Prevent And Treatment Of Chronic Complications In Patients With Type 1 Diabetes Mellitus

BackgroundThe prevalence of type 1 diabetes mellitus(T1DM)among pediatric populations has been increasing globally over the last decade.Type 1 diabetes is the main cause of diabetes in children,accounting for 5-10%of the total number of diabetes.Type 1 diabetes children have poor glycemic control and cannot take the oral hypoglycemic drugs alone with lifelong insulin injections.Insulin is more likely to cause low blood glucose than other oral medications.The better glycated hemoglobin,the more hypoglycemia.The incidence of hypoglycemia is three times than ordinary time.This increases the difficulty of blood glucose control.Long-term hyperglycemia and metabolic disorders lead to serious diabetic complications.Compared with the general population,the life expectancy of patients with type 1 diabetes is reduced by 11-13 years,and the incidence of complications of type 1 diabetes can be as high as 96.5%.The main cause of death in diabetes is cardiovascular complications,which are based on atherosclerosis.At present,there is definite evidencethat metformin can delay atherosclerosis in type 1 diabetes mellitus at the same glycated hemoglobin.The cardiovascular protective effect may be extra and not be its lower blood sugar way.Metformin’ s protective cardiovascular mechanism is specific to diabetes.It prevents diabetic vascular disease by inhibiting the formation of non-enzymatic glycosylation products produced by hyperglycemia.AGEs have strong reactivity and the ability of continuous cross-linking,which can directly form covalent cross-linking with the proteins in the blood vessel wall,stimulate the endothelial cells to over-express adhesion molecules,and lead to damage of the vascular structure and function causing vascular lesions.In addition,AGEs can also cause degradation of anionic polyglycoproteins on the vascular endothelial cell membrane,leading to increased vascular permeability and destruction of vascular endothelial barrier function causing vascular permeability increase,which make excessive expression of vascular cell adhesion molecule 1 and the monocyte chemotactic protein 1 in mononuclear cells.As a result,the adhesion of monocytes to endothelial cells is enhanced,thereby damaging the vascular endothelial structure.AGEs can induce the proliferation of vascular smooth muscle cells and the formation of reactive oxygen species,and induce the activation of nuclear factor κ B transduction pathway,thereby increasing the expression of inflammatory factors and promoting the development of atherosclerosis.Metformin may have a protective effect on the cardiovascular system by scavenging MGO and reducing AGEs.Long-term poor metabolic control may affect linear growth,whereas good metabolic control tends to normalize linear growth.In T1DM,a decrease in serum insulin-like growth factor-1(IGF-1)has been consistently reported,and may be the cause of growth abnormalities Insulin has the crucial role of regulating growth factors and linear growth.Moreover,there is strong evidence that insulin may indirectly affect IGF-1 synthesis.Insulin alters the concentration of IGF-binding proteins(IGFBPs),which regulate IGF-1 bioactivity.Through upregulation of hepatic GH receptor expression,insulin increases hepatic sensitivity to GH stimulation,thereby increasing IGF-1 production.In T1DM,with insufficient insulin action in the liver due to lack of endogenous insulin in the portal vein,dysfunction of the GH/IGF-1 axis may be present.Although these abnormalities have been described in patients with poor glycemic control,the results of previous studies support the existence of a negative association between IGF-1 and glycated hemoglobin Alc(HbAlc).However,one study found that the IGF-1 level in patients with T1DM was low,but did not correlate with HbAlc.Strict glycemic control by subcutaneous injections of exogenous insulin attenuates these abnormalities,but does not completely reverse them.This study consisted of four parts:part one:ApoE mice were induced into juvenile type 1 diabetes model,and the degree of juvenile atherosclerosis was observed.In the second part,ApoE mice were induced into juvenile type 1 diabetes mellitus model,and metformin was used for intervention,and it was found that there was already early atherosclerosis,and metformin was effective for intervention.The third part is the role of metformin in preventing atherosclerosis by removing the late glycosylation products.The fourth part mainly studies whether the height of children with type 1 diabetes is impaired due to long-term poor blood glucose control,and whether the change of insulin-like growth factor-1 affects the height.Part 1 Establ ishment of juvenile atherosclerosis in type 1 diabetes mellitusObjectivesWe used ApoE-/-mice to induce juvenile atherosclerosis of type 1 diabetes mellitus model.Subjects and MethodsAnimal model18 Male ApoE gene knockout mice at age of 4 weeks were injected with STZ for 5 consecutive days and observed for 2 weeks.Appropriate amount of tail was cut off to measure blood glucose.The mice with two times of FPG≥llmmol/L were successfully induced into the diabetes model and randomly enrolled to the diabetes group.The remaining 18 were enrolled in the control group.Experimental animal materials(1)After feeding for 4 weeks,the mice were fasted for 12 hours with no restriction on drinking water.The mice were euthanized.Each one of the control group and the model group was randomly selected to determine whether the model was successful.(2)Mice were anesthetized and taken blood.Biochemical criterion determination:FPG,glycosylated hemoglobin,triglyceride,and low-density lipoprotein cholesterol were determined by centralized automatic biochemical analyzer.(3)After blood collection,the whole aorta was obtained.The aorta was removed from the aortic root to the abdomen,oil red 0 staining was performed,and the plaque area was quantitatively analyzed with image-proplus 6.0.ResultsThe baseline blood glucose before injection was 5.33±0.24 mmol/1.There was a statistically significant difference in blood glucose at enrollment between the diabetic treatment group and the non-diabetic group.There was no significant weight gain at enrollment and after 4 weeks in diabetes group.Atherosclerosis was found in diabetic group.No significant plaque was observed in the non-diabetic group.ConclusionType 1 diabetes mellitus and its juvenile atherosclerosis were successfully established.Part 2 Effect of metformin on juvenile atherosclerosis in type 1 diabetes mellitusObjectivesobserved the degree of juvenile atherosclerosis,and used metformin to intervene it.Subjects and MethodsAnimal model18 Male ApoE gene knockout mice at age of 4 weeks were injected with STZ for 5 consecutive days and observed for 2 weeks.Appropriate amount of tail was cut off to measure blood glucose.The mice with two times of FPG≥11mmol/L were successfully induced into the diabetes model and randomly enrolled to the diabetes group(groups 1,2,and 3).The remaining 18 were enrolled in the control group(groups 4,5 and 6).Groups 1 and group 4 received 100mg/kg/day metformin for 4 weeks.Group 2 and group 5 received 5mg/kg/day simvastatin.Group 3 and group 6 received normal saline for four weeks.Experimental animal materials(1)After feeding for 4 weeks,the mice were fasted for 12 hours with no restriction on drinking water.The mice were euthanized.Each one of the control group and the model group was randomly selected to determine whether the model was successful(2)Mice were anesthetized and taken blood.Biochemical criterion determination:FPG,glycosylated hemoglobin,triglyceride,and low-density lipoprotein cholesterol were determined by centralized automatic biochemical analyzer.(3)After blood collection,the whole aorta was obtained.The aorta was removed from the aortic root to the abdomen,oil red 0 staining was performed,and the plaque area was quantitatively analyzed with image-proplus 6.0.ResultsThe baseline blood glucose before injection was 5.33±0.24 mmol/1.There was a statistically significant difference in blood glucose at enrollment between the diabetic metformin treatment group and the non-diabetic metformin intervention group.There was no significant weight gain at enrollment and after 4 weeks in each subgroup of diabetes.Atherosclerosis was found in diabetic metformin group,diabetic saline intervention group and diabetic simvastatin group.No significant plaque was observed in the non-diabetic simvastatin group and the non-diabetic saline group.In the non-diabetic metformin group,mural thrombus formation trend and intraluminal platelet beam formation were observed.ConclusionMetformin can delay atherosclerosis in type 1 diabetes mellitus.Part 3 The mechanism of metformin delaying juvenile atherosclerosis in type 1 diabetes mellitusObjectivesIn this study,we used ApoE-/-mice to induce juvenile type 1 diabetes mellitus model,observed the degree of juvenile atherosclerosis,and used metformin to intervene,and explored the corresponding mechanism.Subjects and MethodsAnimal model18 Male ApoE-/-mice at age of 4 weeks were injected with STZ for 5 consecutive days and observed for 2 weeks.Appropriate amount of tail was cut off to measure blood glucose.The mice with two times of FPG≥llmmol/L were successfully induced into the diabetes model and randomly enrolled to the diabetes group(groups 1,2,and 3).The remaining 18 were enrolled in the control group(groups 4,5 and 6).Groups 1 and group 4 received 100mg/kg/day metformin for 4 weeks.Group 2 and group 5 received 5mg/kg/day simvastatin.Group 3 and group 6 received normal saline for four weeks.Exper imental animal mater ials(1)After feeding for 4 weeks,the mice were fasted for 12 hours with no restriction on drinking water.The mice were euthanized.Each one of the control group and the model group was randomly selected to determine whether the model was successful.(2)Mice were anesthetized and taken blood.Biochemical criterion determination:FPG,glycosylated hemoglobin,triglyceride,and low-density lipoprotein cholesterol were determined by centralized automatic biochemical analyzer.Plasma CEL and CML levels were detected by ELISA.(3)After blood collection,the whole aorta was obtained.The aorta was removed from the aortic root to the abdomen,oil red 0 staining was performed,and the plaque area was quantitatively analyzed with image-proplus 6.0.The expressions of eNOS and AMPK proteins in aorta were quantitatively detected by immunohistochemistry and Western Blot.ResultsThe baseline blood glucose before injection was 5.33±0.24 mmol/1.There was a statistically significant difference in blood glucose at enrollment between the diabetic metformin treatment group and the non-diabetic metformin intervention group.There was no significant weight gain at enrollment and after 4 weeks in each subgroup of diabetes.Compared with the simvastatin treatment group,the CEL and CML in the diabetic metformin treatment group were significantly lower.There was a statistically significant difference between CEL and CML in the diabetic metformin group and the diabetic saline group.Compared with the non-diabetic simvastatin treatment group,CEL and CML in the diabetic metformin treatment group were significantly higher.CEL and CML in the diabetic metformin treatment group were higher than those in the non-diabetic metformin treatment group,and the difference was statistically significant.Atherosclerosis was found in diabetic metformin group,diabetic saline intervention group and diabetic simvastatin group.No significant plaque was observed in the non-diabetic simvastatin group and the non-diabetic saline group.In the non-diabetic metformin group,mural thrombus formation trend and intraluminal platelet beam formation were observed.eNOS expression was detected in vascular endothelial cells in both the non-diabetic simvastatin treatment group and the diabetic simvastatin treatment group(0.0497±0.0152 vs 0.0398 ± 0.0131,P<0.05).The expression of eNOS in the non-diabetic metformin group(0.0133±0.0019)was similar to that in the non-diabetic saline group(0.0172±0.0013)(P=0.3),but both were lower than that in the diabetic simvastatin treatment group,and the difference was statistically significant(P<0.05).There was no significant expression of eNOS in the diabetic metformin group and the diabetic saline group,both of which were lower than the previous groups.There was no significant expression of AMPK in the six groups.ConclusionMetformin can delay atherosclerosis in type 1 diabetes mellitus.by removing MGO to reduce tAGEs not lowering blood glucose.Part 4 The association of height and insulin-1 ike growth factor-1 in children with type 1 diabetes mellitusObjectivesThe purpose of this study was to assess the height of children with type 1 diabetes is impaired and to explore the association between IGF-1SDS and HSDS.Subjects and MethodsThis study was cross-sectional.Seventy-Two Chinese children with T1DM,who regularly attended the Diabetes clinic in Shandong Provincial Hospital(Jinan,China)for follow-up,were recruited from December 2016 to August 2018.In addition,190 healthy Chinese children of similar age,sex,and body mass index(BMI),attending the Childcare clinic in Shandong Provincial Hospital for health examination,were recruited as healthy controls.ResultsThe data of 72 children with T1DM without signs and symptoms of diabetes complications,and 190 healthy children were analyzed.Baseline clinical data showed no significant differences between the two groups.The average baseline HSDS was 0.49 in the T1DM group and 0.05 in the control group.This difference was significant.A significant increase in HSDS was observed in girls with T1DM,compared with girls in the control group.The HSDS was also higher in boys with T1DM than in boys in the control group;however,this difference was not statistically significant.The mean THSDS was higher in the T1DM group than in the control group.The THSDS was significantly higher in boys with T1DM boys than in boys in the control group;however,there was no difference between girls with T1DM and girls in the control group.The HSDS was higher than the THSDS in all recruited children.The IGF-1 level in the T1DM group was significantly lower than that in the control group.A similar difference was observed for IGF-1SDS;moreover,the difference remained significant when considering boys and girls separately.The HSDS and THSDS of the good glycemic control group were higher than those of the healthy control group,but these differences were not statistically significant.The HSDS was higher than THSDS by 0.48 SDS in the good glycemic control group and by 0.32 SDS in the healthy control group.There was a significant difference in IGF-1SDS between the good glycemic control group and the healthy control group.As expected,FPG and HbAlc remained higher in the good glycemic control group than in the healthy control group.The C-peptide and insulin levels were lower in the good glycemic control group than in the healthy control group.No difference was observed in the insulin dosage,HSDS,or IGF-1SDS between good glycemic control group and the poor glycemic control group.No difference in IGF-1SDS was observed between girls with T1DM and boys with T1DM.A significantly higher insulin dosage was observed in girls with T1DM than in boys with T1DM.There was a significant difference in the insulin dosage among the T1DM subgroups based on the types of insulin.The HSDS was positively correlated with C-peptide,insulin,and IGF-1 levels,as well as IGF-1SDS in all recruited children.The IGF-1SDS was also significantly correlated with HbAlc,C-peptide,and insulin levels in all recruited children.As expected,IGF-1SDS was also positively correlated with C-peptide and insulin levels in the control group.As expected,C-peptide level significantly increased with reduction in the insulin dosage,and there was an interaction between IGF-1 and insulin dosage in the T1DM group.Conclusions1.GH/IGF-1 axis is impaired in T1DM children without complications,but their height is not impaired.2.Height and IGF-1 in in T1DM children do not increase by reducing HbAlc.3.C-peptide and insulin types do not affect the height in T1DM children.4.High.dosages dose of insulin may induce high levels of IGF-1 and tall stature in T1DM.