodies (daclizumab) were used as pre-procedure induction. Using a mid-line incision the new kidney graft was anastomosed to the recipient left external iliac vessels. The ureter was anastomosed with the bladder without anti reflux procedures and the allograft was placed in the retroperitoneum below the previously transplanted kidney. Graftectomy of the first kidney allograft was not performed. After surgery, normal creatinine parameters were restored to a level of 1, 1 mg/dl and an increase in urine output was noted from 1 to 4 liters per day. Oral intake of foods was resumed on the 4th postoperative day and no early complications were observed. 12 months observation period confirmed stabile function of both transplanted organs. Secondary kidney transplantation in patients after spktx is technically possible and may be considered an option in patients with diminishing function of the first kidney allograft.
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PMID:Secondary kidney transplantation in a patient 16 years after simultaneous pancreas and kidney transplantation--a case report. 1702 29

The aim of the study was to assess skeletal status in diabetic and nondiabetic subjects with end-stage renal disease (ESRD). One hundred twenty-three patients with ESRD (57 patients with diabetes: 9 type 1 and 48 type 2) and 66 nondiabetic patients were evaluated. Control group comprised 1541 subjects (614 males and 927 females). Diabetes and/or renal insufficiency was the only reason of bone disease and, in control group, no factors known to influence bone metabolism (chronic diseases or prolonged medications) were noted. Skeletal status was evaluated by quantitative ultrasound measurements at the hand phalanges using DBM 1200 (IGEA, Carpi, Italy), which measures amplitude-dependent speed of sound (Ad-SoS [m/s]). Because of some differences in mean age in subgroups of patients and controls, comparisons were performed using values of Z-score. In all diabetic patients, Z-score was significantly higher compared with nondiabetics (p < 0.05). In all type 1 diabetes patients, Z-score was significantly lower than in all nondiabetic patients (p < 0.05) and in patients with type 2 diabetes (p < 0.001). Z-score was also significantly lower in type 2 diabetics than in nondiabetic females (p < 0.00001) but did not differ in males. Comparisons between Z-scores in controls and patients showed that Z-score in nondiabetic females was significantly lower than in female controls (p < 0.000001), and in nondiabetic males--diabetic type 2 males as well as females--Z-score did not differ vs. results in adequate control group. Z-score was significantly lower in patients with diabetes type 1 vs. all controls (p < 0.001). Correlation analysis showed in all nondiabetic patients that Z-score was negatively affected by duration time of dialysis (r = -0.37, p < 0.01) and parathyroid hormone (PTH) serum level (r = -0.35, p < 0.01). In patients with type 1 diabetes, only PTH influenced significantly Z-score (r = -0.76, p < 0.05) and, in patients with type 2 diabetes, no significant correlations were obtained. Subjects with type 1 diabetes seemed to be sensitive for skeletal disturbances in a course of renal insufficiency, whereas subjects with type 2 diabetes did not show such skeletal pathology as shown by ultrasound measurements at hand phalanges.
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PMID:Quantitative ultrasound measurements in diabetic and nondiabetic patients with end-stage renal disease. 1741 82

Kidney disease is a severe and frequent complication in diabetes. In the terminal phase, treatment requires dialysis and, if possible, kidney transplantation. Provided that there are no contraindications, simultaneous kidney/pancreas transplantation is currently considered the treatment of choice in patients with type 1 diabetes mellitus and terminal kidney disease. Pancreas transplantation is a complex process initially associated with a greater morbidity than kidney transplant alone. At present, however, patient and graft survival is good thereby leading to total normalization of metabolic control and allowing the patient to carry out a normal life without the need to administer insulin and with the consequent benefits in quality of life and the evolution of the complications of the disease. The results of pancreas transplant alone are somewhat worse than those with combined kidney/pancreas transplantation. They are, however, sufficiently satisfactory to be considered a good therapeutic option in patients who have previously received a kidney. Nonetheless, the transplantation of the pancreas alone in diabetic patients without renal insufficiency or previous kidney transplant is another question. Although this type of transplantation would be ideal, it currently remains restricted to patients with a labile diabetes who require repeated hospital admission due to metabolic decompensation and/or severe hypoglycemic episodes accompanied by loss of consciousness.
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PMID:[Diabetes and pancreas transplantation]. 1871 13

Pancreas and kidney transplantation is the treatment of choice for patients with type 1 diabetes mellitus and terminal renal insufficiency. Herein we have presented a series of 35 patients transplanted between 2002 and 2009 including periods before and after 2007 divided based on introduction of some technical aspects. In the first phase (learning period) we have noted complications related to pancreatic surgery with a morbidity among 12 of 18 patients (66.6%). In the second period (stabilization period), complications appeared in 6 out of 17 patients (35.2%; P < .028). The reoperation rate was 83.3% in the learning period and 23.5% in the stabilization period (P < .03). Seven transplantectomies were performed in the first period (P < .004). Five patients died, all of them in the learning group (P < .019). Changes in the technical aspects of the procedure were responsible for improved outcomes obtained among pancreas and kidney transplantations.
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PMID:Importance of technical aspects in the beginnings of a pancreas transplantation program. 2017 40

The natural history of diabetic nephropathy was defined in the 1980s on the basis of longitudinal studies undertaken in patients with type 1 and type 2 diabetes. However, an increasing number of studies have indicated that certain diabetic patients do not present with the same evolution as was then defined: for example, some often have significant initial deterioration of glomerular filtration rate whereas, in others, microalbuminuria is reduced spontaneously. Chronic kidney disease (CKD) may be accompanied, rather than preceded, by macroalbuminuria, or it may develop in patients with microalbuminuria or even in those with albuminuria levels that revert to normal. CKD can also develop in patients whose albuminuria levels remain normal. Progression to macroalbuminuria is, in fact, less frequent than regression to normoalbuminuria or no change in microalbuminuria status in diabetic patients with microalbuminuria, especially in type 1 diabetes. Some experience progressive deterioration of renal function due to diabetes without developing significant proteinuria: this is seen fairly frequently and can affect 50% of patients with renal insufficiency. Such cases are more often older patients treated with renin-angiotensin system blockers who usually have a history of cardiovascular disease. Evolution to end-stage renal disease is slower in this subgroup of patients, although histological analyses may show surprisingly advanced glomerular lesions. The main parameters of surveillance remain regular monitoring of glycaemia, and control of blood pressure and the evolution of initial albuminuria levels. Nevertheless, why some patients exhibit conventional diabetic nephropathy while others have slower declines in renal function associated with normal albuminuria levels or microalbuminuria is unclear. It is hoped that the new pathological classification of diabetic nephropathy will help in our understanding of these discrepancies.
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PMID:The emerging concept of chronic kidney disease without clinical proteinuria in diabetic patients. 2262 76


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