bluuebunny/crossref_metadata_2025 huggingface dataset:
Potentiation of TRPM5 with Stevioside in the Beta Cells Stimulates Insulin Secretion
Authors: PHILIPPAERT KOENRAAD , VENNEKENS RUDI , LIGHT PETER E.
Published: June 2018

The calcium-activated monovalent cation channel TRPM5 is expressed in human and murine beta cells. Members of the TRP ion channel family can be activated by a plethora of different stimuli as temperature, voltage, and ligands, including natural compounds. Studies have shown that TrpM5-knockout mice have increased blood glucose levels and an impaired insulin secretion. Mutations in TRPM5 are more prevalent in patients with diabetes or metabolic syndrome. Stevioside is a sweet tasting organic molecule isolated from the leaves of the scrub plant Stevia rebaudiana, it is widely used in consumer foods and beverages. Despite its wide use, the molecular interactions of stevioside in the body remained elusive. Here we show that stevioside potentiates TRPM5 channel activity. This leads to increased calcium dynamics in both human and mouse islets, which relates to increased insulin secretion. We show that the steviol core of stevioside is responsible for the TRPM5-potentiating effect. When mice on a high fat diet are given stevioside, we observe an attenuation of the development of hyperglycemia in a TRPM5-dependent manner. With this work, we elucidate the molecular mechanism of action of stevioside. Furthermore, we provide a deeper insight in the regulation of insulin secretion from the beta-cells and identify TRPM5 as an important part of a healthy secretion pathway. TRPM5 constitutes a novel possible drug target in the battle against type 2 diabetes.

Disclosure

K. Philippaert: None. R. Vennekens: None. P.E. Light: None.
Stem Cell-Derived Tissue-Associated Regulatory T Cells Suppress Autoimmune Diabetes
Authors: SONG JIANXUN J.
Published: June 2018

Pluripotent stem cells (PSCs) can be utilized to obtain a renewable source of healthy regulatory T cells (Tregs) to treat autoimmune diabetes as they have the ability to create nearly entire cell types in the body, including Tregs. However, the right conditions for the development of auto antigen (Ag)-specific Tregs from PSCs (i.e., PSC-Tregs) has not been fully defined. Auto Ag-specific PSC-Tregs can be programmed to be tissue-associated and infiltrate to local inflamed tissues (e.g., islets) to suppress autoimmune responses after adoptive transfer, thus preventing possible overall immunosuppression from non-specific Tregs. In this study, a new approach was developed to generate functional auto Ag-specific Tregs from induced PSC (iPSCs), i.e., iPSC-Tregs, which have the ability to suppress autoimmunity in a murine model of autoimmune diabetes in auto Ag-associated fashion. Murine iPSCs were retrovirally transduced with a DsRed reporter construct containing genes of ovalbumin (OVA)-specific T cell receptor (TCR) and the transcriptional factor FoxP3. The DsRed+ iPSCs were in vitro differentiated into OVA-specific iPSC-Tregs with an OP9 stromal cell line in the presence of recombinant cytokines. A double transgenic (Tg) mouse model of autoimmune diabetes was established in F1 mice in which the first generation from RIP-OVA Tg mice that were crossed with OT-I T cell receptor (TCR) Tg mice was challenged with vaccinia viruses expressing OVA (VV-OVA). Adoptive transfer of OVA-specific iPSC-Tregs dramatically suppressed autoimmunity in the OVA-induced model of autoimmune diabetes, including the inflammation and prevents the insulin-secreting pancreatic beta cells from destruction. Of note, we demonstrated that the adoptive transfer significantly reduced the higher ratio of CD8+ to CD4+ T cells in diabetic mice. These results indicate that stem cells can be used to develop auto Ag-specific Tregs, which have a therapeutic potential for autoimmune diabetes.

Disclosure

J.J. Song: None.
Dapagliflozin Treatment Impacts ß, but Not a, Cell Function in Normal Human Islets
Authors: DAI CHUNHUA , SHOSTAK ALENA , BOUCHI YASIR H. , HART NATHANIEL , POFFENBERGER GREG , SAUNDERS DIANE C. , HALIYUR RACHANA , DEAN DANIELLE , ARAMANDLA RADHIKA , BRISSOVA MARCELA , SHIOTA MASAKAZU , GREINER DALE L. , SHULTZ LEONARD D. , BOTTINO RITA , POWERS ALVIN C.
Published: June 2018

Dapagliflozin (DAPA), a selective Sodium Glucose Cotransporter-2 (SGLT2) inhibitor, is widely used for the treatment of type 2 diabetes (T2D). In T2D individuals, DAPA increases plasma glucagon, decreases insulin secretion, and improves muscle insulin sensitivity. DAPA has been reported to increase glucagon secretion in cultured normal human islets possibly because SGLT2 was more highly expressed in α cells. To investigate DAPA effect on human islets in vivo, we transplanted normal human islets (n=3 donors) into immunodeficient mice and treated them with DAPA (2mg/kg/day) or NaCl by oral gavage for 4 weeks. Basal blood glucose (NaCl vs. DAPA: 101±8 vs. 85±5 mg/dL, p=0.0858), glucagon (199.5±24.4 vs. 169.9±15.9 pg/mL, p=0.3107), and human insulin (1.15±0.17 vs. 0.99±0.14 ng/mL, p=0.4626) levels were similar in both groups. However, 15 minutes after glucose challenge, DAPA-treated mice had lower blood glucose (375±21 vs. 287±16 mg/dL, p=0.003), unchanged glucagon (86±14 vs. 75±8 pg/mL, p=0.4883), but lower human insulin levels (2.05±0.24 vs. 0.96±0.ng/mL, p<0.0001). The ratio of human insulin/blood glucose was lower in the DAPA group (0.52±0.07 vs. 0.36±0.04, p=0.0322). Ultrastructure of transplanted human islets showed that the DAPA treatment decreased the % immature granules (52±2% vs. 43±2%, p=0.0109) but increased the % empty granules (5.7±0.6% vs. 13.7±0.7%, p<0.0001) in β cells. To investigate if these changes were a consequence of improved insulin sensitivity or DAPA’s direct effect on β cells, we assessed insulin secretion by culturing human islets (n=3 donors) in 3.3 mM and 16.7 mM glucose with DAPA (0.5 μM) or NaCl for 1 hour. DAPA treatment had no effect on glucagon secretion at both glucose concentrations but reduced insulin secretion by 30% at 16.7 mM glucose (p=0.0259). By transcriptional profiling SGLT2 was expressed equally in α and β cells. These data suggest that DAPA does not directly affect glucagon secretion but has a direct impact on human β cell function.

Disclosure

C. Dai: None. A. Shostak: None. Y.H. Bouchi: None. N. Hart: None. G. Poffenberger: None. D.C. Saunders: None. R. Haliyur: None. D. Dean: None. R. Aramandla: None. M. Brissova: None. M. Shiota: None. D.L. Greiner: Consultant; Self; The Jackson Laboratory, Allakos, Inc. L.D. Shultz: None. R. Bottino: None. A.C. Powers: None.
DAG Accumulation due to Type 1 DGK Inhibition Has Contradictory Dual Effect on Ca2+ Signaling in Pancreatic ß Cells
Authors: SAWATANI TOSHIAKI , KANEKO YUKIKO K. , ISHIKAWA TOMOHISA
Published: June 2018

Pathophysiologically, excessive accumulation of diacylglycerol (DAG), a lipid signal messenger, in pancreatic β-cells has been shown to lead to the insufficiency of insulin secretion. Thus, the regulation of intracellular DAG levels is expected to be an important factor in maintaining β-cell function. The intracellular DAG levels are strictly controlled by DAG kinases (DGKs). We have previously shown that DGKα and γ, type I DGK isoforms, are highly expressed in mouse β-cells, and that DAG accumulation resulting from dysfunction of these DGKs reduces insulin secretion. In the present study, we investigated the effect of type I DGK dysfunction on the regulation of intracellular Ca2+ concentration ([Ca2+]i), which is correlated with insulin secretion, in the β-cell line MIN6B. We also analyzed changes in expression levels of DGKα and γ in β-cells of type 2 diabetes model NSY mice. The amplitude of glucose-induced [Ca2+]i oscillations was increased by 1 μM R59949, a type I DGK inhibitor, and by 10 μM DiC8, a DAG analog. These effects were abolished by Ro31-8220, a protein kinase C (PKC) inhibitor. In contrast, 10 μM R59949 and 100 μM DiC8 suppressed the glucose-induced [Ca2+]i elevation, which was insensitive to Ro31-8220, and furthermore reduced voltage-dependent Ca2+ channel (VDCC) currents, which were measured by patch-clamp recording, implying that DAG accumulation due to type I DGK dysfunction suppresses VDCC, thereby reducing [Ca2+]i in β-cells. Real-time qPCR showed that the expression level of DGKα and γ was lower in islets from NSY mice compared with control mice. Taken together, the results obtained here suggest that DAG accumulation due to type I DGK dysfunction has contradictory dual effect in β-cells depending on the degree of accumulation; mild accumulation PKC-dependently induces a stimulatory effect on insulin secretion, whereas excessive accumulation suppresses it independently of PKC. DGK is likely a key molecule for the progression of type 2 diabetes.

Disclosure

T. Sawatani: None. Y.K. Kaneko: None. T. Ishikawa: None.
Nonalcoholic Fatty Liver Disease (NAFLD) Outcome Post–Bariatric Surgery in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) Consortium
Authors: BACHA FIDA , GUPTA RESMI , JENKINS TODD M. , BRANDT MARY , INGE THOMAS H. , KLEINER DAVID , XANTHAKOS STAVRA , CONSORTIUM TEEN-LABS
Published: June 2018

Teen-LABS is a multicenter, prospective observational study of adolescents undergoing bariatric surgery. Predictors of resolution of NAFLD post-surgery are unclear. We evaluated changes in serum ALT levels, an acceptable surrogate when liver biopsy is not feasible, in 219 Teen-LABS subjects 3 years post gastric bypass or vertical sleeve gastrectomy. Three years post-surgery, median BMI declined to 38.4 from 52.6 kg/m2 at baseline (p<0.01). Median ALT (IU/L) decreased between baseline (36.5 ± 2.6 [95% CI: 31.4, 41.7]) and 6 months after surgery (28.9 ± 2.5 [95% CI: 24.4, 33.9]), and remained stable at 1, 2 and 3 years, all p<0.01 vs. baseline. 58% had abnormal ALT at baseline, which decreased to 10% at 3 years. After adjustment by logistic regression, 6 month improvement in BMI, fasting glucose, HOMA-IR, triglycerides, TG/HDL, and HDL were independently associated with reduced ALT. Improvement in metabolic indices remained significantly associated with decline in ALT, after adjusting for BMI (Table).

In conclusion, while weight loss was associated with decreased ALT by 6 months post-surgery, improved fasting glycemia, insulin resistance and dyslipidemia indices were also independently associated with ALT decline.

Association between change in predictor variables and decline in ALT from baseline to 6 months.Change in predictor variables over 6 monthsEstimate (SE) adjusted for age, race, sexp-valueEstimate (SE) adjusted for age, race, sex, change in BMIp-valueDecline in BMI0.64 (0.13)<0.01Decline in fasting glucose0.40 (0.07)<0.010.28 (0.08)0.01Decline in HbA1C4.59 (2.28)0.041.57 (2.32)0.50Decline in HOMA-IR1.11 (0.22)<0.010.82 (0.27)<0.01Decline in Triglycerides0.17 (0.02)<0.010.15 (0.02)<0.01Increase in HDL-0.75 (0.15)<0.01-0.52 (0.16)<0.01Decline in TG/HDL ratio5.11 (0.56)<0.014.85 (0.66)<0.01

Disclosure

F. Bacha: Research Support; Self; AstraZeneca, JAEB Center For Health Research, National Institutes of Health, Pediatric Diabetes Consortium. R. Gupta: None. T.M. Jenkins: None. M. Brandt: None. T.H. Inge: Consultant; Self; Standard Bariatrics, Independent Medical Expert Consulting Services, UpToDate. D. Kleiner: None. S. Xanthakos: None.
DNA Methylation at Birth Is Associated with Adiposity and Infant Growth during the First Six Months of Life in the Healthy Start Study
Authors: BORENGASSER SARAH J. , STARLING ANNE P. , ZHANG WEIMING , FRIEDMAN JACOB , HAMMAN RICHARD F. , YANG IVANA , KECHRIS KATERINA , DABELEA DANA
Published: June 2018

In utero exposures have been shown to impart increased risk for obesity in the offspring and are associated with epigenetic changes. DNA methylation was measured in 351 umbilical cord blood (UCB) samples within the Healthy Start Study, a well-characterized prebirth cohort that is following mother-infant pairs from pregnancy-early childhood. The primary objective was to test if DNA methylation at birth was associated with fat mass (FM) gains and infant growth (weight-for-age Z-score, WAZ) during the first 6 months (mos) of life to identify potential biomarkers of future obesity risk. DNA methylation was assessed in UCB via the Illumina 450K array. Adiposity was measured at birth and 4-6 mos of age via PeaPod. Infant weight was obtained from medical records. After adjusting for cellular heterogeneity, sex, and race we found 742 methylation sites (CpGs) through a univariable analysis that were associated with the rate of FM (g/day) in the first 6 mos of life (p < 0.001). Then, partial least squares (PLS) fitting using a multivariable analysis selected a subset of 235 predictor CpGs in this list for KEGG pathway analysis. Similarly, 1314 CpGs were associated with WAZ (p < 0.001); PLS selected a subset of 198 CpGs for KEGG analysis. Using a FDR < 0.001 for KEGG analysis, 3 pathways were associated with FM gain (Metabolic pathways, Glyoxylate and dicarboxylate metabolism, Neurotrophin signaling) and 8 pathways for WAZ gain (Gastric acid secretion, Oocyte meiosis, Metabolic pathways, Endocytosis, Tight Junction, Oxytocin signaling, GnRH signaling, and Inflammatory mediator regulation of TRP channels). The KEGG: Metabolic pathways was identified for both FM and WAZ gain, and 3 gene targets enriched in this pathway, ATP5C1, CYP26A1, and IDH3A are known to be involved in fat metabolism. Our studies have identified potential candidate methylation biomarkers, present at birth, which can be used for early risk detection in order to mitigate development of childhood obesity.

Disclosure

S.J. Borengasser: None. A.P. Starling: None. W. Zhang: None. J. Friedman: Advisory Panel; Self; Janssen Pharmaceuticals, Inc.. R.F. Hamman: None. I. Yang: None. K. Kechris: None. D. Dabelea: None.
BioChaperone Technology Enables the Development of Pramlintide-Prandial Insulin Combinations
Authors: MEIFFREN GRÉGORY , GEISSLER ALEXANDRE , MEYER YVES , RANSON AYMERIC , FORTIER CHARLES , SOULA OLIVIER , SOULA RÉMI , ALLUIS BERTRAND , CHARVET RICHARD
Published: June 2018

Pramlintide (Symlin®) is currently used on top of mealtime insulin therapy by T1D or T2D patients to achieve a better control of post-prandial glucose excursion. Indeed, pramlintide affects the rate of postprandial glucose appearance by slowing down gastric emptying, reducing postprandial glucagon secretion and modulating satiety, which affects caloric intake. Nevertheless, the use of pramlintide is currently limited as it cannot be combined with prandial insulin due to formulation pH incompatibility and results in a high burden of the number of injections. BioChaperone (BC) technology stabilizes pramlintide in aqueous solution at neutral pH and enables a pramlintide - prandial insulin co-formulation. BC pramlintide-human insulin (BC Pram Ins) formulation is physically and chemically stable for at least 6 weeks at 30°C and 9 weeks at 25°C. Physical stability was evidenced by visual inspection and MFI analysis. Chemical stability (recovery measured by RP-HPLC and high molecular weight species measured by SE-HPLC) was similar to that of commercial Humulin® and Symlin®. Under simulated in-use pump conditions at 37°C, BC Pram Ins formulation shows excellent physical and chemical stability for at least 1 week, with insulin and pramlintide recoveries higher than 95% and a formulation essentially free of particles. The pharmacokinetics of pramlintide was evaluated following single subcutaneous administration (0.1875 U/kg insulin, 1.125 µg/kg pramlintide) of BC Pram Ins formulation and pramlintide co-injected with human insulin (separate injections) to fasted healthy pigs. BC Pram Ins shows a slower absorption of pramlintide (LSM ratio [95% CI] ΔAUCPram0-30min: 0.45 [0.20; 1.05]) while the late exposure to pramlintide is higher (ΔAUCPram60-180min: 2.65 [1.44; 4.90]) compared to the separate injections.

In conclusion, the in-vitro and preclinical PD properties of BC Pram Ins support its clinical development to afford a better mealtime treatment for T1D and T2D patients.

Disclosure

G. Meiffren: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. A. Geissler: None. Y. Meyer: None. A. Ranson: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. C. Fortier: None. O. Soula: Board Member; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. Employee; Spouse/Partner; ADOCIA. R. Soula: Employee; Self; ADOCIA. Stock/Shareholder; Self; ADOCIA. Board Member; Self; Cellnovo. B. Alluis: None. R. Charvet: None.
Improvements in A1C and Time-in-Range in DIY Closed-Loop (OpenAPS) Users
Authors: LEWIS DANA M. , SWAIN RICHARD S. , DONNER THOMAS W.
Published: June 2018

Overview: We performed a retrospective study that analyzed outcomes from a subset (n=20) of the Do It Yourself (DIY) closed loop community. This already well-controlled, highly motivated T1D population realized further improvements in A1c and glucose time in range (TIR), and a reduction in time spent high and low during all timeframes after beginning a DIY hybrid closed loop “artificial pancreas” system.

Objective: To compare mean BG, TIR (70-180 mg/dl), and time above and below clinically meaningful thresholds before and after OpenAPS initiation.

Methods: We performed a retrospective cross-over analysis of continuous BG readings recorded during 2-week segments 4-6 weeks before and after initiation of OpenAPS (Johns Hopkins IRB00121066). Mean BG and TIR were analyzed overall, as well as by day (7am-11pm) and night (11pm-7am), and statistical significance was assessed using paired t-tests.

Results: Mean BG and TIR improved in every time category. Overall, mean BG (mg/dl) improved (135.7 to 128.3); as did mean estimated HbA1c (6.4 to 6.1%). TIR increased from 75.8 to 82.2% overall. Overnight, BG time <70 was reduced from 6.4 to 4.2%, and time <50 was reduced from 2.3 to 1.0%. Overall, BG excursions >300 were reduced from 1.7 to 0.35%.

Conclusion: Even with tight initial control, persons with T1D saw meaningful improvements in estimated A1c, TIR, and a reduction in time spent high and low, during the day and at night, after initiating OpenAPS.

Disclosure

D.M. Lewis: Consultant; Self; Tandem Diabetes Care, Inc.. R.S. Swain: None. T.W. Donner: Research Support; Self; Novo Nordisk Inc., Viacyte, Inc..
The Role of GLP-1 Receptor Expressed in Pancreatic a Cells in Regulating Glucagon Secretion
Authors: ZHANG YANQING , PARAJULI KESHAB R. , SMITH GENEVIEVE E. , GUPTA RAJESH , XU WEIWEI , NGUYEN LAUREN U. , ZAKARIA ANADIL F. , MAUVAIS-JARVIS FRANCK , FONSECA VIVIAN , SLOOP KYLE W. , WU HONGJU
Published: June 2018

Glucagon-like peptide-1 (GLP-1) inhibits glucagon secretion from a cells and stimulates insulin secretion from ß cells in a blood-glucose dependent manner. Whereas the effects of GLP-1 on ß cells are mediated by GLP-1 receptor (GLP-1R) has been described in detail. The action of GLP-1 on a-cells, however, is not clear. To determine whether the inhibition is due to a direct effect that occurs through GLP-1R of a-cells, or indirect effect on a-cells through insulin stimulation from ß-cells, we generated a-cell specific GLP-1R knockout (aGLP-1R KO) mice after GLP-1R expression was verified by glucagon-producing a-cells at protein and mRNA level in both mouse and human pancreas. Compared to control mice, the aGLP-1R KO female mice had impaired glucose tolerance following intraperitoneal glucose administration, and had more impaired glucose tolerance after 1m high fat diet-fed, but their insulin secretion and insulin sensitivity were maintained. Interestingly, non-fasting glucagon level of aGLP-1R KO mice was significantly higher than that of the control mice, whereas insulin and GLP-1 levels were similar between the two groups of mice. More importantly, we found glucagon secretion was stimulated by glucose 15 minutes following glucose administration in the aGLP-1R KO mice, but not in the control mice. Furthermore, we isolated islets from aGLP-1R KO mice and directly examined the effects of aGLP-1R deletion on glucagon secretion. Glucose-stimulated insulin secretion assay showed the aGLP-1R KO islets had no significant differences from the control islets. However, arginine significantly stimulated glucagon secretion in the two group islets and the stimulation was significantly enhanced in aGLP-1R KO islets. Taken together, these data showed that aGLP-1R deletion disturbed glucose-dependent glucagon secretion, whereas insulin secretion was not affected, demonstrating aGLP-1R plays a direct role in regulating glucagon secretion.

Disclosure

Y. Zhang: None. K.R. Parajuli: None. G.E. Smith: None. R. Gupta: None. W. Xu: None. L.U. Nguyen: None. A.F. Zakaria: None. F. Mauvais-Jarvis: Research Support; Self; Boehringer Ingelheim Pharmaceuticals, Inc. V. Fonseca: Consultant; Self; Abbott. Board Member; Self; American Association of Clinical Endocrinologists. Consultant; Self; Eli Lilly and Company. Stock/Shareholder; Self; Amgen Inc.. Consultant; Self; Asahi Kasei Corporation, AstraZeneca, Novo Nordisk Inc., ADOCIA, Intarcia Therapeutics, Inc., Sanofi-Aventis. K.W. Sloop: Employee; Self; Eli Lilly and Company. H. Wu: None.
Brain Insulin Sensitivity Predicts Adiposity—Nine-Year Results of the Tulip Study
Authors: SCHMID VERA , TSCHRITTER OTTO , MACHANN JÜRGEN , WAGNER ROBERT , STEFAN NORBERT , PREISSL HUBERT , HAERING HANS-ULRICH , FRITSCHE ANDREAS , HENI MARTIN
Published: June 2018

Lifestyle intervention reduces body weight and prevents type 2 diabetes. One crucial modulator of food intake and whole body energy metabolism is insulin action in the brain. We now test whether brain insulin sensitivity is a long-term predictor of weight and body fat distribution during and after a lifestyle intervention program. Before, after 9 months, at the end of lifestyle intervention at 24 months, as well as after 8.7 ±1.6 years follow-up, participants of the Tuebingen Lifestyle Intervention Program underwent a 75g OGTT, and whole body MRI. Brain insulin sensitivity was measured at baseline by changes in neuronal signals (theta frequency band) with magnetoencephalography during a hyperinsulinemic-euglycemic clamp in a subgroup of 28 participants of whom long-term follow-up was available in 15 persons. Higher brain insulin sensitivity before lifestyle intervention was associated with a more pronounced reduction in total and visceral fat during the lifestyle intervention (all p<0.01). High brain insulin sensitivity was also associated with less regain of fat mass during the long-term follow-up. In contrast to visceral fat, changes in subcutaneous adipose tissue were independent of the brain insulin responsiveness. Our results extend previous findings on the role of brain insulin for the success of lifestyle intervention to a long-term perspective. Insulin action in the human brain appears to be not only important for weight loss, but seems to determine regain of body weight and especially total and visceral fat mass thereafter. Experimental findings demonstrated that insulin administration to the brain modulates peripheral energy fluxes in humans. In line, our results indicate fat depots specific effects of brain insulin with particular benefits in the visceral compartment. These findings support the role of brain insulin in the regulation of body fat distribution and body weight.

Disclosure

V. Schmid: None. O. Tschritter: None. J. Machann: None. R. Wagner: None. N. Stefan: Consultant; Self; Merck Sharp & Dohme Corp.. Speaker's Bureau; Self; Novo Nordisk A/S. Research Support; Self; AstraZeneca. Speaker's Bureau; Self; AstraZeneca, OmniaMed Ltd.. H. Preissl: None. H. Haering: None. A. Fritsche: Advisory Panel; Self; Sanofi-Aventis Deutschland GmbH, Novo Nordisk A/S, Eli Lilly and Company, Boehringer Ingelheim GmbH. M. Heni: Research Support; Self; Boehringer Ingelheim GmbH. Speaker's Bureau; Self; Boehringer Ingelheim GmbH, Merck Sharp & Dohme Corp., Novo Nordisk Inc..
Deciphering a GABAergic Neural Circuit in Critical Control of Leptin-Mediated Feeding, Body Weight, and Glucose Homeostasis
Authors: WU QI , HAN YONG
Published: June 2018

Leptin plays a major role in control of glucose metabolism and feeding behavior by acting upon the LepR neurons that widely distribute through the brain. Although several LepR-expressing neuronal groups were identified in distinct nuclei, a dominant neural circuit that mediates the physiological roles of leptin remains elusive, largely due to the inadequate phenotypes as a result of developmental and neural compensations. In this report, a novel, non-sense suppression-based, inducible genetic system is implemented to rapidly delete a specific group of LepR signaling from adult mice within 4 days. Acute deletion of LepR from AgRP neurons show a drastic increase of food intake, massive weight gain, and severe glucose intolerance, developing in a rate with tight manifestation of the global leptin deficiency. Furthermore, a neural circuit comprising of LepR-expressing AgRP neurons and downstream GABAergic neurons in the DMH is mapped by genetic and functional tracing approaches. Optogenetic manipulation of AgRPLepR-DMHGABA neural circuit or the post-synaptic DMHMC4R neurons strongly altered food intake and glucose tolerance in a bidirectional controlled manner. Among all GABAA subunits examined, Gabra3 (encoding GABAA α3 subunits) displayed the most robust changes in response to genetic inactivation of LepRAgRP signaling. Using CRISPR/Cas9 gene editing technique, loss of Gabra3 in DMHMC4R neurons reduced food intake and enhanced glucose intolerance. Surprisingly, chronic infusion of bicuculline into the DMH fully reversed the obesity and glucose intolerance as a result of acute deletion of LepRAgRP signaling. Furthermore, genetic ablation of GABADMH neurons blunted leptin-mediated control of glucose metabolism and food intake.

In conclusion, we unveil a novel AgRPLepR-DMHGABA neural circuit and associated GABAA receptor signaling system in fundamental control of leptin-associated obesity and diabetes.

Disclosure

Q. Wu: None. Y. Han: None.
Microglia Activation Regulates Systemic Glucose Tolerance
Authors: DOUGLASS JOHN , VALDEARCOS MARTIN , KOLIWAD SUNEIL K. , THALER JOSH
Published: June 2018

Obesity and high fat diet (HFD) consumption in rodents is associated with hypothalamic inflammation and activation of microglia, the resident CNS immune cells. Recently, we provided evidence that microglia are critical intermediary cells that transmit the inflammatory signal induced by HFD exposure. Mice with a conditional knockout of IKKb specifically in microglia (CX3CR1CreERT2 x IKKbeta fl/fl, MGKO) have reduced susceptibility to HFD-associated hyperphagia and DIO compared with IKKb fl/fl littermate controls (Ctl). Surprisingly, despite their reduced fat mass, HFD-fed MGKO mice have equal glucose intolerance to Ctls as well as no improvement in white adipose tissue inflammation or hepatic triglyceride content. Together these data suggest dissociation between microglial regulation of energy and glucose homeostasis. To address this possibility, we pair-fed MGKO mice to Ctl mice, resulting in matched body weights during HFD feeding. Pair-fed MGKO mice showed a greater degree of impairment in glucose tolerance and insulin sensitivity with preserved insulin secretion compared to controls. Similarly, chemical inactivation of microglia using centrally-administered minocycline worsens insulin sensitivity in HFD-fed rats. Finally, using several distinct genetic models, we show that microglial activation acutely improves glucose tolerance and insulin sensitivity. Together, these data reveal a novel aspect of CNS regulation of metabolism in which microglial inflammatory activation promotes HFD overconsumption and weight gain but offsets obesity-associated dysregulation of glucose homeostasis. These results indicate the need for pathway-specific targeting to develop glial-based therapeutics for obesity and diabetes.

Disclosure

J. Douglass: None. M. Valdearcos: None. S.K. Koliwad: None. J. Thaler: Research Support; Self; Novo Nordisk A/S.
Continuous Glucose Monitoring in Patients With or Without Symptoms of Hypoglycemia after Bariatric Surgery
Authors: LEE CLARE , BROWN TODD , SCHWEITZER MICHAEL , MAGNUSON THOMAS , CLARK JEANNE
Published: June 2018

Objective: Hypoglycemia after bariatric surgery is an increasingly recognized metabolic complication. We sought to determine the sensitivity and specificity of a prior hypo-sx survey in detecting post-bariatric surgery hypoglycemia (PBSH) using a continuous glucose monitor (CGM).

Methods: Among the patients who underwent bariatric surgery at our institution and completed the hypo-sx survey, we enrolled 13 Roux-en-Y gastric bypass (RYGB, 7 with and 6 without hypo-sx) and 19 sleeve gastrectomy (SG, 9 with and 10 without hypo-sx) patients. Patients wore the CGM (Dexcom, San Diego, CA) for 72-120 hours at home. Hypoglycemia was defined as postprandial interstitial glucose (IG)<54 mg/dl. We used Kruskal Wallis test to compare the difference in hypoglycemia across groups.

Results: A total of 19 patients (59%) had hypoglycemia (Table 1), with a mean low glucose of 46.8 mg/dl. Two patients reported hypo-sx. The prevalence of hypoglycemia did not differ by the type of surgery (69% vs. 53%) or the presence of hypo-sx by survey (63% vs. 56%). The survey had a specificity of 53.8% and sensitivity of 52.6% for measured PBSH.

Conclusions: Asymptomatic postprandial hypoglycemia was common in post-bariatric patients regardless of surgery type. Assessments that focus on hypoglycemic symptoms may not adequately capture PBSH. Future studies should consider CGM to assess the true prevalence and impact of PBSH.

Table 1. Baseline Characteristics and Results from continuous glucose monitoring on post-bariatric surgery patients who were categorized as with or without symptoms of hypoglycemia based on their survey responsesRYGB with Hypo-sx (N=7)RYGB without Hypo-sx (N=6)SG with Hypo-sx (N=9)SG without Hypo-sx (N=10)P ALLP RYGB vs SGP With vs Without Hypo-sxMean Age, years52.9 (5.1)52.0 (10.0)41.9 (11.3)44.8 (11.9)% Female67%56%89%82%% Caucasian71%67%33%60%Time since surgery (years)7.3 (3.2)4.8 (1.3)4.7 (0.7)4.2 (0.8)Percent Patients with Postprandial Hypoglycemia (N)71% (5)67% (4)56% (5)50% (5)Total Average IG (mg/dl, SD)97.0 (6.7)103.5 (12.5)93.0 (8.1)96.9 (6.4)0.3730.2270.228Average Minimum IG (mg/dl, SD)47.7 (10.9)45.8 (9.7)46.4 (5.6)47.0 (9.9)0.8570.7440.429Postprandial Minutes/day IG <54 mg/dl (SD)9.5 (12.7)4.7 (4.9)3.0 (3.9)11.3 (25.1)0.8020.3370.955Abbreviations: SD: standard deviation , RYGB: Roux-en-Y gastric bypass, Hypo-sx: hypoglycemic symptoms, SG: sleeve gastrectomy, IG: interstitial glucose, Postprandial: within 3 hours of eating

Disclosure

C. Lee: None. T. Brown: Advisory Panel; Self; Merck & Co., Inc. M. Schweitzer: Consultant; Self; Ethicon US, LLC.. T. Magnuson: None. J. Clark: None.
Hospitalization and Emergency Department Visits for Severe Hypoglycemia among U.S. Adults with Diabetes and Serious Comorbid Conditions
Authors: MCCOY ROZALINA G. , VAN HOUTEN HOLLY , LIPSKA KASIA J. , SHAH NILAY
Published: June 2018

Diabetes care guidelines recommend more relaxed glycemic targets for patients with specific chronic conditions because they are thought to have an increased risk of hypoglycemia, limited life expectancy, and/or high clinical complexity. These include dementia, end stage renal disease (ESRD), stages 3-4 chronic kidney disease (CKD), myocardial infarction, heart failure, cerebrovascular disease, chronic obstructive pulmonary disease, cancer, arthritis, urinary incontinence, falls, depression, hypertension, cirrhosis, proliferative retinopathy, and peripheral neuropathy. The rates of severe hypoglycemia among patients with these conditions are unknown. We quantified rates of hospital and emergency department care for hypoglycemia among 216,839 adults (mean 65.5 years old) with diabetes in 2015 using the OptumLabs Data Warehouse (administrative database of >100 million commercially-insured and Medicare Advantage beneficiaries). Hypoglycemia rates varied widely: 10.6/1000 person-years (PY) in patients with hypertension, 26.9/1000 PY with CKD, 26.8/1000 PY with cirrhosis, 37.7/1000 PY with dementia, and 58.3/1000 PY with ESRD. Hypoglycemia was rare among patients with no conditions (2.0/1000 PY). After adjustment for all conditions, prior hypoglycemia, age, sex, race, HbA1c, and diabetes medications, the risk of severe hypoglycemia was significantly increased for all conditions except arthritis, incontinence, and cancer. Hypoglycemia risk increased rapidly with the number of comorbidities: OR 1.8 (95% CI 1.4, 2.2) for 2 conditions, 7.7 (6.2, 9.64) for 5, 16.6 (13.1, 21.1) for 7, and 25.6 (30.4, 32.2) for ?8 conditions compared with ?1 condition. Severe hypoglycemia is common among patients with chronic conditions. Rates vary between conditions but increase dramatically in patients with multiple comorbidities. These data can help inform decisions about glucose-lowering therapy for patients with comorbidities.

Disclosure

R.G. McCoy: None. H. Van Houten: None. K.J. Lipska: Other Relationship; Self; Centers for Medicare and Medicaid Services. Research Support; Self; National Institutes of Health. N. Shah: None.
Beta-Blocker Usage and Hypoglycemia in Hospitalized Patients with Diabetes Mellitus
Authors: MERRILL JENNIFER , DUNGAN KATHLEEN M.
Published: June 2018

Background: Although ?-blockers (BB) theoretically increase the risk of severe or prolonged hypoglycemia, studies have suggested that BB may decrease the risk of hypoglycemia-associated arrhythmias and death. However, there is little evidence in hospitalized patients on insulin.

Aim: To determine the relationship between BB use and incidence of hypoglycemia and mortality in hospitalized patients.

Methods: We retrospectively identified non-critically ill hospitalized patients receiving subcutaneous insulin and undergoing bedside glucose monitoring over a 2 year period. BB and basal insulin use were identified on the admission medication list. Hypoglycemia, defined as any glucose < 70 mg/dl within 24 hours of admission (Hypo24) or throughout the hospitalization (HypoT) and any glucose <40 mg/dl throughout the hospitalization (Hypo40) were compared between patients with and without BB.

Results: 13,424 patients were included, with 2648 patients receiving a BB at admission (19.7%). After controlling for other variables, the odds of Hypo24 HypoT and Hypo40 were higher for BB recipients (Hypo24 OR 3.79, 95% CI 3.21-4.50, p<0.0001, fully adjusted model; HypoT OR 7.70, 95% CI 6.77-8.77, p<0.0001, fully adjusted model; Hypo40 OR 1.95, 95% CI 1.49-2.57, p<0.0001). However, there was a significant interaction across basal insulin usage, with increased odds of HypoT and Hypo40 among basal insulin non-users but not basal insulin users. Hypo24, HypoT, and Hypo40 were associated with increased mortality in adjusted models. There was evidence of an interaction by BB status in the relationship between Hypo24 and mortality (with increased mortality among non-users but not users), but not at other time points.

Conclusions: BB use is associated with higher risk of hypoglycemia in hospitalized basal insulin non-users, but not basal insulin users. Hypoglycemia is associated with increased hospital mortality, regardless of BB use, but early hypoglycemia-associated mortality risk is attenuated by BB use.

Disclosure

J. Merrill: None. K.M. Dungan: Research Support; Self; Novo Nordisk Inc.. Advisory Panel; Self; Sanofi-Aventis. Research Support; Self; Sanofi-Aventis, GlaxoSmithKline plc.. Consultant; Self; GlaxoSmithKline plc.. Research Support; Self; AstraZeneca. Other Relationship; Self; DKBmed, Horizon, Projects in knowledge, Rockpointe.
Effect of Hypoglycemia during Intensive Insulin Therapy on Long-Term Glycemic Control in Patients with Newly Diagnosed Type 2 Diabetes
Authors: XU LIJUAN , LI YANBING
Published: June 2018

Aims: Short-term intensive insulin therapy induces long-term drug-free euglycemic remission in half of patients with newly diagnosed type 2 diabetes mellitus (T2DM) but causes an increased risk of hypoglycemia. Studies identifying the impact of hypoglycemia are necessary.

Methods: We analyzed data from three randomized prospective trials conducted at our institution from 2002 to 2015. A continuous subcutaneous insulin infusion (CSII) was provided to achieve the glycemic goals and then maintained for 14 days.

Results: Patients who attained one-year drug-free glycemic remission were younger (48.06±9.85 vs. 50.95±11.70 years, P=0.037) and had a higher body mass index (BMI) (25.53±3.52 vs. 24.66±3.20 kg/m2, P=0.046) than those who did not. Notably, the median number of episodes of mild hypoglycemia with nadir glucose values of 3.0-3.9 mmol/L was higher in the remission group than in the non-remission group (5 (6) vs. 2 (5), P<0.001). However, the number of episodes of clinically significant hypoglycemia (<3.0 mmol/L) was insignificantly lower in the remission group (0 (1) vs. 0 (1), P=0.273). Patients with higher glucose levels (glycated hemoglobin (HbA1c), fasting plasma glucose (FPG) and postprandial glucose (PPG)) and lower ?-cell functions (homeostasis model assessment of ?-cell function (HOMA-B)) at baseline faced a greater risk of clinically significant hypoglycemia (OR=2.02, 95% CI 1.40-2.92, P<0.001). According to the logistic regression analysis, mild hypoglycemic episodes were positively and independently related to long-term glycemic remission.

Conclusions: Mild hypoglycemic episodes during CSII therapy are related to better long-term drug-free glycemic remission in patients with newly diagnosed T2DM. However, clinically significant hypoglycemia is not correlated and should be avoided.

Disclosure

L. Xu: None. Y. Li: None.
Postprandial Insulin Initiation—Evaluation of Adverse Outcomes in Older Veterans
Authors: TSENG CHIN-LIN , SOROKA ORYSYA , POGACH LEONARD
Published: June 2018

We assessed one-year adverse outcomes (emergency department visits for hypoglycemia (HYPO-ED), death) and potential overtreatment (A1c <6.5%) post prandial initiation in veterans >= 65 years receiving only basal insulin in 2009-2011 and dually enrolled in Veterans Health Administration and Medicare using linked data. Rates were compared by race (blacks, whites, others) and comorbidity categories (advanced diabetes complications (D), diminished life expectancy (L), major neurological disorders/dementia/cognitive impairment/major depression/substance abuse (M) and cardio vascular conditions (C)). Of the 3,465 studied patients, 457 (13%) died or incurred HYPO-ED. Of the 200 (5.8%) that incurred HYPO-ED, 16%, 24.5%, and 23% had the event within 1, 2-3, and 4-6 months, respectively; of the 271 (7.8%) deaths, 10.7%, 12.5%, and 25.8% occurred in the same time intervals. Of the 2,789 (80%) patients having some A1c values within a year post-prandial, 10% had an A1c <6.5%. Compared to whites (n=2,708; 78%), blacks (336; 10%) had a higher HYPO-ED rate (8.0% vs. 5.6%, p=0.08) and a comparable death rate (8.6% vs. 8.4%, p=0.88). Both races had similar rates of having an A1c <6.5% (11.6% vs. 13.1%, p=0.48). Most (85%) patients had at least one of the studied comorbidity categories; the prevalence order was: C (69%), D (39%), M (21%), and L (16%). Patients with M (21%) had higher rates in adverse outcomes than those with only C (26%) and those without any studied comorbidities (15%): for HYPO-ED, the rates were 6.3%, 5.9%, and 5.4% (p=0.76); for death, 12.6%, 5.8%, and 2.3% (p<0.001); for having an A1c <6.5%, 14.5%, 11.8%, and 10.2% (p=0.11). Among basal insulin users started on prandial, we found that within a year after prandial initiation, HYPO-ED rate was 1.4 fold greater in blacks than whites, patients with mental/cognitive/neurological diseases had higher rates in HYPO-ED and death, and at least one in ten had an A1c <6.5%. Prandial insulin should be used cautiously in older adults with complex comorbidities.

Disclosure

C. Tseng: None. O. Soroka: None. L. Pogach: None.
Risk of Hypoglycemia in Aging Population with Insulin-Requiring Diabetes
Authors: MUNSHI MEDHA , SLYNE CHRISTINE , ATAKOV-CASTILLO ASTRID , GREENBERG JORDAN , GREAVES TORI , CARL SAM P. , TOSCHI ELENA
Published: June 2018

Background: The impact of aging on insulin-dependent diabetes is not well studied.

Methods: We evaluated insulin-dependent older adults (age >65 years) with type 1(T1D) and type 2 diabetes (T2D). All patients completed questionnaires for demographics, hypoglycemia fear survey (HFS II), hypoglycemia unawareness (Clarke’s method) and assessment of comorbidities. A1c was measured, and blinded CGM was performed over 2-week period.

Results: We evaluated 32 insulin-dependent older adults: 23 had T1D (age 70±4 years, A1C 8%) and 9 had T2D (age 80±9 years, A1C 8.9%). All with T1D were either on insulin pump or on ≥4 insulin injections/day compared to 55% of patients with T2D. Clinically significant hypoglycemia (glucose < 55 mg/dl for ≥ 20 mins/episode) was observed in 91% of patients with T1D (21 of 23), compared with 22% with T2D (2 of 9). Nocturnal hypoglycemic episodes (10 pm-6 am) were observed in 15 out of 23 (65%) T1D patients, compared to 1 out of 9 (11%) with T2D. Older adults with T1D had greater fear of hypoglycemia as shown by HFS II score of 34 compared to 15 in T2D. However, hypoglycemia unawareness was similar in the two groups (9 of 23 (39%) with T1D, and 3 of 9 (33%) with T2D. Age-associated comorbidities in T1D and T2D older adults included Cognitive impairment (68% vs. 100%), depression (27% vs. 43%), recent falls within 6-months (24% vs. 43%), vision impairment (27% vs. 43%), and hearing impairment (36% vs. 50%) respectively.

Conclusions: Insulin-dependent older adults with T1D have a higher risk of total and nocturnal hypoglycemia compared to older adults with T2D. Associated multiple age-related comorbidities put them at higher risk of poor outcomes.

Disclosure

M. Munshi: Consultant; Self; Sanofi. C. Slyne: None. A. Atakov-Castillo: None. J. Greenberg: None. T. Greaves: None. S.P. Carl: None. E. Toschi: None.
The Impact of Fatty Liver Disease and Metabolic Syndrome on the Progression of Coronary Artery Calcification
Authors: CHO YUN KYUNG , KANG YU MI , PARK CHEOL-YOUNG , PARK SUNG-WOO , LEE WOO JE , PARK JOONG-YEOL , JUNG CHANG HEE
Published: June 2018

Objectives: Fatty liver disease (FLD) is a well-known risk factor for cardiovascular disease (CVD). However, it is unclear whether FLD per se is an independent risk factor of CVD or combined unfavorable metabolic components with metabolic syndrome (MetS). In this study, we examined the independent impact of FLD on the coronary artery calcification (CAC) score progression.

Methods: We examined 1,173 asymptomatic participants who underwent repeated CAC score measurement during routine health examinations. Subjects were categorized into 4 groups according to the presence (+) or absence (-) of FLD and MetS. The CAC score progression was defined as either incident CAC in a population free of CAC at baseline or increase ≥ 2.5 units between the baseline and final square root of CAC scores participants who had detectable CAC at baseline examination.

Results: Among the participants, 44.8% (526), 23.2% (272), 8.8% (103) and 23.2% (272) were classified as FLD(-)/MetS(-), FLD(+)/MetS(-), FLD(-)/MetS(+), and FLD(+)/MetS(+), respectively. The proportions of subjects who developed CAC progression was 18.6% (98), 28.3% (77), 29.1% (30) and 32.0% (87) in FLD(-)/Mets(-), FLD(+)/Mets(-), FLD(-)/MetS(+), and FLD(+)/MetS(+), respectively. In logistic regression analysis, FLD(+)/MetS(+) were at significantly higher risk of CAC progression compared to FLD(-)/MetS(-) [multivariate adjusted-odds ratio (OR) 1.76, 95% confidence interval (CI) 1.18-2.62]. FLD(+)/MetS(-) also demonstrated higher risk of CAC progression [multivariate adjusted-OR 1.53, 95% CI 1.05-2.23].

Conclusions: FLD is an independent risk factor for CAC progression irrespective of the presence of metabolic syndrome. Special attention should be paid to subjects with FLD for the prevention of future cardiovascular events, even though MetS does not coexist.

Disclosure

Y. Cho: None. Y. Kang: None. C. Park: None. S. Park: None. W. Lee: None. J. Park: None. C. Jung: None.
Temperature Regulating Shoes for Prevention of Diabetic Foot Ulcers
Authors: ERSEN ALI , ADAMS LINDA S. , MYERS RYAN T. , HIRSCHMAN GORDON B. , LAVERY LAWRENCE A. , YAVUZ METIN
Published: June 2018

Diabetic foot ulcers (DFU) continue to burden Americans with over 100,000 amputations every year. We believe that better understanding of the etiology and a multi-factorial approach that combines in-shoe temperature regulation along with plantar stress reduction could dramatically improve this outcome. Previous research indicated that soft tissue is prone to ulceration at warmer temperatures. Likewise, animal studies indicate higher tissue resistance to break-down when cooled to 25 °C to 28 °C. Insulated diabetic footwear and load-bearing activity lead to high plantar tissue temperatures and increased risk of DFU. The purpose of this study was to design/develop a novel temperature regulating footwear and test cooling effectiveness. An extra-depth diabetic shoe was instrumented with temperature control apparatus set to cool to 28 °C. Three subjects wore this shoe and a non-cooling (control) shoe while walking for 10 minutes. Post-walking thermographs of the regulated foot revealed: forefoot temperatures below 28 °C; heel temperatures around 28 °C with a 3.9 °C bilateral cooling effect; midfoot regions 2.9 °C less than the control foot but still over 28 °C, perhaps due to poor contact with the cooling insole or a need for increased localized control of cooling. These results suggest feasibility of in-shoe temperature regulation. Further research is needed to improve our design and ultimately explore DFU prevention in a clinical trial.

Disclosure

A. Ersen: Other Relationship; Self; Vivonics Inc. L.S. Adams: Other Relationship; Self; Vivonics, Inc. R.T. Myers: Employee; Self; Vivonics, Inc. G.B. Hirschman: Stock/Shareholder; Self; Vivonics, Inc.. Employee; Self; Vivonics, Inc.. Board Member; Self; Vivonics, Inc. L.A. Lavery: Speaker's Bureau; Self; Osiris Therapeutics, Inc., Integra LifeSciences. Research Support; Self; Cardinal. Speaker's Bureau; Self; Smith & Nephew. Research Support; Self; EO2. Consultant; Self; Aplion, Harbor MedTech, Boehringer Ingelheim GmbH, Medline Industries, Inc. M. Yavuz: Research Support; Self; Derma Sciences, PulseFlow Technologies. Other Relationship; Self; vivonics.
Pro-B-Type Natriuretic Peptide Strongly Predicts Future Cardiovascular Events in Cardiovascular Disease Patients with Type 2 Diabetes as Well as in Those Without Type 2 Diabetes
Authors: SAELY CHRISTOPH H. , VONBANK ALEXANDER , HEINZLE CHRISTINE , ZANOLIN DANIELA , LARCHER BARBARA , MADER ARTHUR , LEIHERER ANDREAS , MUENDLEIN AXEL , DREXEL HEINZ
Published: June 2018

Pro-B-type natriuretic peptide (proBNP) is a prognostic biomarker in various patient populations. Its power to predict cardiovascular events in the extremely high risk group of patients with the combination of established cardiovascular disease (CVD) and type 2 diabetes (T2DM) is unclear and is addressed in the present study. We measured serum proBNP in 900 patients with established CVD including 591 patients with angiographically verified coronary artery disease and 309 patients with sonographically proven peripheral artery disease. Prospectively, we recorded vascular events over 6.3±2.0 years. At baseline, proBNP was significantly higher in patients with (n=317) than in those without T2DM (990±2556 vs. 742±2328 pg/ml; p=0.003). The cardiovascular event rate was significantly higher among CVD patients with than among those without T2DM (50.5 vs. 35.1%; p<0.001). ProBNP significantly predicted the incidence of cardiovascular events after adjustment for age, gender, BMI, smoking, systolic and diastolic blood pressure, LDL cholesterol, HDL cholesterol and the eGFR both in patients with T2DM (standardized adjusted HR 1.48 [1.28-1.73]; p<0.001) and in subjects without T2DM (HR 1.33 [1.20-1.47]; p<0.001). We conclude that serum proBNP in patients with established CVD predicts future cardiovascular events independently of established cardiovascular risk factors both among those with as well as among those without T2DM.

Disclosure

C.H. Saely: None. A. Vonbank: None. C. Heinzle: None. D. Zanolin: None. B. Larcher: None. A. Mader: None. A. Leiherer: None. A. Muendlein: None. H. Drexel: None.