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The Heterogeneity of Diabetes

Unraveling a Dispute: Is Systemic Inflammation Related to Islet Autoimmunity?

¹ Laboratory of Immunogenetics, The Brehm Center for Type 1 Diabetes and Analysis, Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
² Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania

Address correspondence and reprint requests to Massimo Pietropaolo MD, Laboratory of Immunogenetics, The Brehm Center for Type 1 Diabetes and Analysis, 2039 Biomedical Scientific Research Building, 109 Zina Pitcher Place, Ann Arbor, MI 48109. E-mail: maxtp{at}umich.edu

Abbreviations: CHS, Cardiovascular Health Study; CRP, C-reactive protein; DC, dendritic cell; ICA, islet cell antibody; IFN-, -interferon; IL, interleukin; LADA, latent autoimmune diabetes of the adult; M, macrophages; MHC, major histocompatibility complex; NF, nuclear factor; NK, natural killer; TCR, T-cell receptor; TNF, tumor necrosis factor; TZD, thiazolidindione; UKPDS, U.K. Prospective Diabetes Study

Diabetes is an emblematic example of a heterogeneous disease. Systemic inflammation has emerged as a prominent factor in the type 2 diabetes pathoetiology, but it remains ill-defined in type 1 diabetes. There is a wide spectrum of associations between inflammatory responses and diabetic syndromes. At one end of this spectrum, there is type 1 diabetes for which there is convincing evidence that chronic inflammation of pancreatic islets is a central aspect of disease pathogenesis. At the opposite end, is type 2 diabetes that is clearly associated with systemic inflammation, which could be either the cause or simply mark the underlying pathology. Accumulating evidence has substantiated that a subgroup of adult patients clinically diagnosed with type 2 diabetes exhibit autoantibody responses to islet autoantigens. The presence of these immunologic abnormalities is associated with a severe insulin secretory defect and the absence of signs of systemic inflammation as documented by plasma C-reactive protein and fibrinogen levels that are comparable with those of control populations. Islet autoantibody evaluation should be part of the diagnostic assessment for clinically diagnosed type 2 diabetes not only because it might predict the rate of progression to insulin requirement in adult populations but also to identify a pathogenically distinct disease phenotype characterized by the absence of systemic inflammation and its related disorders. A more appropriate characterization of this subgroup of clinically diagnosed type 2 diabetes, diabetes of autoimmune pathogenesis, will promote future research into the etiology, natural history, and treatment.

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