Clinical significance of cardiovascular dysmetabolic syndrome

Although diabetes mellitus is predominantly a metabolic disorder, recent data suggest that it is as much a vascular disorder. Cardiovascular complications are the leading cause of death and disability in patients with diabetes mellitus. A number of recent reports have emphasized that many patients already have atherosclerosis in progression by the time they are diagnosed with clinical evidence of diabetes mellitus. The increased risk of atherosclerosis and cardiovascular complications in diabetic patients is related to the frequently associated dyslipidemia, hypertension, hyperglycemia, hyperinsulinemia, and endothelial dysfunction. The evolving knowledge regarding the variety of metabolic, hormonal, and hemodynamic abnormalities in patients with diabetes mellitus has led to efforts designed for early identification of individuals at risk of subsequent disease. It has been suggested that insulin resistance, the key abnormality in type II diabetes, often precedes clinical features of diabetes by 5–6 years. Careful attention to the criteria described for the cardiovascular dysmetabolic syndrome should help identify those at risk at an early stage. The application of nonpharmacologic as well as newer emerging pharmacologic therapies can have beneficial effects in individuals with cardiovascular dysmetabolic syndrome and/or diabetes mellitus by improving insulin sensitivity and related abnormalities. Early identification and implementation of appropriate therapeutic strategies would be necessary to contain the emerging new epidemic of cardiovascular disease related to diabetes.     

Nrf2及其药理性活化剂在糖尿病心血管并发症中的作用

糖尿病(DM)导致的心脑血管并发症是危害人类健康的重大疾病。氧化应激被认为是DM相关心血管并发症发生、发展的重要机制,但通过补充外源性抗氧化剂并未能使心血管疾病患者远期获益。核因子E2相关因子2(Nrf2)可增加内源性抗氧化酶的活性从而提高机体的抗氧化应激能力,可能是治疗糖尿病心血管并发症的一个重要靶点,提示靶向Nrf2药物的开发可能获得防治糖尿病相关血管并发症的新一代药物。本文就Nrf2在糖尿病相关心血管并发症发生、发展中的作用及其药理性活化剂对糖尿病(DM)相关心血管病变的治疗作用进行综述。     

The effects of type 1 diabetes on the hypothalamic, pituitary and testes axis

Type 1 diabetes is an autoimmune disorder characterized by a lack of insulin production by the beta cells of the pancreas. This lack of insulin causes a variety of systemic effects on whole-body metabolism. Poorly managed type 1 diabetes can lead to cardiovascular disease, diabetic neuropathy, and diabetic retinopathy. Increasingly, even well-managed type 1 diabetic patients show damage to peripheral organs related to complications from the disease. The central role of insulin in energy homeostasis also renders it an important signaling factor in the reproductive tract. type 1 diabetes has now been demonstrated to cause defects in sperm and testes. The aim of this review is to present the known effects of insulin's role in the function of the male reproductive tract. These effects might be mediated through hormonal alterations in the hypothalamic pituitary gonadal axis or through the direct interaction of insulin on the testes and sperm cells. Although fertility complications also occur in type 2 diabetic males, this review will focus on the defects specifically linked with the lack of insulin seen in type 1 diabetes.     

Proteinuria: value as predictor of cardiovascular mortality in insulin dependent diabetes mellitus.

The relation between diabetic microangiopathy and macroangiopathy was studied by analysing the relative mortality from cardiovascular disease in patients with insulin dependent diabetes mellitus with and without persistent proteinuria. The study group comprised 2890 diabetics diagnosed between 1933 and 1972 before the age of 31, and the study was conducted by using the linear logistic discrete failure time model. In patients with proteinuria the relative mortality from cardiovascular disease was 37 times that in the general population; in patients without proteinuria it was 4.2 times that in the general population. In both groups women had a relative mortality twice to 2.6 times that of men. In neither group was relative mortality correlated with duration of diabetes, suggesting that the association between diabetes and cardiovascular disease may be conferred by factors other than hyperglycaemia and hyperinsulinaemia. The high relative mortality from cardiovascular disease in diabetics with proteinuria indicates a strong association between diabetic microangiopathy and macroangiopathy, suggesting a common (pathogenetic?) mechanism for these two late diabetic complications.     

Nouveaux marqueurs dans l’homéostasie glucidique : physiologie et physiopathologie

The term diabetes mellitus describes a metabolic disorder resulting from defects in insulin secretion, insulin action, or both. People with diabetes are at increased risk of cardiovascular, peripheral and cerebrovascular disease. In consequence, it is important to better understand early step in this disease in order to prevent complications. Incretine hormones are defined as intestinal hormones released in response to nutrient ingestion, which potentiate the glucose-induced insulin response. The incretine effect is mainly caused by two peptide hormones, glucose-dependent insulin releasing polypeptide (GIP) and glucagons-like peptide-1 (GLP-1). Analogs of GLP-1 and dipeptidyl-peptidase IV (DPP-IV) inhibitors are actually used as antidiabetic drugs. Adiponectin is an adipokine, which is expressed in adipose tissue and is thought to play an important role in glucose metabolism. Hypoadiponectinemia was related to obesity, insulin-resistance and as a risk factor of diabetes, cardiovascular events and death. Plasmatic quantification of GLP-1 and adiponectin should improve insulin-resistance diagnosis and diabetes prevention.     

Betaine Down Regulates Apelin Gene Expression in Cardiac and Adipose Tissues of Insulin Resistant Diabetic Rats Fed by High-Calorie Diet

Apelin is a newly discovered peptide that its serum level increases in diabetic patients with cardiovascular dysfunction. Recent studies indicate the beneficial actions of betaine in reducing the cardiovascular and metabolic complications, however data related to its effect on adipocytokine expression is limited. The aim of this study was to evaluate the effect of betaine supplementation on Apelin gene expression in cardiac muscle and adipose tissue of insulin resistance, diabetic rats fed by a high calorie diet. To induce insulin resistance rats were fed with high fat/high carbohydrate diet for five weeks and then 30 mg/kg STZ was injected intraperitoneally. After confirming of diabetes incidence (serum glucose above 7.5 mmol/l) the animals were treated with 1 % betaine in drinking water for 28 days. At days 14 and 28 after treatment, animals were euthanized and Apelin gene expression was evaluated by real time PCR and western blot in heart and adipose tissues. Serum levels of insulin, Apelin and glucose and HOMA–IR were also measured. Our results showed that feeding of rats by a high calorie diets caused insulin resistance, which was manifested by elevated plasma insulin, glucose and Apelin levels and also HOMA–IR. Apelin gene expression in heart and adipose tissues were significantly increased simultaneously with the progression of diabetes. Betaine supplementation decreased serum Apelin and down regulated Apelin expression in adipose tissue and cardiac muscle, particularly at day 28 of treatment. We concluded that betaine might improve metabolic and cardiovascular complications in diabetic patients by regulation of Apelin expression and secretion.     

基因技术在治疗2型糖尿病中的应用*

2型糖尿病(type 2 diabetes mellitus, T2DM)是一类由于胰岛β细胞损伤和机体对胰岛素耐受引发的慢性代谢性疾病,其快速增长的患病率和并发症所带来的高病死率已成为人类面临的医学难题。目前,T2DM主要是以降糖药物及胰岛素增敏剂等药物进行治疗,但是这类药物会产生严重的副作用,而且不能长期良好控制血糖和防止各种慢性并发症。因此,基因治疗是未来医疗发展的主要方向。基因治疗不仅可以靶向调控血糖水平进而提高降糖的效果,而且能够减少糖代谢异常引起的并发症,保护组织器官免受损伤。在认识传统药物治疗糖尿病的基础上,综述了基因技术在治疗T2DM中的应用,讨论了基因技术治疗T2DM的意义及存在的问题。基因技术的应用不仅有利于T2DM的预防和个体化治疗,同时也为糖尿病并发症提供了新的治疗途径。     

Hypertriglyceridemia: cause or consequence of insulin resistance?

An overproduction of VLDL by the liver and a slower clearance of these lipoproteins are usually seen in diabetic patients. There is correlation between insulin resistance and plasma triglyceride concentration. Triglyceride may influence an early step in the insulin action pathway and alternatively, insulin resistance may cause hypertriglyceridemia. Hyperinsulinemia and/or hypertriglyceridemia may play a strong role in the cardiovascular risk of patients with type II diabetes. There is an important need to conduct trials to define therapy that can reduce the risk of cardiovascular complications.     

Insulin-producing cells derived from stem cells: recent progress and future directions

Type 1 diabetes is characterized by the selective destruction of pancreatic beta-cells caused by an autoimmune attack. Type 2 diabetes is a more complex pathology which, in addition to beta-cell loss caused by apoptotic programs, includes beta-cell dedifferentiation and peripheric insulin resistance. beta-Cells are responsible for insulin production, storage and secretion in accordance to the demanding concentrations of glucose and fatty acids. The absence of insulin results in death and therefore diabetic patients require daily injections of the hormone for survival. However, they cannot avoid the appearance of secondary complications affecting the peripheral nerves as well as the eyes, kidneys and cardiovascular system. These afflictions are caused by the fact that external insulin injection does not mimic the tight control that pancreatic-derived insulin secretion exerts on the body's glycemia. Restoration of damaged beta-cells by transplantation from exogenous sources or by endocrine pancreas regeneration would be ideal therapeutic options. In this context, stem cells of both embryonic and adult origin (including beta-cell/islet progenitors) offer some interesting alternatives, taking into account the recent data indicating that these cells could be the building blocks from which insulin secreting cells could be generated in vitro under appropriate culture conditions. Although in many cases insulin-producing cells derived from stem cells have been shown to reverse experimentally induced diabetes in animal models, several concerns need to be solved before finding a definite medical application. These refer mainly to the obtainment of a cell population as similar as possible to pancreatic beta-cells, and to the problems related with the immune compatibility and tumor formation. This review will summarize the different approaches that have been used to obtain insulin-producing cells from embryonic and adult stem cells, and the main problems that hamper the clinical applications of this technology.     

The BBZDR/Wor rat model for investigating the complications of type 2 diabetes mellitus

Congenic and inbred strains of rats offer researchers invaluable insight into the etiopathogenesis of diabetes and associated complications. The inbred Bio-Breeding Zucker diabetic rat (BBZDR)/Wor rat strain is a relatively new and emerging model of type 2 diabetes. This strain was created by classical breeding methods used to introgress the defective leptin receptor gene (Lepr(fa)) from insulin-resistant Zucker fatty rats into the inbred BBDR/Wor strain background. The diabetic male BBZDR/Wor rat is homozygous for the fatty mutation and shares the genetic background of the original BB strain. Although lean littermates are phenotypically normal, obese juvenile BBZDR/Wor rats are hyperlipidemic and hyperleptinemic, become insulin resistant, and ultimately develop hyperglycemia. Furthermore, the BBZDR/Wor rat is immune competent and does not develop autoimmunity. Similar to patients with clinical diabetes, the BBZDR/Wor rat develops complications associated with hyperglycemia. The BBZDR/Wor rat is a model system that fully encompasses the ability to study the complications that affect human type 2 diabetic patients. In this review, recent work that has evaluated type 2 diabetic complications in BBZDR/Wor rats is discussed, including the authors' preliminary unpublished studies on cardiovascular disease.     

PON1 55 and 192 Gene Polymorphisms in Type 2 Diabetes Mellitus Patients in a Turkish Population

Diabetes mellitus is a multifactorial metabolic disease, caused by the complete or relative absence of insulin hormone, which results in the deterioration of carbohydrate, protein, and lipid metabolism. The PON1 55 and 192 polymorphisms have been reported to be associated with type 2 diabetes and its complications. In this study, the involvement of the PON1 55 and 192 polymorphisms and paraoxonase enzyme activity in diabetic complications was assessed. The MM and QQ genotypes were the most frequent in complications of type 2 diabetes in both of the polymorphisms. PON enzyme activity was lower in the type 2 diabetes group with respect to the control group. Regarding both genotypes and enzyme activity, correlations were found between the PON1 55 and 192 genotypes and diabetic complications. This study thus helps to outline a genotype?Cphenotype relation for the PON1 gene in a Turkish population.     

Mitochondria in the pathogenesis of diabetes: a proteomic view

Diabetes mellitus is a complex metabolic disorder characterized by chronic hyperglycemia due to absolute or relative lack of insulin. Though great efforts have been made to investigate the pathogenesis of diabetes, the underlying mechanism behind the development of diabetes and its complications remains unexplored. Cumulative evidence has linked mitochondrial modification to the pathogenesis of diabetes and its complications and they are also observed in various tissues affected by diabetes. Proteomics is an attractive tool for the study of diabetes since it allows researchers to compare normal and diabetic samples by identifying and quantifying the differentially expressed proteins in tissues, cells or organelles. Great progress has already been made in mitochondrial proteomics to elucidate the role of mitochondria in the pathogenesis of diabetes and its complications. Further studies on the changes of mitochondrial protein specifically post-translational modifications during the diabetic state using proteomic tools, would provide more information to better understand diabetes.     

Physical exercise improves glucose metabolism in lifestyle-related diseases

The beneficial effects of physical exercise on the decreased insulin sensitivity caused by detrimental lifestyle were reviewed based on experimental evidences. In epidemiological studies, disease prevention has been considered at three levels: primary (avoiding the occurrence of disease), secondary (early detection and reversal), and tertiary (prevention or delay of complications). The major purpose of physical exercise for primary prevention and treatment of lifestyle-related diseases is to improve insulin sensitivity. It is known that, during physical exercise, glucose uptake by the working muscles rises 7 to 20 times over the basal level, depending on the intensity of the work performed. However, intense exercise provokes the release of insulin-counter regulatory hormones such as glucagons and catecholamines, which ultimately cause a reduction in the insulin action. Continued physical training improves the reduced peripheral tissue sensitivity to insulin in impaired glucose tolerance and Type II diabetes, along with regularization of abnormal lipid metabolism. Furthermore, combination of salt intake restriction and physical training ameliorates hypertension. In practical terms, before diabetic patients undertake any program of physical exercise, various medical examinations are needed to determine whether they have good glycemic control and are without progressive complications. Because the effect of exercise that is manifested in improved insulin sensitivity decreases within 3 days after exercise and is no longer apparent after 1 week, a continued program is needed. For a safety practice, moderate- or low-intensity exercise is preferable. In conclusion, we have found sufficient evidences that support the theory that, combined with other forms of therapy, mild exercise training increases insulin action despite no influence on body mass index or maximal oxygen uptake. Along with evident benefits in health promotion, moderate-intensity exercise might play an important role in facilitating treatment of various diseases.     

FGF1:一种治疗糖尿病的新型潜在药物

糖尿病是一种常见的内分泌代谢性疾病,它及其并发症的治疗是现代医学仍未解决的难题。常见的药物治疗有诸多不良反应,譬如胰岛素的长期使用会产生胰岛素耐受性。近年研究发现,酸性成纤维细胞因子（Fibroblast growth factor 1,FGF1或aFGF）及其衍生物能够使2型糖尿病小鼠的血糖快速恢复至正常水平,并且具有胰岛素增敏效果,规避了胰岛素治疗产生耐受性的问题。因此,人们对FGF1及其衍生物在开发新型T2DM疗法方面给予诸多期待。该综述系统介绍了FGF1的结构与功能、降糖功效的机制及新发现,对FGF1的2种注射方式和FGF家族在降糖作用方面进行了比较,并对FGF1在治疗糖尿病方面的研究进程进行展望,旨在为调节血糖、解决胰岛素耐受性问题提供一种新的思路和方法。     

Maturity-onset diabetes of the young

Maturity-onset diabetes of the young (MODY) is a subtype of noninsulin dependent diabetes mellitus (NIDDM). It is characterized by an early age of onset and autosomal dominant mode of inheritance. These features and the availability of large multigenerational pedigrees make MODY useful for genetic studies of diabetes. In the large, 5-generational RW pedigree, MODY is tightly linked to genetic markers on chromosome 20q. Affected subjects in this family show abnormalities of carbohydrate metabolism varying from impaired glucose tolerance (IGT) to severe diabetes. Approximately 30% of diabetic subjects become insulin requiring and vascular complications occur. MODY is also linked to the glucokinase gene on chromosome 7p and many different mutations associated with MODY have been identified in this gene. MODY due to mutations in the glucokinase gene is a relatively mild form of diabetes with mild fasting hyperglycemia and IGT in the majority. It is rarely insulin requiring and rarely has vascular complications. Clinical studies indicate that the genetic or primary defect in MODY is characterized by deranged and deficient insulin secretion and not by insulin resistance and that there are quantitative and qualitative differences in insulin secretory defects which differentiate subjects with MODY due to glucokinase mutations from those with mutations in the gene on chromosome 20q. These differences correlate with the severity of diabetes between these two genetic forms of MODY.     

Macroangiopathy in adults and children with diabetes: from molecular mechanisms to vascular damage (part 1).

Type 2 diabetes mellitus (T2DM) is an increasing problem in childhood; however type 1 diabetes mellitus (T1DM) remains by far the most common type of diabetes in this age group. In this review we will focus on T1DM, because this will have the greatest implication for patients diagnosed in childhood. During the atherosclerotic process, several molecular, receptorial and cellular factors provide a continous mechanism of vascular damage. In diabetic children this state seems to be enhanced and facilitated so that accelerated atherosclerosis is associated with an increased risk of cardiovascular events in respect to the non diabetic population. Hyperglycemia PER SE and associated with diabetes is an important risk factor for atherosclerosis. At present a substantial part of children with diabetes do not reach satisfactory glycemic control. Other risk factors for the development and progression of atherosclerosis may be inherited or develop in the course of the disease: hypertension, dyslipidemia, insulin resistance, obesity, cigarette smoking, physical inactivity, disturbance of platelet function, coagulation and fibrinolysis. The development and progression of atherosclerosis should be blocked at an early age, if possible. Primary prevention to all risk factors for cardiovascular disease is important and intervention is indicated if necessary. At the moment the best therapeutic strategy is to maintain metabolic control at a physiologic level and perform screening and early intervention for vascular complications.     

Comparison of therapeutic regimens in the amelioration of alterations in rat gastrointestinal mucosal DNA, RNA and protein induced by streptozotocin diabetes mellitus

Type 1 diabetes mellitus is characterized by hyperglycemia, insulinopenia, and secondary neural, renal and vascular complications. Clinical manifestations in the gastrointestinal tract range from initial mild complications to more severe complications as the disease progresses, but as of yet, are poorly understood. The current study has two main foci 1) to monitor the alterations in gastrointestinal DNA, RNA and protein content induced by streptozotocin diabetes and 2) to use these parameters to monitor the efficacy of intensive insulin treatment versus pancreatic islet transplantation in the amelioration of the diabetes induced alterations. Female Wistar Furth rats were rendered diabetic by streptozotocin injection and measured for alterations in gastrointestinal DNA, RNA and protein content. Similarly, animals which had streptozotocin-induced diabetes were also treated by intensive insulin therapy or pancreatic islet transplant and monitored for alterations in gastrointestinal DNA, RNA and protein content. In general, diabetes induced increases in stomach, duodenal, jejunal and colonic macromolecular content. With few exceptions, treatment with either intensive insulin or pancreatic islet transplantation returned each variable measured back to control levels. In every case, pancreatic islet transplantation was comparable to intensive insulin therapy. In the short term the treatments are comparable, but long term analyses are needed to determine if the treatments offer any difference in their ability to prevent the long term complications related to diabetes mellitus.     

Cardiovascular pleiotropic actions of DPP-4 inhibitors: A step at the cutting edge in understanding their additional therapeutic potentials

Dipeptidyl peptidase 4 (DPP-4) is a serine protease enzyme expressed widely in many tissues, including the cardiovascular system. The incretin hormones such as glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) are released from the small intestine into the vasculature during a meal, and these incretins have a potential to release insulin from pancreatic beta cells of islets of Langerhans, affording a glucose-lowering action. However, both incretins are hurriedly degraded by the DPP-4. Inhibitors of DPP-4, therefore, enhance the bioavailability of GLP-1 and GIP, and thus have been approved for better glycemic management in patients afflicted with type 2 diabetes mellitus (T2DM). Five different DPP-4 inhibitors, often called as ‘gliptins’, namely sitagliptin, vildagliptin, saxagliptin, linagliptin and alogliptin have been approved hitherto for clinical use. These drugs are used along with diet and exercise to lower blood sugar in diabetic subjects. T2DM is intricately related with an increased risk of cardiovascular disease. Growing body of evidence suggests that gliptins, in addition to their persuasive anti-diabetic action, have a beneficial pleiotropic action on the heart and vessels. In view of the fact of cardiovascular disease susceptibility of patients afflicted with T2DM, gliptins might offer additional therapeutic benefits in treating diabetic cardiovascular complications. Exploring further the cardiovascular pleiotropic potentials of gliptins might open a panorama in impeccably employing these agents for the dual management of T2DM and T2DM-associated perilous cardiovascular complications. This review will shed lights on the newly identified beneficial pleiotropic actions of gliptins on the cardiovascular system.