Celiac disease and type I (insulin-dependent) diabetes mellitus in childhood: follow-up study.

To ascertain the specificity of IgA and IgG antigliadin (IgA-AGA, IgG-AGA), IgA-antireticulin (R1-ARA), and antiendomysial (AEA) antibodies for the diagnosis of celiac disease, we evaluated 133 type I diabetic children aged 1.4-28.4 years (mean 14.1 +/- 6.6), with diabetes from onset to 20.5 years. Fifty-three patients were considered at onset and 49 of these also during follow-up. IgA-AGA and IgG-AGA were determined by enzyme-linked immunosorbent assay (ELISA), R1-ARA and AEA by indirect immunofluorescence. IgA-AGA were positive in 20 of 133 (15%), IgG-AGA were positive in seven of 133 (5.26%), while R1-ARA and AEA were positive in three patients. At the onset of disease we found elevated IgA-AGA in 17 of 53 (32%) patients, IgG-AGA in four (7.55%) patients, three of them with IgA-AGA as well; R1-ARA and AEA were present in three (5.66%) patients, all with high IgA-AGA levels. During 1-10 year follow-up IgA-AGA decreased to within the normal range in 13 patients, with elevated IgA-AGA at onset but without R1-ARA and AEA; in four patients with high IgA-AGA at onset, IgA-AGA remained constantly elevated as did R1-ARA and AEA in three of them; and two patients, without IgA-AGA, R1-ARA, and AEA at onset, became positive for all three antibodies. Intestinal biopsy confirmed a diagnosis of celiac disease in five of these with IgA-AGA, R1-ARA, and AEA, but not in one patient with persistent IgA-AGA but no AEA and R1-ARA, suggesting that R1-ARA and AEA are more reliable markers for the screening of celiac disease in type I diabetic patients.

Increased urinary N-acetyl-beta-glucosaminidase (NAG) excretion in young insulin-dependent diabetic patients.

We evaluated urinary N-acetyl-beta-glucosaminidase (NAG) excretion in overnight and in second morning urine in 50 young diabetic patients, aged 7.4-25 years with a disease duration from 2-19.6 years. In all patients we evaluated urinary NAG and creatinine excretion, in both overnight and second morning urine, glycosuria, fasting blood glucose and HbA1c levels, insulin requirement, blood pressure, and the presence of microangiopathic complications. Urinary NAG excretion was also evaluated in 69 age- and sex-matched controls. NAG was determined using 3-cresolsulfonphtaleinyl-beta-N-acetylglucosaminide as substrate (Boehringer Mannheim, Germany). In the diabetic patients NAG/Cre ratios were significantly higher than in controls both in overnight and second morning urine (P < 0.0005, respectively). We observed significantly higher NAG/Cre ratio levels in the second morning than in overnight urine, both in controls and in diabetics (P < 0.0005, respectively). Elevated (above 2 S.D. of the mean) NAG/Cre ratios were found in 17/50 patients (34%) in overnight urine and in 29/50 (58%) in second morning urine. No correlation was observed between NAG/Cre ratio levels and age, duration of disease, pubertal stage, body mass index, fasting blood glucose, glycosuria, insulin requirement and blood pressure. The patients with one or more complications did show NAG/Cre ratio levels significantly higher than those without complications (P < 0.005) in second morning urine, but not in overnight urine. Our study has demonstrated an increased rate of urinary NAG excretion in young IDDM patients, in particular in those with microangiopathic complications.

Hyperinsulinemia in children and adolescents after bone marrow transplantation.

We report 34 patients (aged 5-18 years) with acute (n = 26) or chronic (n = 1) leukemia, non-Hodgkin's lymphoma (n = 3) or severe aplastic anemia (n = 4) evaluated for pancreatic beta-cell function 9 months to 10.2 years after autologous (n = 19) or allogeneic (n = 15) BMT. Before BMT, all patients received cytotoxic drugs, combined with total body irradiation (TBI) in 24 cases or thoracoabdominal irradiation (TAI) in 4 children. Patients were investigated for fasting blood glucose (FBG), HbA1C, anti-insulin (IAA) and islet cell antibodies (ICA), first-phase insulin response (FPIR) and insulinemia/glycemia (I/G) ratio on i.v. glucose tolerance test (GTT) and C-peptide response after glucagon 1 mg i.v. Results were compared with those obtained in 21 age- and sex-matched controls. None of the patients or controls had IAA and/or ICA. FBG and HbA1C were normal in all children. In the patients, glycemia on i.v. GTT was similar to controls whereas insulin levels I/G ratio and FPIR were significantly higher in patients than in controls, as well as C-peptide levels. We divided the patients on the basis of the radiotherapy into group I with TBI (n = 18), group II with TAI (n = 4) and group III who were not irradiated (n = 4). The I/G ratio, FPIR on i.v. GTT and C-peptide response were significantly higher in group I compared with the other two groups and controls. The increased insulin and C-peptide levels in our patients with normal glycemia might be interpreted as a state of insulin resistance, more evident in patients who received TBL.

Final height attainment in girls and boys with insulin-dependent diabetes mellitus.

We compared final height to height at diagnosis (expressed as a standard deviation score, SDS), predicted adult height (according to the Bayley and Pinneau method) and target genetic height (expressed as mean parental height in cm, +6.5 for males and -6.5 for females) in 37 patients (15 males, 22 females) with insulin-dependent diabetes mellitus (IDDM), aged 20.6 +/- 3.3 years (16.6-27), with 11.8 +/- 3.7 years (5.2-19.2) mean duration of disease. In the 22 females, final height (162.4 +/- 5.7 cm; range, 150-174 cm) was higher than predicted (161.5 +/- 7.8 cm; range, 146-176.2 cm) and target genetic height (159.7 +/- 3.8 cm; range, 152.8-167.3 cm), although not significantly. Female patients showed a positive correlation between final height and both predicted (P < 0.05) and target genetic height (P < 0.005). No difference was observed in final height between patients diagnosed in the prepubertal or pubertal phase (162.2 +/- 4.6 cm vs. 163.4 +/- 6.2 cm; P-value n.s.). In the 15 males, final height (173.4 +/- 4.4 cm; range, 166.5-181 cm), lower than predicted (175.4 +/- 4.9 cm; range, 166-183 cm), was higher than target genetic height (169.9 +/- 4.8 cm; range, 162.4-177 cm) (P < 0.05). Male patients showed a positive correlation between final height and target genetic height (P < 0.05). No difference was found in final height between patients diagnosed in the prepubertal or pubertal phase (173.6 +/- 3.5 cm vs. 172.7 +/- 5.5 cm; P-value n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

Cytotoxic activity in children with insulin-dependent diabetes mellitus.

We determined the percentage of circulating natural killer (NK) cells, using the monoclonal antibodies anti-CD57 and anti-CD16, NK cytotoxic activity (lytic units/10(6)) and lymphokine-activated killer (LAK) activity in 25 IDDM patients aged 3-23 years, 12 with disease for < 1 year (Group I) and 13 with disease for > 3 years (Group II). Nine age-matched healthy subjects served as controls. The percentage of CD57+ cells was similar in IDDM patients and controls, while the percentage of CD16+ cells was lower in IDDM patients (P < 0.05) than in controls. NK cell cytotoxic activity was lower in IDDM patients than in controls (P < 0.01), in Group I and II compared with controls (P < 0.005). LAK activity was similar in IDDM patients and in controls. No correlation was found between NK cytotoxic activity and metabolic control, HLA typing, while a negative correlation was found between NK cytotoxic activity and insulin requirement (P < 0.05). The decreased NK cytotoxic activity observed in our patients, in particular in long-standing diabetics, with normal NK cell number, could be due to a qualitative defect of the NK cells, or to a deficient IL-2 and/or TNF-alpha production, or to a immunomodulatory or immunosuppressing effect of insulin.

CD5-positive B cells in type 1 (insulin-dependent) diabetic children.

We have measured CD5+ B cell levels in the peripheral blood of 35 type 1 (insulin-dependent) diabetic children, aged 1.1-21.2 years (10.7 +/- 4.6 years). Patients were divided into two groups according to disease duration (group I < 6 months and group II > 1.5 years). Group I included 18 patients and group II 17 patients. Thirty-nine healthy subjects, comparable for age and sex, served as controls. CD5+ B cells were identified by double immunofluorescence staining with rhodamine-conjugated rabbit anti-human immunoglobulin and with a mouse anti-CD5 monoclonal antibody revealed by a fluorescein-conjugated goat anti-mouse immunoglobulin. We found that CD5+ B cell levels (expressed as percentages of peripheral blood B lymphocytes) were significantly higher in group I (median 24; range 4-48) than in controls (median 14; range 0-36, P < 0.001) and in group II (median 4; range 0-20, P < 0.001). A follow-up study of 12 group I patients showed a significant decline in CD5+ B cell levels. The data obtained in our diabetic patients suggest that CD5+ B cells are expanded in the early phase of type 1 diabetes mellitus and may play a role in the autoimmune process of the disease.

Transient IgG subclass deficiencies in newly diagnosed diabetic children.

In 27 children (15 males and 12 females) with insulin-dependent diabetes mellitus (IDDM), aged 1.2-13.5 years (mean 9.9 +/- 3.6 years) we investigated immunoglobulins (IgG, IgA, IgM), IgG subclass levels and islet-cell antibodies (ICA) at diagnosis and at 6 and 12 months after disease onset. At diagnosis, IgG levels were lower than -2SD in 7 patients (26%), IgA in 1 (3.7%), IgM in 1 (3.7%). IgG subclass levels were below the 3rd percentile in 13 patients (48.1%); in particular IgG1 in 7 (26%), IgG2 in 3 (11.1%), IgG3 in 2 and IgG4 undetectable in 1 case. In 3 out of the 13 patients combined IgG1-IgG3, IgG1-IgG2 and IgG1-IgG4-IgA deficiencies were observed. ICA were greater than 20 Juvenile Diabetes Foundation units in 17/27 patients. The HLA-DR2 frequency was higher in patients with IgG subclass deficiency than in patients with normal IgG subclass levels. During follow up, IgG levels normalized in 6 patients while IgA and IgM did not change. IgG1 normalized in 5 out of the 7 patients, IgG2 in all patients while IgG3 and IgG4 did not change. One year later ICA were still present in 8/27 patients. The hypogammaglobulinaemia and IgG subclass deficiencies observed in our patients could have either a genetic or an acquired basis.

Exocrine pancreatic function in children and adolescents with insulin-dependent diabetes mellitus.

Exocrine pancreatic function was evaluated in 21 diabetic children on the basis of a p-aminobenzoic acid (PABA) test and a determination of fasting serum amylase, pancreatic isoamylase, lipase, trypsin and elastase levels. Fecal chymotrypsin was also measured. Compared to the controls, the diabetic children had significantly lower levels of trypsin (P less than 0.001) and elastase (P less than 0.02). Fecal chymotrypsin appeared to be significantly lower (P less than 0.01) in diabetic children than in controls but in all patients fecal chymotrypsin values registered above the limit considered to be normal. No significant correlation was observed between pancreatic enzyme concentrations, serum and urinary PABA values, and chronologic age, HbA1 and insulin requirement. Only for serum PABA a significant negative correlation with duration of disease (P less than 0.01) has been observed. These data show that exocrine pancreatic function may be abnormal in children with IDDM.

Alterations of in vitro interleukin 1 and 2 in diabetic children.

We studied interleukin 1 (IL-1) and interleukin 2 (IL-2) production in unstimulated and stimulated cultures from 27 young diabetic patients and 21 age-matched healthy subjects. In unstimulated cultures monocytes from newly diagnosed patients produced significantly higher levels of IL-1 than controls. In lipopolysaccharide (LPS)-stimulated cultures, IL-1 production in patients with fresh and long-standing diabetes was no different from that of controls. IL-2 production was low or absent in unstimulated cultures from insulin-dependent diabetes mellitus (IDDM) patients and controls. In phytohaemagglutinin (PHA)-stimulated cultures both patient groups produced significantly less IL-2 than controls. No correlation was observed between IL-1, IL-2 production and HbA1 levels or the presence of HLA-DR3 or DR4. Our data on "spontaneous" IL-1 production support the hypothesis that monocytes from some newly diagnosed IDDM patients may circulate in a "preactivated" state. The low levels of IL-2 might be explained by an abnormal consumption or by the presence of increased soluble IL-2 receptor levels or by a serum factor which interferes with IL-2 production. Alternatively, it may be a genetically determined trait.

Spontaneous and pokeweed mitogen-induced in vitro IgM production in children and adolescents with insulin-dependent diabetes mellitus.

Serum IgA, IgG and IgM levels, spontaneous and pokeweed mitogen (PWM)-induced in vitro IgM production (determined by ELISA) and blastogenic responses of peripheral mononuclear cells to PWM were evaluated in 4 insulin-dependent (IDDM) children, at the onset and after 4, 8, 12 months of disease, and in 32 children and adolescents with IDDM of 1-14 years duration (mean 4.8 +/- 3.8 years). Fifteen age-matched healthy subjects served as controls. Serum immunoglobulin levels were normal in 31 (86%) patients. Spontaneous in vitro IgM production showed no significant difference between IDDM patients and controls. The PWM-stimulated lymphocytes from IDDM patients at onset or after 4 months of disease produced significantly lower concentrations of IgM compared to long-standing IDDM patients or to controls. No different blastogenic response to PWM was observed in IDDM patients compared to controls. No correlation was present between the immunological parameters evaluated and metabolic control. Our data suggest that a defect of antibody producing B lymphocytes or an alteration of T cell can occur during the early stages of diabetes.

Dexamethasone fails to suppress hyperendorphinaemia of obese children.

In order to evaluate the origin of hyperendorphinaemia in obese patients, plasma B-endorphin (B-EP), B-lipotropin (B-LPH) and cortisol levels were measured in basal conditions and after overnight treatment with 1 mg of dexamethasone. Thirteen obese children (weight excess ranging from 44 to 100%) and 10 normal weight controls were studied. Weight gain started in prepuberty and could not be explained by concurrent diseases. Hormone levels were measured by RIA, either directly in the plasma (cortisol) or after silicic acid extraction and Sephadex G-75 column chromatography (B-EP and B-LPH). Basal B-EP levels in the obese children (19.4 +/- 4.9 pmol/l, mean +/- SEM) were significantly higher than in the controls (7.8 +/- 1.2, P less than 0.01), whereas B-LPH and cortisol was within normal range. In the controls, post-dexamethasone morning and afternoon hormone levels were significantly suppressed. In the obese children, B-EP concentrations remained unaffected by the treatment (14.6 +/- 5.3 and 14.9 +/- 5.2 at 08.00 and 16.00 h, respectively), whereas both B-LPH and cortisol values were significantly decreased. These data demonstrate that a short-term dexamethasone treatment is unable to correct the increased B-EP levels which characterize obese children, whereas it is effective on B-LPH and cortisol concentrations. It can be concluded that circulating B-EP in this condition loses the control of CRH. However, the origin of hyperendorphinaemia in obese patients still remains to be investigated.